It's a circular world. What goes around, comes around.

In an intriguing piece in Health Service Journal, NHS head honcho David Nicholson shakes off his reputation as a centraliser by promising to reinvent the top-down, 'doing change to the service' approach. Basically, Nicholson is going to reinvent the NHS Modernisation Agency (abolished in 2005) on a regional basis.

Nicholson says, “It could be that we set ourselves the task of doing four or five things everywhere in the same way at the same kind of time, and we could create regional support teams to make that happen.”

So here comes the Modernisation Agency, again. And I think that its reinvention on some kind of regional basis is probably not a bad thing.

I found the MA were one of the more effective parts of the DH. This is of course entirely unconnected to the fact I did a few bits and pieces of communications work for them; I mention it to show my bias and financial interest.

In the cash-strapped NHS, spreading good practice will be a priority, but it will have to be achieved in an environment of doing more with less. The MA's 'boots on the ground' approach to spreading learning and good practice seemed effective when the money was only starting to roll in and waiting lists were still long.

The penny has dropped about financial constraint
The overall aim of the piece is to convince the NHS that the penny has dropped about the financial squeeze ahead. He terms the "need to move away from the NHS being built for growth to being able to sustain itself in a prolonged limitation on resources” as an "ideological offensive".

An ideological offensive on NHS marketisation seems to be more the order of the day for both Unite and the BMA. It all seems to be getting to BMA consultants' committee chair Dr Johnathan Fielden: he has found NHS managers without faces.

Warning that “for the first time in working memory, we may see real cuts in health spending (which) will provoke some stark choices: what is kept, what is cut, what can the NHS afford?" Fielden wants to "ensure that it’s doctors making those difficult decisions in partnership with our patients and healthcare colleagues, not faceless bureaucrats, accountants, and those out to fleece the taxpayer.”

Just say no to dogmatic fetishes!
Fielden also suggests that "management consultants, brought up in the tarnished world of finance fail to understand" the NHS ethos. What would he make of NHS managers turned management consultants?

The use of market mechanisms in the NHS is not a one-size-fits-all solution. Too often, management consultants with little or no understanding of the sector have been brought in by central dictat or through force of habit. Too often, assessment of the value added by external management consultants has simply not happened.

Yet it can still be efficient to hire a few days a month of the time of someone who has genuine and rare expertise. It depends how they are used.

The tendency should be to avoid dognatically fetishising either the public or the private sector. The best approach would be to look at the evidence about what delivers the best results for the money we can afford.