'Over-centralised and over-politicised'

The Government has staked its reputation on improving the NHS and on meeting its targets for the service. Having given generous funding increases to the NHS since 1999, ministers are anxious to show that the new money is making a difference. Above all, they are keen to show that they are reducing waiting times, be it for elective surgery, a visit to a GP or an emergency admission to hospital.

At the same time, NHS hospitals have in recent years developed observation wards for people who attend Accident and Emergency departments, who will need time to be assessed before being admitted to a normal ward. Observation wards are ideal places to determine whether a patient with chest pain, for example, has a heart problem or just indigestion, away from the noise and chaos of casualty.

There have been concerns, however, that the use of observation wards is being distorted by NHS managers anxious to meet government targets. Some have argued that people are sent to observation wards simply to speed them out of A&E units, while in a few cases people are kept in observation wards for longer than is recommended. To what extent this is true no one really knows, but the chances are that such manipulation is very rare.

Wider questions about the way the NHS is run do, however, remain. Since the National Audit Office report on waiting list manipulation was published a few months ago, the suspicion that figures are being fiddled is at the front of people's minds.

NHS managers are struggling to keep up with the welter of instructions, guidance notes, targets and service frameworks they are sent from the NHS Executive and the Department of Health. They are under extra pressure from the new "star ratings" system. If their organisations perform well, they get more freedom from central control, but if they do badly, managers now face losing their jobs. The result is that local innovation is stifled in favour of pursuing paper targets.

At the same time, the NHS still faces a serious staffing shortfall. Across the service, doctors, nurses and other health workers are in short supply. Meanwhile, outside the NHS, nursing homes and other care services are struggling to keep up with demand - a situation that has been exacerbated in London and the South-East by the closure of many care homes. This situation leaves older patients particularly vulnerable to getting caught in the gaps, most notoriously when they are left in hospital for too long because care packages cannot be arranged for them.

The NHS is over-centralised, over-politicised and short of resources. This need not be the case - it is not inevitable. But until these problems are ironed out, suspicions of manipulation will remain, as will fears that the figures NHS managers are required to churn out to justify their existence are being massaged.