The Royal College of Surgeons' response to the White Paper offers several amuse-gueules of food for thought.

It is more favourable than many of recent vintage, welcoming the independent NHS commissioning board unequivocally. Alan Maynard will be pissing himself about its call for clinicians to have access to timely routinely-collected data and analysis; and happy about the RCS position that participation in national clinical audit should be mandatory for revalidation. However, he will also point out that revalidation is currently on hiatus.

Its most significant comments come on regulation, as it observes, "there is confusion over which organisations will require a licence from Monitor to deliver NHS services, and this requires clarification.

"It is essential that patients and the services they receive must not be disadvantaged by the proposed changes to the regulatory environment. Some essential services must be defined and protected from the full competitive environment, and this will require smart tariff setting and the ability to recognise critical interdependencies of some services. In particular, we would want the economic regulator to prioritise support for the development of managed clinical networks in, for example, children’s surgery, and ensure that the tariffs reflect the complexity of care delivered, supporting each element of the network".