Crisis is probably too strong a word.  Chaos is not quite right either.  However, two issues emerged quietly into the news arena last week and predictably the mainstream press let them pass by.

First; London's biggest, most troubled hospital group was forced to close its doors.  It was full.  The potential consequence of that cascade, redistributing patients to other near capacity units, could easily have culminated in a London-wide failure.  Call it a near miss. 

Around 30 London CCGs with no proper rationale behind their boundaries and the underwhelming LATs means there is no London wide strategic grip.  LaLa closed NHS London.  Anxious London Mayor Boris-the-Bike has hired former NHS London boss Dame Ruth Carnell to advise him on how, with no budget and no power, he can chaperone strategic planning for London. 

I suspect it is only a matter of time before the leaders of our other great cities do the same.  Manchester and Birmingham are working in similar mazes. An accumulation of pressures, staff shortages and money problems is not unique to London.  I think it would be right to describe this predicament as serious and I see no obvious way out.

The second issue; GPs havebeen quitting CCGs, they are too busy and too preoccupied.   The overall proportion of CCG board members who are GPs is only 43%.  Astounding, as these reforms are all about Docs being in the driving street.  We are well on our way back to PCTs.

In consequence LaLite is stuck.  All he can do is behave as though the reforms never happened.  Hence he is making more announcements than the Tannoy on Waterloo Station.  Primary care and hospitals are not his job but faced with crisis and confusion he is being forced to circumvent unworkable reforms.

LaLa's plan was to balance the NHS on three legs; the DH, the Carbuncle and Off-Sick.  In fact they have turned out to be three sides of a Bermuda Triangle.  Three organisations have created 'interfaces'; joins where their boundaries, interests and responsibilities overlap, leading to tensions and confusion. 

Basic, MBA first-year student stuff; a case study in 'wrong'.  The situation is aggravated by confusion between the CQC and Off-Sick.  Berwick and Francis both majored on it in their reports.  Experience is proving them right.  Something as sprawling as the NHS needs strong, decisive, identifiable, crystal clear leadership.   The more it is fragmented the greater the need for leadership.  The presence of a panicking Minister makes a bad situation worse.  LaLite knows, in practice he has only two strings to his bow; laws and bungs.

The NHS is suffering from bad law and there is no time to change it. I am yet to meet a supporter of the reforms.  Francis, Berwick, Royal Colleges, unions, patient organisations, managers, commentators and the press are all critical.  By now the reforms should be starting to bed-in.  Actually, with every day more fault lines appear and LaLite pops up again with another wheeze.

Faced with the potential of a catastrophic winter what can LaLite do? We know we need more A&E doctors but it is too late.  Thirty days from winter is no time to go looking. Trusts are already trying to recruit staff from India and the Far East.  Locum agencies are set for a bonanza of wage cost inflation.

We all know GPs could be more helpful but there are not enough of them and rectifying this is a ten year haul; young doctors need to be persuaded there is a career outside hospital.

Solutions?  Practice based budgets for elder-care might be one answer. HCAs calling on at risk +70yrs for half an hour every other day might head-off a few problems?  Streaming vulnerable elderly, by-passing A&E, into dedicated 'Silver Service' elder-care units, seen by a geriatrician within an hour, plus 24-7 social services planning discharge might help.

These are quick fixes and don't solve the strategic problems we are faced with in the long term.  In the meantime LaLite can do no more than ignore the reforms and arrange more bungs.  

'Liberating the NHS' has taken us on an elliptical, �3bn journey, to get back to where we started - 'twas ever thus.