The funeral-black cloud rolled across the sky, casting a slate shadow over the barren landscape. Women ran to gather up their children, strong men hurried home to lock doors and barricade windows.

At first you couldn't hear it... it started with people feeling a low rumble. Dogs pricked their ears. It came; rattling, shaking and vibrating everything in its path. Distraught voices asked each other; 'What is it... what's happening?'

In whispered tones the answer came; 'It is the chickens coming home to roost'.

And so it is, in the austere landscape of healthcare, poisoned by Andrew Lansley's toxic reforms; the sky is thick with chickens coming home to roost. Distant voices had warned, tried to raise the alarm but hubris hounded out the soothsayers and haruspex. The confluence of a collapsing economy, convoluted reform and crushing demand has delivered the scenario from hell. There is not enough money and too many patients.

In an unprecedented development Trusts have rejected the calculations from Monitor thus they are unable to achieve agreement and set a tariff for next April.

In the same way that schools have Ofsted, and the lecky market has OfGem, health care has Off-Sick, aka Monitor. Their most important job; set the price list for healthcare. The tariff. They can't do it. Despite consultation and wearing out the battery in their calculator they cannot come up with a menu of prices that Trusts can afford to charge and stay solvent and safe.

Trusts, emboldened by the Shelford Group, have said 'no', in enough numbers to trigger a stall in proceedings and probably, a referral to the Competition and Markets Authority.

Whichever way you look at it, for Monitor, this represents a huge vote of no confidence. Some say it is an impossible job; Indiana Jones couldn't do it but Monitor inspires little confidence or even connection with the organisations they are responsible for.

The boss, David Bennett, a re-tread from the Blair era with no experience of running health services, was a career consultant with McKinsey and enjoys a £282.5k salary. Heavily criticised, by the Public Accounts Committee, for doubling as chief executive and chairman, contrary to his own advice on corporate governance, Bennett commands little support; hence, in part, the revolution.

Is this just a few arrogant Trusts kicking off? An attempt to divide and rule? I don't think so.   Consider the predicament of the Queen Elizabeth Trust in Brum. The proposed tariff will cost the hospital £60m a year in lost revenue. The convolutions in the existing tariff have perverse incentives enough, on top of which QEB faces 3.8% cuts to the cost of providing care and changes to the way specialist treatments are funded.

As QEB's chief finance officer told the press; 'The current situation is untenable.' Savings of this magnitude and this timescale can only come from the biggest cost centre and that is staffing, mainly nurses. Reduce staffing and you jeopardise safety and quality. All roads lead back to Mid-Staffs.

Don't make the savings, overspend and risk being put in special measures by Monitor. Do make the savings, cut staff numbers; risk grief from the flat-earthers at the CQC.

Either way; the news gets out and it becomes impossible to recruit. This is not regulating Trusts this is waterboarding Trusts.

The 'chickens home to roost' phrase comes from Robert Southey's epic poem The Curse of Kehama. It tells of an evil priest who gains demonic power in a quest to become god.

I am sure Monitor see themselves as 'god' but if they are, they are tin gods. Failed in their mission because the task is not doable and they should say so. You can't spend a pound twice or make 100p buy 110p of healthcare.

It's time to end the expense of commodious Monitor, dump the misbegotten market and tariff, its costs and complications.

How fast could we develop a formula to bring us to population based, capitated budgets? How urgently could we drive vertical integration and create local health economies that include social care? How quick could we develop outcome based measures?  If we really, really wanted to, my guess is pretty quick.  Here's a starter for ten. 

Big ask, yes of course but what's the alternative? What we have doesn't work.

The chickens are turning into albatross.  

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'What is the point of a select committee' come and join me in conversation with Dr Sarah Wollaston MP, chair of the Health Select Committee.

 Kings Fund 11th March - details here. 

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roy.lilley@nhsmanagers.net 

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