As I look back at 2011 I am disappointed it has been a year of clinical commissioning overwhelmingly focused on local secondary care. Now I am the first to say we need strong services providing care closer to patients and the local acute trust has the biggest slice of the pie, but £165M of £870M should not need 95% of our commissioning energy. My GP commissioning colleagues have struck me with their desire to get into the prevention game and move upstream of secondary care; drain the swamp rather than shoot crocodiles. Now we are a ‘Healthy City’ and I need to stress that is an aspirant title because the reality reads like a problem case in a Public Health masterclass. I am very proud of our interventional cardiology unit but wouldn’t I rather have citizens whose hearts required no intervention? This won’t occur while we have a smoking rate above that of urban Newcastle and wards with cancer rates approaching double the national average. Even within the city there is a life expectancy difference between virtually adjacent neighbourhoods of 10 years. Less than one in five of us have our five a day but more than a quarter of us drinks excessively. The only marker in which we excel is teenage pregnancy but cannot match it with breast feeding. The city near the Lake District has air quality in the worst quartile of the country; does this contribute to our excess winter deaths index of 17% and is this not more important than how the cataract contract is carrying on?