At the very lowest level of scale, variation exists simply between the costs of things. Again a significant focus of Lord Coles review was on cost efficiencies. The cost of locums has inexorably risen year on year. The NHS is seemingly at the mercy of locum agencies whose revenues, many £100’s millions, are the result of commission they charge the NHS. This is a cost that the NHS could largely do without as it has plenty of doctors of its own. The NHS simply needs better systems for organising their own doctors and employing them directly as locums when needed. Pennine Acute Hospitals is leading the way in this regard. The Pennine Acute Messenger, an innovative app and system, has helped them grow their bank of “internal” doctors and encourages them to work directly for the Trust as locums, commission free!