Modernisation is so old-hat

After all, a policy of privatisation is being pursued in the funding of new hospitals through the private finance initiative, and is under active consideration in the funding of social care through long-term insurance.

So what is to be made of the prime minister's unprecedented announcement concerning future funding of the NHS? It doesn't fit the pattern.

Whatever the reality, there is much loose talk about underfunding and what other EU countries spend. Great caution is called for. We should also look in our own backyard for some pointers.

A fact overlooked by the English media is that the NHS in Wales, Scotland and Northern Ireland is already significantly better funded than the NHS in England.

In Scotland, expenditure is 25 per cent higher per head of population.

But the more interesting questions are: is the NHS better or under less pressure in Scotland, Wales and Northern Ireland?

And does the higher spending result in better health outcomes than might otherwise be expected? Scotland has an appalling health record. Would it have been worse without the additional spending? Or might the impact on the population's health have been more dramatic had the funds been spent elsewhere?

Until we have answers to these questions it would be premature to launch into a major NHS investment programme. Maybe the lesson from Wales, Scotland and Northern Ireland is that while increased spending on healthcare services may result in less stretched and run-down facilities, the impact on improved health is negligible.

If so, then there are major implications for the government's broader health agenda and its commitment to narrowing the health gap.

This, as recent Organisation for Economic Development and Cooperation figures on poverty levels reveal, is the highest among developed countries, including the US.

As the Swedish health economist Goran Dahlgren has argued, there is actually very little connection between healthcare reform and the attempt to improve the health of populations and communities. Most reform is designed to achieve quite different objectives, especially market-style changes.

Britain may have rejected the worst excesses arising from marketisation, but the NHS remains vulnerable to repeated attempts by those who seek to undermine it at every available opportunity.

The NHS modernisation programme has actually been little more than a commitment to the status quo - a policy of more of the same (for example, shorter waiting lists, better use of hospital beds through closures and mergers, and evidencebased medicine through protocols and guidelines).

The building blocks for a post-modern health policy are already in place.

They include the health strategy, health improvement programmes, the rejuvenation of primary care, regional public health observatories, the new Health Development Agency, the commitment to partnerships and wholesystems thinking.

But what is missing from this raft of initiatives is a well-articulated and robust vision linking the various components.

There remains too much ad hoc , reactive policy and too many isolated policy initiatives (such as NHS Direct, walk-in clinics), which appear disconnected and designed to pander to the worst features of consumerism.

Simply putting more resources into the NHS, welcome though that may be for sprucing up the front-of-house features of its dilapidated estate, is a palliative.

It will provide shortterm pain relief, but before long the NHS will once again be back in the headlines as a terminal case.

The government has an opportunity to be both bold and visionary and rethink our entire approach to health and healthcare.

HImPs and the national service framework on mental health and the forthcoming one on coronary heart disease already begin to do this by insisting that proper attention and resources be directed to primary and secondary prevention.

In this broader agenda, the role of the NHS might diminish, and even cease to be the centre of attention.

That would be a good thing and a sure sign that the government's postmodern health policy is working.

The NHS occupies an important place in the government's health policy and in the nation's affections, but it should not be seen as the totality of what that policy is about.

The logic of this position is that there are implications for how the additional resources promised to the NHS should be allocated. Should the NHS receive them all? Should a proportion go to other public services - notably housing5which probably have a greater impact on health?

Such questions deserve to be addressed or else any injection of new resources will most likely go on downstream healthcare services.

Where is the evidence of wholesystems thinking in such an approach?

For example, we know that many acute beds are inappropriately occupied by elderly people because of a lack of alternative provision in the areas of prevention and rehabilitation.

What is the most appropriate course of investment: to put the funds into more hospital beds, support mechanisms, or better housing to prevent hospital admission in the first place? Let's not miss the opportunity presented for a bold policy lead.