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If you ever want to know how to make a complete mess of implementing reform or bringing about radical modernisation and change, then you need go no further than to study the way in which the coalition government has handled its legislative changes on health.

It is of course matched (in order once again to demonstrate their radical and 鈥渘o prisoners taken鈥� approach to reform) by its proposals under the heading of National Planning Policy Framework. In that instance managing to upset just about everyone concurrently, for completely contradictory reasons, and with the likelihood of an outcome which is bizarrely the very opposite of that which they set out to achieve. Even to the point where the prime minister himself has had to intervene to get the National Trust back on side. But more of that another time.

Clinical Commissioning Groups (CCGs) are the local commissioning group led by GPs but now with nursing and clinical input. Commissioning consortiums pull these together at sub regional level. A commissioning board operates at national level for England as a whole 鈥� Scotland and Wales have their own separate NHS structure. Monitor has an extended role but after the rerun of legislation through the House of Commons, the emphasis on promoting competition has been modified to add the requirement to ensure a degree of joined up cooperation.

Health is one of the most sensitive political issues for any government (which paradoxically was understood by Margaret Thatcher)

Health, and in particular the National Health Service established after the Second World War, has always been, and remains, one of the most sensitive political issues for any government (which paradoxically was understood by Margaret Thatcher). For a Conservative-led government it is particularly important that there are not contradictory signals. On the one hand, that nothing matters more to the prime minister than the NHS from which his family have benefitted, and on the other, that the whole framework is to be transformed, arrangements thrown up in the air, and vast sums of money (anything between 拢2.5bn and 拢3bn) spent on bringing about change.

Then, just to add to the confusion you - the government - are not entirely sure what you want to do with the development of new technology which is not only crucial for your long-term pledge for 鈥減aperless鈥� communication with government, but for any kind of sensible up to date record keeping and of course, transfer of vital information. Use of technology in modern medicine requires not only accuracy and transferability, but also an acknowledgement that in future people will not only be treated long distances from their home or workplace, but also by distance medicine, using techniques now in development for oversight of surgery by experts many miles away from the hands-on intervention in the local operating theatre or modern medical centre.

It is this contradiction that is most obvious in relation to both investment in buildings and hardware, and in the ambivalent approach to technology, which strikes such a discordant chord. What sort of hospitals can we expect from the byzantine procedures which are now to be set in train for the commissioning, oversight and monitoring, and configuration of the health service?

The more ministers indicate that power will lie at the local level the more we can see that decisions will be fragmented, uncoordinated and lacking in any strategic framework

The more that ministers endeavour to prove that they will no longer be involved in critical decisions, the more they prove that that is exactly where we will be in years to come. The more they indicate that power will lie at the local level (with the abolition of Strategic Health Authorities and Primary Care Trusts) the more we can see that decisions will be fragmented, uncoordinated and lacking in any strategic framework.

The one thing that is certain is that uncertainty is disastrous. Those whose job it is to plan services in the medium and long term, as well as those charged with delivering the health service, cannot do so unless there is clarity, continuity and confidence in the future. This applies just as much to those delivering equipment and technical services as it does to construction.

Complicated schemes, not least those funded through the PFI route will be particularly difficult. As commissioning consortiums at sub regional level will be commissioning primary care and dental services, it will fall to the National Commissioning Board to oversee the planning, development and funding arrangements for major build - without any clear definition of what will fall into that category. This is just one of a number of examples of how 鈥渄ecentralisation鈥� will actually be the exact reverse.

To create such uncertainty is bad enough. To then fail to achieve the stated outcome is incompetent. And that is what appears at this stage to be happening.
The paradox of course is that it could have been very different. Had the coalition chosen to simply build on the reform agenda and modernisation that had already taken place, and incrementally to bring about further changes, they could have achieved their outcome without the 鈥減ermanent Maoist revolution鈥� famously referred to by the business secretary Vince Cable.

Most of those in the medical field, and those supplying them, as well as the public, were supportive of further well thought through change. Much of what the government claimed it wanted was already in train, and substantial benefits were already accruing. Now, with waiting lists lengthening, waiting times going through the roof and reductions in spending being accelerated by the diversion of resources for structural change, we have the worst of all worlds.

Who do we hold to account for that?