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I find the assumption that further demographic ageing will inevitably hike up costs really interesting - and, like John Appleby, overly pessimistic.

At present, the oldest areas (which are grappling with the highest burdens of chronic disease and disability) do NOT receive the highest funding allocations. These actually go to areas with really young (but deprived) populations who would indeed benefit from effective preventative interventions (which probably lie outside the NHS).

While ageism (and technical flaws in resource allocation) is probably playing a big role in the lower funding in older areas, there are some positive factors at work - e.g. a compression of morbidity, greater compliance (in affluent areas) with treatment and lifestyle regimes and good primary care.

These should make us question projections that NHS expenditure is going to spiral out of control with the 'burden' of ageing.

I'd also question whether a one-fit model of larger practices is universally applicable (one encounters excellent smaller practices that manage the health and social care needs of vulnerable older patients in incredibly creative and caring ways).

That said, if concerns about spiraling costs make us reconsider the cost benefits of maintaining a purchaser provider split (and associated costs), I'd welcome that!