Your editorial on care trusts taking over responsibility for housing (comment, page 19, 14 December) argues that there is surely a limit to the extra responsibilities that the NHS can take on. It illustrates how far we have come from understanding what a publicly funded health business needs to be.

Too many managers have spent years controlling money and collating numbers, the outcome of which - in real people's 'health' terms - they neither knew nor got brownie points for investigating.

It is like Marks & Spencer delivering the same product without realising its customer base is changing. A patient focus requires, in business terms, the whole of the supplier chain to be recognised. For managers involved in a public health service this must now be from the patient's reality rather than from 'what we normally offer'.

We do not all experience M&S in the same way; neither do we all experience cancer or the common cold in the same way.

Each of us has an individual, psycho-social, economic, family/ethnic background underpinned by greatly varying experiences.

Clinical governance and the Commission for Health Improvement could push managers toward trying to 'quality control' or 'performance manage' traditional model assessment and delivery methods rather than questioning if they ever worked.

We must move from reductionist, functional control to an holistic, whole-systems awareness. We must involve clients in integrated service pathway/guideline design and outcome tracking. If this offends the old order and appears to be a complex supplier chain to manage, so be it.

Bernice Baker Freelance consultant nurse Horsham West Sussex