"All bets are off" as David Nicholson tells NHS to prepare for cuts (HSJ 4June - updated Pulse 27Nov09). Massive investment over the last 8 years hasn't improved productivity (HSJ 28May). PCTs aren't making use of the wealth of experience and enthusiasm available through Practice Based Commissioning (PBC) (Primary Care Today May/June 09). The same old ideas are put forward as the solutions to all our problems - more care out of hospital, more innovation, more work led by nurses, more Health centres, more salaried GPs. Why haven't these 'obvious' solutions delivered?