'We have a centrally run, demand-driven, hospital-orientated system for an ageing, consumer society with untreated long-term conditions. This recipe will be unsustainable.if the 2007-08 spending round produces a big squeeze'

The past few weeks have demonstrated that the future of the NHS depends on political consensus. Both our aspiring leaders agree that state funding for healthcare.should meet individual needs. The difference is in how they propose to deliver reform. This is absolutely crucial.

There are countless ways of icing the NHS cake and I think we have seen nearly all possible policy tweaks over the past decade. However, it is not these minor variations but the fundamental ingredients that will matter most.

Currently, we have a centrally run, demand-driven, hospital-orientated system for an ageing, consumer society with untreated long-term conditions. This recipe will be unsustainable if the 2007-08 spending round produces a big squeeze.

Recently, arguments have centred on how to localise services and engage the professions delivering those services, while at the same time effectively decentralising a bureaucracy. Most of these strategies will just not work.

Starting from scratch

We have heard of the need for local voices in healthcare planning in the umpteenth round of public representative body reorganisations. We have heard the calls for GP surgeries to open 25 hours a day, eight days a week. We have heard of.the need to review out-of-hours services, with patients choosing their own route to accident and emergency. Addressing some of these options will undoubtedly help, but better icing does not improve the overall recipe.

The best ideas of the moment must start to look at the raw ingredients of healthcare and consider a fundamental shake-up in our approach to public health. Public health crosses all spheres of government and the delivery of all public services -.investment in housing improvements for those with respiratory conditions, healthy living classes for school children and proactive risk assessment in social services may do more for health than any hospital building. Should primary care trusts.commission public health programmes in the same way they commission GPs or acute admissions?

Take a step back and look at the facts. Three risk factors - smoking, poor diet and lack of exercise - contribute to four chronic conditions: heart disease, type 2 diabetes, respiratory disease and many cancers. These four conditions account for 50 per cent of deaths worldwide.

Individuals must start to take responsibility for their own lifestyle choices.if we are to sustain the consensus. Yet research into public health interventions is fundamentally lacking. Is it time.for a new funding stream and research body into public health?

Commissioning matters

Whether you are a clinician or a manager, political rhetoric will have offered some new ingredients. Strip out the arguments of plural providers from the voluntary or independent sector and place to one side your views on whether the NHS is a purchaser of goods (market driven) or people (personnel driven). The answer to all these conundrums at the heart of the NHS is good commissioning.

The current political and leadership contests detract from the importance of conducting local assessments, co-ordinating services, managing information and seeking patient engagement. Good commissioning that encompasses all disciplines, public health and local authorities is patchy. It does not come from individuals but from organisations. It can be partially purchased but instilling it takes time.

We need to put the fundamentals right now or the NHS is going to need a very big chequebook - even bigger than now.