Writing about what happened this year is not as important as writing about what's going to happen next year; I predict a year of bungs, beatings and the ballot-box.

We all know the NHS is creaking like a Pantomime Dame's corset but the first sign that the stays are giving way came by way of a leak from the ambulance services; they want to give up on some of their targets. They can't move the patients, so they want to move the target. If LaLite gives the blue lights the green light it will shine a bright light on the politics of targets.

On Sunday LaLite Tweeted a complete denial it was his plan to double waiting times.  He didn't say they wouldn't be, in some way attenuated.  That's his problem; after the Lansley fiasco no one believes the Tories on healthcare.

There is plenty of political evidence that not hitting targets is bad for the government. However, I'd like to see the clinical evidence that leaving a stroke patient hanging around is good for them.

Why is the NHS sooooo, busy? Poor access in primary care, too many people dialling 999, too many people in hospital beds and too few people to help them get home safely. Too many people getting old and frail, too many people getting drunk and off-their-face. Too many gaps in our manpower planning, too late to do anything about it now and too many tomorrows will pass before we'll come close to fixing it.

Too many 18-34 year olds, not being able to see their GP, pitching up at A&E; the biggest, growing group... not the elderly as the ageists and the gerontophobes might have you believe.

Too many A&Es missing the four hour target? Well if the ambulance targets can be changed, let's change A&E, too. The first A&E targets were set back in Tony Blair's days; 90% in four hours. It got hiked to 98%, later lowered to the present 95%.

Targets are as much a political issue as a clinical issue; clinical evidence about '4hrs' is far from concrete. Tony Blair felt the targets had been successful in achieving their aim. "We feel... we've managed to (achieve the target)... and that has promoted... improvements in A&E... by setting a clear target".

Back in 2004 forty-eight per cent of A&Es didn't meet the target. By 2005-06, 98.2% of patients were seen, diagnosed and treated within four hours, the first full financial year it happened. If you are a patient it was a huge improvement.

The use of a target as a quality measure or as a stick to beat people is in doubt. It is a process measure and not a quality measure. It gives us some idea of the flow through the system and when the flow slows, the 'target' is missed... we should be asking 'why' the flow is interrupted, not turn up, give the staff a kicking or change the target.

Targets encourage gaming and may hide real problems or delay their discovery, they may also encourage unnecessary admissions; panic when the sand in the timer runs out. Zero-hour admissions. In a well-functioning system the 4 hours would be irrelevant; it would be met as a matter of course. The fact the flow though the ED is silted-up is the real issue.

A hospital is like a Xmas balloon, squeeze it in one place and you get a bulge someplace else.

The old days of patients trailing through A&E, seen by a junior doctor, then by a registrar and then an A&E consultant or a specialist team are pretty well over. Modern A&Es flow; it's the rest of the system that doesn't.

The healthcare is a whole system, each part interdependent and when it works it's like poetry. Stanza by stanza, pentameter by pentameter. There is rhythm and rhyme. For the front door of the NHS to work all the other gatekeepers, the exit staff, the back-office, everyone has to play their part... and they do.

If you really understand the NHS you will know we are measuring the wrong things, for the wrong reasons and drawing the wrong conclusions. The NHS is not a shop window for politicians it is a window on a hugely complex world of people trying their damndest to do the right thing... because it is the right thing to do.

Thank you for doing it. Thank you everyone.

I hope to share your company again, next year. Merry Christmas!

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What's the future for primary care?

If you want to know, too, join me, the NHSE Primary care Tsar and Deputy Medical Director Mike Bewick, leading GP Dr Clare Gerada and the president of the NAPC and former policy advisor Dr James Kingsland, at the Kings Fund for a night of

 The Big Conversation about Primary Care. 

  Details here. 

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