Perhaps it is just seasonal religiosity, but it is starting to look as though 2012 will see some significant battles between the NHS’s competing spiritual forces.

Unless the government pre-empts it first, the Francis inquiry report is likely to unleash a fresh dose of navel gazing about the false dualism required, the theory goes, to stop the spirit of economic necessity vanquishing the spirit of quality.

But in practice, Monitor has never merely scrutinised foundation trust finances, as its governance role makes particularly clear.

And the case of Southern Cross showed that, with large scale providers at least, even a quality regulator will worry about the potential knock-on effects its intervention could have on a provider’s reputation and therefore economic viability; a “quality” concern in so far as the worst care (one would hope) is no care at all.

The distinction is even harder to sustain once you throw in Monitor’s new price setting role. That will involve calculating a price that enables providers to at least maintain, if not improve, quality. This raises the question: who will determine what constitutes “quality” at the individual level of a tariff procedure – Monitor or the Care Quality Commission? 

Or shall we just leave it all to the NHS Commissioning Board?

If that particular dialectic does not inspire you, there will be plenty more. The Liberal Democrats are adamant about debating where the austerity line should be drawn between universal and means tested benefits.

Only the naive believe the NHS will escape scot free – even if the upshot is a freshly evidenced reaffirmation of the hidden costs of means testing, as opposed to the more precarious political logic of buying middle class support for the welfare state.

Along the way, the strong willed may have another go at the commissioner-provider split. But hopefully we will all find some new year cheer in the commissioning reforms which exhausts the lazy rhetorical distinction between clinicians and managers, foretelling a new peaceful era of patient-centred administration. Either that or Armageddon.

Sally Gainsbury is a news reporter for the Financial Times.

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