I worry. I really do. I worry. I worry about what I eat and when I eat it. I worry about The Duchess. I worry about deadlines. I worry that the chinos I bought last year will fit me this year. Believe it or not; I worry about typos and spellling (though I am on the verge of giving up). I worry I might run out of things to worry about!

Most particularly I worry about the future of the NHS. I think it is important we preserve it. Not fossilise it or pickle it, I mean sustain the system; tax funded, there when you need it... whatever.

To do that we have to sort the 'money thing' and we haven't.  Politicians are yet to realise; lobbing in �8bn is only enough to keep the NHS afloat, on an even keel. In reality it means the NHS doing what kayakers call 'attainment'... paddling upstream, against the tide.

For �8bn NHS energy and focus will be on 'attainment'; 1,000's of nurses, hundreds of doctors, longer opening and targets all come with a higher price.

And, the biggest 'and' of all, it depends on the NHS delivering 3% efficiency gains. Historically the NHS has managed 1.5% and in the last four years (preoccupied by a catastrophic reorganisation, plagued by poor workforce planning and unpredicted demand) the figure is 0.4%.

If that is true, the size of the shortfall the NHS has to fill with efficiencies, by 2020-1, might be about �25bn.  If 3% is achievable, that means finding �22bn by being smarter, quicker and slicker. (Here)

The big idea for efficiency gain is shifting care away from hospitals that are designed to flex, absorb demand and have efficiencies of scale... to primary care, which has none of these advantages.  It strikes me as barmy. If care in hospital is more expensive the solution is to find a way to make it less so. Or, dare I suggest, reappraise the accounting principles that make it thus.

That said (and someone had to) there is one area of NHS efficiency that needs a real kick;  the delivery of healthcare by the use of technology. Time and again I hear reasons why it cannot be done.

For example, near patient testing. It is possible to use a small amount of blood and mix it with a range of reagents to carry out blood tests, there and then, in a GP's surgery. They are cheaper, faster and smarter. GPs say they are more expensive, patients don't mind waiting and they are not reliable. What pathology people say is unprintable.

In 1999 a systematic review concluded there was little evidence to guide the expansion of NPT. Here we are in 2015; technology and accuracy has moved on.  Medica (every year I go); it's the world's largest medical kit-n-stuff exhibition and full of working examples but here there has been almost no progress.

The UK turns up its nose at science whilst the world gets on and does the appliance of science. Apps, telecare, telehealth and telemed? The NHS seems to be stuck in black and white whilst the rest of the world is in colour.

There is no shortage of Apps. Small companies, individuals working in back-rooms, polishing bright ideas in the hope they will catch the eye of bigger companies and funders.

Few have a commercial future. One of the exceptions might be Babylon; putting 24-7 GP access in your pocket. There are 37 million smart phone users in the UK. If only a small proportion of frustrated middle-class commuters, who can't get to see their GP and the Waitrose Gentry cotton-on to this; expect mayhem in primary care. EMIS can already download your medical records onto the iPad health app.

Public expectations and exasperation will drive efficiencies quicker than we think.

I'm guessing but I think 40% of patients with long term conditions could be managed by Telecare?  By that I do not mean cobbling together a hotchpotch to connect them to an already over stretched practice. Expecting frazzled community nurses and doctors to monitor algorithms, on top of the day job, is a non-starter.

Custom-built call-centres with a clinical front line and smart software to automatically flag-up outliers would be a goer for populations around 500,000. That would mean practices letting go, a new payment mechanism and a sector confident enough to consolidate and invest for the long term.

It's a big ask and beyond locals and LATs to organise. As I see it there is no strategic power, energy, weight, coercion, passion, vigour, influence that can make innovative, disruptive change happen at scale and that is a real worry. 

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Sir Robert Francis,

in conversation with Roy Lilley 

Details here 

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