The Prime Minister may come to regret ever involving Sir Derek Wanless in the NHS.

His first report, five years ago, was supposed to spare Gordon Brown’s blushes at pouring money into an unreformed service. To do so flew in the face of the then Chancellor’s claims of financial prudence.

Sir Derek’s advice opened the spigots, and the NHS has been awash with money ever since. Now that Mr Brown is Prime Minister, the last thing he wanted was for Sir Derek to turn his beady eye on how that money was spent.

Broad hints from Sir Derek that a five-year review was desirable went unheeded. Thankfully, there are a few bodies left that are not in thrall to the Government, and the King’s Fund commissioned the report that the Treasury ought to have ordered.

Sir Derek’s verdict is far from encouraging, even if it does find some evidence of improvements.

His discovery that productivity has failed to rise should surprise nobody. When the NHS budget rises, its productivity falls. The last time productivity rose was under the Conservatives, with their so-called “cuts” in NHS budgets.

These were not, of course, cuts, but merely a slowing of the rates of increase. They were accompanied by productivity increases. No doubt when the budget slows in the next few years we will see similar rises in productivity. They mean nothing.

Basically, the NHS uses cash to reward those who work in it, and to spin its wheels a trifle faster. What it has never mastered is using money to make improvements in efficiency that then enable it to treat more patients more economically.

About the only evidence of cost saving Sir Derek can find is in the prescription of statins, the cholesterol-lowering heart drugs. The NHS finally latched on to these at about the time when the patents were running out, and has strong-armed doctors into prescribing the out-of-patent versions, because they are cheaper.

On the reforms so far, Sir Derek is cautious. They may work, and it would be foolish to change them now, but evidence is in rather short supply. Some lack evidence altogether, such as the Government’s belief that care is best delivered in the community, not in hospitals.

And the combination of patient choice and payment by results, with its inevitable corollary that popular hospitals will flourish and unpopular one fail, has not been thought through. No real consideration has been given to the consequences of failure.

Nor is this policy in any way consistent with the desire to delgate management of the NHS to local organisations. The record shows that local organisations, call them what you will (the current name is Primary Care Trusts) are constitutionally reluctant to rock the boat.

Who can blame them? Closing hospitals or even reconfiguring services releases demons that make even the bravest quail. PCTs that run into trouble over such changes get no support from the Department of Health, which will betray them without a second thought.

Sir Derek’s sharpest barbs are reserved for public health, which has languished despite an avalanche of initiatives, strategies, and ministerial hanky-waving. Seldom has such an important part of the nation’s health been so neglected.

Small wonder that obesity is rising as fast as the NHS budget, and with as little control.

The NHS is probably unreformable. But the combination of constant organisational change, dollops of cash, and sharp policy swerves that we have witnessed over the past decade has not provided the best-possible test of this contention.

The NHS used to be underfunded and ineffective. Now it is only one of these. No prizes for guessing which.

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