On a train.  Across the gangway, a youngster.  Late twenties.  Don't know what he does; by the looks of it a slim-fit model for Burberry Prorsum.   TiGi hair, stubble, open neck blue cotton shirt, turned back cuffs.  Skinny grey trousers and pointy black shoes.  If your daughter turned up with him you might be relieved but feel very old!

His Etymotic ear-buds are plugged into a super-slim phone that might make an after dinner mint think about a diet.  Everything about him is slim.  Cool slim.  Is he listening to Justin Timberlake's 'Suit and Tie'?   No, he's having a row with his car insurance company.  Giving them a larruping.  Ouch!  It struck me; slim-boy is on the move and he expects everyone and everything to be on the move with him.

I would never think about fixing my car insurance using a mobile phone, on a train.  For slim-boy it is second nature. 

I wonder what will happen when, one day, he needs to speak to his GP?  Will he know about the golden minutes between 0823 and 0828 when he can make an appointment for that day?  Or, if he needs a hospital appointment, how kindly will he take to the idea that someone will write to him and tell him when to turn up?

I was homeward bound, from a really interesting and welcoming conference.  Liverpool, the British Association of Dermatology.  Hugely interesting; 50% of their work is skin cancer.   

My theme was the Big-Blue-Bit-of-Death.  However much we may not want it, don't like it, the Big Blue is Coming for You!  They nodded, agreed and said the NHS had to change.  However, they were not able to help as their contribution to the NHS was misunderstood, pivotal and providing optimal outcomes.  But, of course, everyone else would have to... change.

Here's my problem.  In the last month I have spoken to audiences of nurses, cardiologists, orthopods, pharmacists, A&E people, mental health staff and GPs. My theme has been the Big-Blue-Bit-of-Death.

They all nodded, agreed and said the NHS had to change.  However, they were not able to help as their contribution to the NHS was misunderstood, pivotal and providing optimal outcomes.

It's hopeless.  Everyone thinks changing the NHS is everyone else's problem.  I despair; everyone thinks their bit is too important and too well run to mess with.  And, they are right.  Places and specialities and the nooks and crannies of the NHS are making a contribution to the NHS that is misunderstood, pivotal and they are probably, all providing optimal out comes.  They all say the NHS has to change but from what to what?  No one knows.   

The Carbuncle is embarking on a consultation.  Twenty four pages of flim-flam concluding with options; 'do nothing', 'expect more cash' or 'charge'.  All three are ruled out.  Do they really have no idea, or do they have an oven ready plan they dare not show us?  It is a hopeless document.  Truly hopeless, pathetic, unhelpful and inspires no original thinking.   It can't be this bad without being deliberate. 

Am I a member of a diminishing band who thinks there is more than enough money to run a fabulous NHS? 

I was with a CCG; they'd spent �45,000 on lawyer's fees, management time and arbitration trying to sort out an argy-bargy over a contract for services totalling less than �300k.  The new, private, incumbents were bitching; their inherited block contract was overheating.

It made me think.  If all 211 CCGs had a similar problem, �45k times 211 = �9,495,000.  Guessing that there might be 10 contracts in serious dispute in every CCG, the front-line could spend �94,950,000 trying to run a market.  Add to that; contracting costs and market testing palaver, plus Two-Job's salary and the cost of Monitor and you might find enough cash to keep a couple of hospitals going.  We don't need a market, Scotland doesn't why should we?

The Carbuncle, consulting on saving money, costs �400m in management and is just about to double its media relations team 'to get on the front-foot of telling the NHS's story'.   I think the money might be better spent 'on the front-line'.  Close it and move back into a slim-line DH.