Everybody knows that UK healthcare requires more funding than is available. Such a public system potentially produces infinite 'demand' from finite funding. Even a non-profit public service needs to define its business and put accountable controls in place: dilemma.

The management 'answer' is to control what is delivered and ensure consistency and quality. This is the basis of managed care, but everyone knows that the US is struggling with it ('Party poopers', page 28, 9 December).

Both clinicians and patients hate it - this needs reflection, not reproduction. Presumably it does not reflect the needs of the 'business', since neither group finds it meets their needs. It does not 'control' the business, it attempts to control the money spent on what is defined and managed as the needs - not necessarily the same thing.

Failing to consider this results in managers blaming insufficient funds alone as the problem. But does it not come down to a complete and multi-agency reconsideration of healthcare and how we deliver it?

This threatens established roles and hierarchies - managerial and clinical. Knee-jerk reaction: look for more money from a different source to keep business going; charge at GP surgeries.

Healthcare is complex, chaotic, difficult. The creation of the NHS achieved much good but also created a passive welfare culture, which needs innovation. This requires vision, leadership and an understanding of a business system which should not need to compete for 'managed' medical intervention delivery but demonstrate how effectively the need for this can be avoided. In other words partnership, ownership and empowerment of communities in a dynamic learning system. This needs time and sensible funding - not just a few short-term bucks to maintain what we do now.

Bernice Baker Freelance nurse consultant Horsham West Sussex