While politicians are fighting on the campaign trail they will not reveal how they intend to drive up productivity. But once reality is restored the pain will begin

The two main political parties assure us NHS funding will be ringfenced. At the same time, back of the envelope scribbles from McKinsey are being used by the Department of Health to insist £15bn-£20bn must be “saved” and recycled to meet increased patient demand and technological advances. The future of the NHS looks “interesting”.

Both Labour and the Conservatives need to come clean. Pay standstills may not be enough to hold the NHS together

Labour is obsessed by the post-Darzi drive for “quality” and increased productivity. But what does this mean? Is the focus of this frenzy increased output of widgets, which may or may not improve patient health? Or is it the production of improved patient outcomes? The confused language is likely to lead to the production of more output that does little to improve patient health.

Productivity can be increased within a static budget by improving outcomes with fewer staff and by cutting the price of staff. Neither Labour nor the Conservatives are prepared to discuss the latter policy systematically.

The Conservatives advocate “competition”, which involves creating uncertainty about job tenure in the belief that this will lead to innovation and increased productivity. Labour also appear to like this idea now the concept of the NHS as preferred provider seems to have disappeared.

Unless pay and pensions policy is radically reformed competition won’t work. This is because privatisation means staff are “TUPEd” across, maintaining NHS pay and pensions, and this may not be affordable after the election. How then can the use of the third sector or private enterprise be more efficient?

Both Labour and the Conservatives need to come clean. Pay standstills may not be enough to hold the NHS together in the next five years. Will these vote-maximising politicians break down existing collective agreements, cut real wages of the better paid by, say, 5 per cent and cap pensionable income at £100,000? Will they reform or abolish inefficient policies such as clinical excellence awards? These are policy debates which both political parties will do their best to avoid during the Tom and Jerry election antics.

Complex alternatives

An alternative to pay and pensions controls is redundancy. But can patient care be maintained with fewer staff or changes in skill mix? The answer to this is complex. Expensive GPs replaced by nurse practitioners, for example? Double GP list sizes and reduce the demand for such physicians by half? Expensive registered nurses could be replaced

by assistant practitioners. Evidence suggests skill mix changes such as these could be cost effective.

However, the potential for skill mix is limited by the power of the craft guilds, especially the royal colleges. The errors of Alan Milburn and other recent health secretaries have cursed skill mix changes. As a result of their increasing medical school intake we have 6,000 new medical graduates being produced and only 3,000 practitioners retiring annually. Medical graduates, their articulate middle class parents, the trade unions and royal colleges to which they belong expect to be kept in the style to which they are accustomed.

The intellectually challenged media regards unemployed doctors as a heinous crime. But giving them NHS jobs limits the skill mix changes which may be necessary if the NHS is to survive.

The number of nurses qualifying compares well with those retiring. However, making all new registered nurses graduates raises the expectation that they too will be offered job guarantees. Have either Labour or the Conservatives the courage to say to medical and nursing students: train at your own risk because a guarantee of an NHS job is not an option? Even if such declarations come, will the politicians deliver evidence based skill mix changes? History is not encouraging.

Labour, the Conservatives and the Liberal Democrats will strive to avoid fundamental issues such as these during the election campaign. They will emphasise public health and prevention while doing their best to gloss over the fact that the most efficient policies in these areas require penalising the alcohol, tobacco and soft drinks industries which rot livers, create cancers and condemn the young to avoidable obesity and diabetes.

The competing parties will avoid too radical an approach to “redisorganising” structures even though “world class commissioning” is nonsense and primary care trusts and hospitals will be merged rapidly, regardless of which party gains power. Honesty in this and other important areas before 6 May will bring redundancies and cost votes.

So stand by for an “interesting ride”, whether or not the NHS as we need it is to survive.

NHS pay: will you dare to lead by example?