With the rate of investment expected to slow down from 2008, it is vital to use resources to extract maximum value from the NHS. Adrian O'Dowd investigates

The future good financial health of the NHS is certain to preoccupy many minds at the party conferences. The stakes are high: a massive£83.8bn will be spent on the NHS this financial year and the subject of deficits, as well as thousands of redundancies around the country, have seldom left the news headlines in the past 12 months.

Health secretary Patricia Hewitt has said patients and the general public focus on quality of care, but the use of resources in healthcare organisations is absolutely critical to that. So just how healthy a financial future does the NHS have?

Value for money is a key question in the Health Hotel fringe events, and Healthcare Commission chief executive Anna Walker is leading on the debate about whether we get what we pay for in the NHS.

'The huge investment that the Labour government has put into the NHS has clearly paid off in the sense that there have been some very significant improvements, particularly capacity and access and also the better treatment and handling of the big killers - coronary heart disease, cancer and stroke,' she says.

'But what our work also shows is that there remain what we call Cinderella services - mental health, learning disabilities and care of older people.'

There are also divergent views between patients and the public. 'The patient survey views are surprisingly positive and over a period of time they show improvements,' says Ms Walker. 'I think the public are unsettled by issues about NHS financial deficits.'

Doing it better

The annual assessments carried out by the commission show huge variance in the performance of healthcare organisations. Ms Walker says this must be used to drive up standards.

'Assessment and regulation can identify best practice and encourage those who are performing least well to learn from those who are performing better. That is one way we can get genuinely better value for money out of our NHS,' she says.

'It is because of the significance of that value for money that this year for the first time our annual health check will have a rating for use of resources and quality of care. We want to drive home the message that both matter and neither can be sacrificed. We are saying how you use your resources matters hugely on behalf of the patients.'

Another debate - is the NHS in its prime or past its time? - will feature Dr Jonathan Fielden, deputy chair of the British Medical Association's central consultants and specialists committee, who believes that while it is not past its prime, there is a lot of room for improvement.

'The NHS's ability to provide healthcare free at the point of need equitably and pretty much universally is admired throughout the world,' says Dr Fielden.

'However, that value and purpose need to be maintained. We are in a process of change at the moment. What isn't happening properly is a wide public debate on the involvement or otherwise of private sector in healthcare. We have a government which feels, whether there is good evidence or not, that bringing in the private sector is good.'

Dr Fielden believes in the need for two fundamental debates: what is the NHS for and how much does it provide? And also whether market-based health reform is correct or not.

Dr Fielden says the NHS has improved significantly since Labour came to power, but fundamental problems persist. Most of those problems, he believes, are rooted in forced change in the health service that is not properly integrated with existing services and around which staff are not engaged or enthusiastic.

'There is either an inability or lack of desire to involve clinicians across the board properly in healthcare policy. That is beginning to change, however,' he says, 'We have some more pain to go through. Between now and 2008-09 when the Treasury will cease the extra investment into the NHS, we have to have a much leaner health service and the inevitable consequence of that will be service reconfiguration and some closures.'

For NHS Confederation chief executive Dr Gill Morgan there is no debate: 'The NHS is still in its prime and its underlying values - to make sure that all people, irrespective of wealth, get access to first-rate health services - are still important to us.

'The issue is how do we increase its reputation, and what do we have to do to make sure it remains in its prime?'

Dr Morgan says the past year has been hard but that, as in any organisation, there are 'years of plenty' and others that are more challenging.

'Without doubt, we in a very difficult period,' she adds. 'It is extremely challenging for the system to deliver all the aspirations with the resources available. That is why one of the things the NHS needs to do for the future is to be much clearer about what packagese we offer, what the priorities are.'

Talk of priorities is something that troubles Unison head of health Karen Jennings, who is involved in a Health Hotel event entitled 'Decision Impossible: choosing between funding drugs, patients or NHS staff'.

'We are increasingly being told we can't afford the NHS and at some point we are going to have to make choices about what we can and cannot afford and whether there needs to be co-payment,' says Ms Jennings. 'This is all part of a master plan about marketisation and co-payments and preparing people for a very different future.

'My argument is that a health service, properly funded, is affordable. It's possible to choose all three [drugs, patients and NHS staff] if you take a very clear, honest approach to what is the most effective way to provide healthcare.'

Ms Jennings believes NHS debts are 'solvable' and that it is targets for resolving them, rather than financial pressures themselves, that are at the heart of money problems.

'The target to make those trusts that are in debt resolve those debts quickly has created a crisis of confidence in the NHS. That is because of continuous announcements about redundancies and detrimental comments about managers and their inability to manage,' she says.

'We have to slow down the reforms, look at the direction of travel, start engaging staff and patients and allow them to influence the reforms. There can be a healthy financial future for the NHS, but the direction of travel we are going in at the moment means that won't be the case. There will be more competition and a lack of collaboration and trust.'

Sustaining success

Specific issues will also be debated at the Health Hotel events, including whether or not cancer is a 'ticked box'.

Cancer Research UK chief executive Professor Alex Markham believes huge strides have been made in improving cancer services, but it is still not a case of job done.

'The NHS cancer plan has been massively successful in transforming cancer services in England, delivering impressive results in the areas it is targeting,' he says. 'In that sense, the NHS deserves a big tick for its commitment to improving cancer services. But no, cancer is not a ticked box.

In fact, a report commissioned by us from the King's Fund has called for a revised NHS cancer plan. The report makes it clear that an ageing population, the expense of developing and providing new treatments and meeting people's rising expectations of the NHS all mean that actually the challenge of cancer - and the opportunities to beat it - is growing, not shrinking.

'It is essential that ministers start considering now how to sustain progress so that NHS cancer services really are fit for purpose in the 21st century.

'I think the ultimate test has to be how effectively money is spent. As we know, the rate of increase in the NHS budget is expected to slow from 2008. That's why it's never been more important to plan ahead, so that the government extracts the maximum benefit from its investment'.