The General Election is upon us, and on Friday this country may have a new Government. What should the next Health Secretary do with the NHS? Rob Findlay takes a look at some of the options.

“We won’t cut the NHS”, say politicians of all parties. But after years of rising budgets, everyone knows the coming financial squeeze is going to be painful. So what should the new Health Secretary do to balance the books, without hitting quality and access at the same time?

The main thing the new Health Secretary will need to get a grip on is demand: the big issue for PCTs and Trusts alike. PCTs cannot put a cap on GP referrals (and rightly so). But in the long run PCTs nevertheless have to pay for the all patients that GPs refer, whether they can afford to or not. This dilemma cannot be resolved by the PCTs alone and, as the finances dry up, some will find that they cannot balance the books.

Demand squeezes the Trusts too. Even though the tariff entitles Trusts to payment for the work they do, the NHS contract does not give them freedom to do unlimited amounts of it in any given year. If activity falls short of demand, then all the shortfall ends up on the waiting list and raises pressure on waiting times. Even if the new Health Secretary is minded to go easy on targets, they are unlikely (and would be unwise) to let go of waiting times completely. That means that Trusts are in the demand squeeze as well.

If Trusts cannot control demand, and PCTs cannot control demand, then who can? Conventionally the answer is: the GPs who refer the patients in the first place. But this gives rise to new problems, such as: how do you stop a (hypothetical) unscrupulous GP from lining his or her pockets by simple dodges like delaying Edith’s hip operation or cutting her prescriptions? That was the big objection to GP Fundholding back in the 1980s, and is likely to be the objection again now. I suggest that there are more interesting ways of looking at this problem, which include players other than GPs (notably patients themselves), and that the problems are indeed soluble. But that is a longer discussion that will need to wait for a future post.

For an organisation that is fundamentally about people, the NHS has an unhealthy obsession with buildings and organisational charts. This needs to change. Buildings and organisations are merely services that help front-line professionals care for and advise their patients. In that spirit, acute provision should move closer to the front line, as hospital consultants rediscover their heritage and become consultants again in the true sense. With theatre time costing something like £25 per minute, why do operating sessions so often start half an hour late, and would that still happen if the theatre was being hired out of the consultants’ own pockets? It is hard to deny that there is scope for improvement here, and the concerns about improper self-enrichment are far less pressing because the incentives would be the same as for any existing independent-sector provider. Most of the obstacles that used to stand in the way of more independent consultants have already been removed, including that of the NHS pension, so all that is now needed is a favourable political climate.

All this devolution to the front line would be held back, however, if top-down initiatives were not reined in. There are some obvious action points here: bringing the World Class Commissioning movement to a dignified close, decentralising decisions on IT investment and innovation, and refocusing SHAs into a more supporting rather than controlling role. Likewise the vast numbers of centrally-directed targets should be devolved to become local performance standards, so long as this process happens no faster than the devolution of financial control to the front line. I would make an exception of the 18-week target, however, and retain that as a national requirement in order to focus attention onto demand and pathway management.

Finally, the new Health Secretary should lead the NHS in taking a different view about the meaning of the word strategy. The NHS conventionally uses “strategy” to mean a kind of long-range plan, with all the objectives, the interactions between different players, and the intermediate steps mapped out and described in detail. Such strategies change frequently, which in itself suggests that this approach is not helpful. Instead (following General Carl von Clausewitz) “strategy” should be thought of as comprising: the overall objectives (e.g. better, cheaper healthcare); theories about how those objectives can be achieved (e.g. by devolving financial control to front-line professionals); and then those theories are used to guide both deliberate action and (more usually) the many and continuing daily responses to unforeseeable events. Again, this is a theme we will pick up in future posts, and it applies particularly to the planning process.