Will NHS chief executive David Nicholson be eating words as well as turkey this Christmas?

Two of his favourite aphorisms - ‘Stop Kremlin watching - look out to your communities, not up to Richmond House’, and ‘I haven’t got the money in a safe in my office’, are looking increasingly hard to justify in the wake of the new operating framework and the coming year’s financial settlement.

The operating framework is awash with targets. And, like a bureaucratic Russian doll, many of the major targets conceal yet more targets inside (for more details, click here).

For example, the PCT Network has counted 60 instructions to primary care trusts, some of which unpack to reveal subsidiary directions.

On top of the framework, the health service still has the full list of ‘vital signs’ to look forward to; the 13 pages-worth outlined so far are just the beginning.

It is not that any of the goals are, in themselves, wrong, or that there should not be national targets for a national health service. It is that the rhetoric of the last six months does not match the reality of the operating framework.

The relentless localist spin continues unabated in the framework itself, despite the clear evidence to the contrary.

Mr Nicholson’s introduction says: ‘The Operating Framework for 2008-09 marks the beginning of a new chapter in the journey to transform the NHS, enshrining the ability for local NHS organisations and the communities they serve to have greater autonomy in determining their own priorities.’

A few pages further on, in a clumsy attempt at diagrammatic spinning, we are presented with a triangle labelled with ‘national requirement’ at the top and ‘local action’ at the bottom. Guess what? The local segment is much bigger than the national one. Free at last!

David Nicholson and health secretary Alan Johnson have made considerable strides in renewing trust between the Department of Health and NHS staff. But if they want to build on this they need to work harder on delivering their promise of a locally driven health service.

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