Hello again. The past couple of weeks have been insanely busy with other work, hence my temporary absence from the parish. The estimable Tom Smith has been holding the fort with aplomb and putting my absence to shame. Thank you, Tom.

As well as Tom's latest Health Policy Today, today we also have the latest instalment of The Maynard Doctrine. Due to holiday commitments, this was in fact written a week ago, before Chancellor Alistair Darling's striking interview in The Guardian, in which the morale-boosting chancellor let it be known that the country faces its most challenging economic circumstances for 60 years and that voters are "pissed off" with New Labour.

Those involved in health policy will be avowed practitioners of political Kremlinology - the fascinating pseudo-science of deducing true intent. Perhaps the greatest example of this was - appropriiately - apocryphal. The great 19th century German diplomat and polictician Metternich, on hearing of the death of the equally great Talleyrand, reportedly mused, "I wonder what he meant by that?"

Yet as The Guardian's consistently impressive Larry Elliott points out, those attacking Darling's candour are missing a substantial point: "The International Monetary Fund has said the financial crisis is the worst since the 1930s. The deputy governor of the Bank of England, Charles Bean, told a conference in America last week that Britain was facing conditions just as challenging as those in the 1970s."

Today, currency and trading markets reacted to Darling's comments with shock and awe - proving yet further that the market motivators of greed, fear and herd instinct may enable wealth creation in favourable conditions, but are no sign of wisdom.

Money, money, money
Politics and economics are at the root of most health policy. It is evident that the UK economy is slowing down faster than even the more pessimistic forcasts of the IMF and the Bank of England had suggested.

This is going to hit health budgets hard, and as Maynard has pointed out in his latest column, this may be a good thing if it leads to reappraisal of existing working practices and changes where they are not efficient.

NHS South West chief executive Sir Ian Carruthers once told me, in a rare interview (published in Health Service Journal) that "there is no such thing as a financial problem - just a history of management decisions that created it". Carruthers took over at West Dorset when it was in a parlous financial state and repeated the trick when he added Hampshire and Isle Of Wight SHA to his original SHA.

Less money is going to be available after the current spending round. That is clear.

And this may become part of the solution - if it successfully focuses attention on the cost-effectiveness of and clinical variations in existing services. This will need attention (using data in tools such as the NHS Information Centre's NHS Comparators), from both the top down in management teams throughout the country and bottom-up, as practice-based commissioning consortia must now get organised and start to show some bite.

Clinical engagement has to be at the heart of these changes. Tom's Health Policy Today has rightly noted that the BMA is shifting to an 'if you can't beat 'em, join 'em' stance on polyclinics. This may - hopefully - see some detente in the cold-hot-hotter war of words between the Government and the BMA.

Stumbling into topping up
I'm feeling slightly uneasy about the report in The Observer over the weekend that the NHS Confederation is going to recommend that patients should be allowed to top up to pay for expensive cancer drugs without losing their right to NHS care in its submission to the Richards review.

The Confed often read the signals from Government well, and indeed make some of the running.

At the same time, I find it hard to be specific about why. I'm generally in favour of letting people spend their money as they wish to. There are concerns around equity, but only an extreme ideologue would currently assert that the NHS currently delivers equity. In many ways, from small to the Barnett allocation formula, it is not an equitable system as it stands.

Some clinicians have better outcomes than others. It has taken a very long time to get to the current embryonic steps towards outing this fact. Once commissioning starts to bite, some commissioners will be better than others, and they will make their healthcare pound go further.

No, my uneasy feeling is that the debate over topping-up wihtout losing NHS care has become a proxy for attacks on NICE of the kind that have dominated the media, as Tom Smith has been tracking in Health Policy Today throughout August.

Countries throughout the developed world are mainly developing their own domestic versions of NICE to look at drug pricing. The well-orchestrated anti-NICE PR campaign being run by organisations such as the Rarer Cancers Forum (sponsored by Roche) and other bodies who don't even get publicly named in the media are bouncing policy towards a point where cost becomes removed from the equations used by NICE to decide what the NHS will pay for. It will never be all that the pharmaceutical industry can make.

No, on reflection, perhaps the best solution is to allow those who can afford to do so to pay for top-up drugs that the NHS will not, and to systematically collect and analyse data on the extra life and health so gained. In that way, it will become apparent if NICE has made the wrong decisions - or whether it has got things just about right.

This will, of course, make things no better for the patient who may be in the next bed, or sat in the next waiting room chair, or living next door who cannot afford that option. In that context, the observation in The Observer piece that "One group of terminally ill women consulted by the charity Breast Cancer Care concluded that relaxing the rules was morally wrong because of the impact on those too poor to afford top-up treatments, although they admitted they would have remortgaged their homes to buy themselves more time if they could" struck me as a very human response to a tough dilemma.