The ideals of commissioning are mocked. One may sympathise with policy-making born of frustration, but when rhetoric begets sham and folly, then challenge should be clearly heard.

The ideals of commissioning are mocked. One may sympathise with policy-making born of frustration, but when rhetoric begets sham and folly, then challenge should be clearly heard.

Efficient allocation of funding, in a fast-changing world of increasing complexity and specialisation, cannot depend on armchair reaction to ponderous and simplistic 'outcome metrics'. If limited data is aggregated above local circumstance, and if selected statistics and derived dogma are elevated above the calculus to be gained from measurable clinical expertise and measurable patient appreciation, then we will have not the use but the abuse of 'evidence from measurement'.

In truth, the armchair attributions made across supposed patterns of 'input' from still further back are admitted to be lacking as evidence - in relation to party rhetoric, ambiguous national strategy, and desperate local reconfiguration cuts. Evidence to follow is the refrain.

Specialist family planning presents an excellent example. The provision of family planning having been attacked by innuendo in Choosing Health - patchy in quality and variable in coverage across the country - access to specialist care is being 'disappeared'. Demoralising cash-raid command, against patient and GP choice, and non-replacement of staff - even to the point of denying need for locum cover to sustain service emergency reliability - are threatening reliability and viability.

Balanced input

The need to consult either relevant clinicians or representative patients is either not seen or feasible for hard-pressed, deal-making chief executives. If our directors of public health were to risk specific involvement of clinicians and patients, cash-desperate PCTs might at least preserve service viability for future development.

More likely, I fear, is a re-hashing of dogma, presented at strategy events for the approval of well-meaning but poorly-engaged commissioners and providers, nominated or appointed to serve executive understanding of our travel direction. Detailed analysis from experience is it seems discounted. In my own locality, managers (with PCT backgrounds) doubt that clinical voices will be required, invited or allowed for a promised PCT event. 'Sometime in May' has become 'sometime next month'. Busy front-line doctors may be invited at the last minute, if at all.

Dialogue between central perspective and front-line experience will always be necessary. How not to conduct such essential dialogue is being currently spelled out for posterity.

Name and address supplied.