Andrew Jones on which way now?

The one prerequisite for health policy now must surely be consolidation. Many factors favour this, with a general election probably less than two years away (some commentators say it could be as early as.October), the comprehensive spending review due in the autumn and the fact that our 152 primary care trusts are yet to celebrate a first birthday.

I witnessed this plea for consolidation first-hand during the Conservative health policy review, where respondents were asked for their one big idea. The resounding answer from everyone, yes everyone, was: 'No big ideas please!' Step forward prime minister Brown, with the likeable appointment of Alan Johnson to the Department of Health - an undoubted safe pair of hands - and Lord Darzi to a junior health post.

All seemed well until it was decided to publish a piece of aspirational fiction entitled Healthcare for London: a framework for action shortly after announcing a review of the whole NHS, also by Lord Darzi. I assume in chess terms the ploy was to bewilder the electorate and most senior managers into second guessing the next steps. I have no hidden insights at this point, but then I am told the Brown team didn't have many either on taking the reins.

At this point I select two pieces of reading. The first is the Cabinet Office capability review published in June that places the DoH as the second worst-run office in Whitehall..That is no mean feat given the immovable Home Office in last place. In business terms, this is pretty worrying, with all of the leadership attributes in the red zone; serious concerns over direction; urgent development to ignite passion, pace and drive; development required in both responsibility and capability. Strategy faired little better - an urgent focus required on outcomes; urgent need to base choices on evidence and development to build a common purpose. In short, in a 10-point capability plan, near disaster is cited for the initial seven pointers for leadership and strategy.

In a piece of extraordinary optimism, the permanent secretary, chief executive and chief medical officer.replied: 'This capability review could not have been better timed for the DoH. It brings a valuable set of external insights to bear on the issues we knew we had to address as we built new leadership arrangements for the department and planned the next phase of our journey.'

Second selected reading is the Ipsos MORI ongoing poll of public attitudes to the NHS, which shows that although media coverage of the NHS continues to be.largely negative, 59 per cent of the public is still.satisfied with the running of the health service, in line with earlier waves.

However, optimism about the future of the NHS remains at its lowest level since 2000. This wave's findings show little change since the spring, and may signify a steadying of opinion, but the position is challenging. Asked whether the NHS will improve or get worse over the next few years, a quarter said it will improve (25 per cent now, compared to 23 per cent in spring 2006). The proportion who believe the NHS will get worse still exceeds the number predicting improvements - 39 per cent said it will get worse now, compared with 40 per cent in spring 2006.

The long-term financial security of the NHS is at a nadir and current policy confusion, further reviews and rationing are not helping. There is currently no single clear articulation of the way forward for the whole of the NHS, health and well-being agenda. It is impossible in these circumstances for commissioning or practice-based commissioning to mature. For many, patient engagement is the key tenet for success but I suspect a review of the Wanless work will show we are going backwards. Staff are unclear about the vision for health and social care and feel little sense of ownership of it.

So how do we move forward? The spending review will provide an important opportunity to secure future resources. Hopefully, the DoH will finalise an immediate leadership and strategic direction. But my prescription above all else is to create the next big NHS plan around health and well-being in an NHS system that champions public health and full patient engagement.