Published: 15/12/2005 Volume 115 No. 5986 Page 3

Health policy has veered dangerously into incoherence over the past nine months, with the balance of emphasis between provision and commissioning becoming out of sync. These are not HSJ's words, but the view of Professor Chris Ham, until last year the Department of Health's head of strategy (news, page 6).

Professor Ham's uncharacteristic outspokenness in his speech to the Healthcare Financial Management Association conference signals how a fear of unstitched policy is growing at all levels of the NHS. And he is not the only figure who has operated at that senior level to sense uncertainty - both about how policy can be better aligned and whether the government, as Professor Ham puts it, is 'willing to live with the consequences of the creative destruction' involved.

In one sense incoherence is part of the point of reform: if a move from being provider-led to being market-led does not feel unstable you are probably not paying enough attention. But that makes confidence in the end goal all the more vital.

As Laura Donnelly argues in her new column (page 17), a health secretary who says she doesn't like the word 'market' risks raising doubts that the government will hold its nerve and see the reforms through.

The prospect of managers absorbing all the pain of reform without enjoying the end result would be bitter indeed.

There are two reasons for confidence, however, that next year will see more coherence. This week saw the first fruits of the labour of DoH director of policy Bill McCarthy: Health Reform in England: update and next steps clearly begins the much-needed stitching. Every manager would benefit from reading it closely.

And McKinsey consultants are assessing both the Department of Health's top team and its whole structure (news, page 7).

Whatever the result - and 'major changes' are expected - the result should be a centre better suited to clarity.