Yes, it's me again. I'm sorry but I just couldn't let this go. Something dropped into my inbox that made me soooo cross, I put it on Twitter and Twitter exploded; now a lot more people are angry.

This is not the time of the year to be annoyed. This is about good cheer, mince pies, sprouts and peace but I'll have to get this off my chest before I can settle down to my slice of Norfolk.

It's a letter sent to medical directors from the three blind mice; the Carbuncle, the Totally Dismal Army the TDA and over-paid Monitor (The boss costs us, in total, probably close on a quarter of a million a year), the purpose is to remind medical directors that the NHS is busy and there are targets to be met.

It is signed by two people I doubt you would know if they popped out of your Christmas cracker and the third, unbelievably, Uncle Bruce. I think Bruce Keogh is the most trusted man in the NHS and why he has put his name to this I cannot imagine.

This letter epitomises what is wrong with today's NHS. First, it is signed by three people. Who runs the NHS? If I want tickets for the Cup Final I could ring up Greg Dyke, the chairman of the FA. If I have a complaint about a dress I bought in Top Shop I could ring Phil Green. I know who runs these organisations. Who runs the NHS? Who do I ring? If Martians land in the back garden and demand 'take me to your leader' where do you go? Train to Leeds, Tube to Elephant&Castle or cab to Whitehall?

The second irritating, exasperating, infuriating thing is the tone of the letter. 'There should be zero tolerance of over 12 hours waits for admission'. YES, WE ALL KNOW THAT! And, eleven hours and 10, 9, 8, 7 and even half an hour. That is why the NHS is straining everything it's got, to work in this silted up, fragmented, short of people system.

When social services can't get people home safely, patients are two in a bed and there are six ambulances parked outside, should we show this letter to the patients and say; 'Please go home, we have no hope in seeing you in the target time and we will get into trouble if you stay'.

This letter is simply backside covering; when the inevitable headline appears in the Daily Mail and LaLite goes off on one, these two and god knows why, Uncle Bruce, can say, 'We wrote a letter, Minister'.

Does it say 'if you have a problem ring me'? No. Does it say here are ten really good ideas that might give you some help. No. Does it say we have a plan, a brainwave, anything helpful, useful, assistive? No.

So, when the anonymous ones are feet up, snoozing after their Xmas lunch they can dose-off in the knowledge that whilst the rest of the NHS is busting a gut, heaving, sweating, pushing, shoving, straining and working 'till they drop... they have written a billet-doux. They've done their bit.

And their 'bit' is? Point out that the NHS is busy and if you foul up send in a root-cause analysis, in triplicate, by Monday.

This letter says it all about the NHS; poor leadership, clunky communications, dysfunctional triplicated, distributed leadership model, buck-passing, annoying, petty, unhelpful people looking busy. It says 'I'm covering my back by loading stuff onto your back'.

This has to stop. The pointless TDA have to be scaled back, rolled into a slimmed down Monitor. NHS leaders have to behave like leaders.  If things can't be done they have to say so, figure out why and fix it if it can be fixed.  We need 2015 to be the year of stripped-pine honesty.

If the service is going to get through the next few months threatening letters disguised as seasonal greetings won't help. They fool no one and are at the heart of the other corrosive NHS malaise; bullying, whistleblowing and getting to the truth. You can bet your life Medical Directors will be shoving this letter down the pipeline and down the throats of the front line; heaping more pressure onto people who dare not complain or question because they see whistle-blowers lose their jobs. 

Bullying starts at the top and this letter is testament to that.

Leaders must learn, when targets are failed only one word matters; 'why'. Serious incident reports will never discover more than reflective management. Leaders must celebrate success and share best practice, give time and space for good people to do great things.

Merry Xmas, again... 

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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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