Will London's new mayor be able to do anything more substantive than meddle in the health arena - and how will managers cope with a new arrival on the political scene? Patrick Butler reports

I would like to see what happens the first time a chief executive invites Ken to come and open something in their hospital, ' says one London NHS manager mischievously.

'I'm sure a dim view would be taken in Richmond House of allowing Ken to be seen doing NHS good works.'

Ken Livingstone had barely settled into his London mayoral offices in Romney House, Westminster last Friday before the health service was buzzing with the potentially fraught implications of his triumphal election.

The etiquette of handling VIP visits from the People's Mayor is the least of the London NHS manager's worries. A greater concern is that the health service will be caught in the crossfire between the mayor and the government if, as some suspect, Mr Livingstone uses his position to attack New Labour.

Formally, the mayor has no control over health policy or its management in the capital. Mr Livingstone has shown almost no major interest in NHS matters other than routine local issues - such as ward closures and patient complaints - encountered in his Brent East parliamentary constituency. But the NHS is unlikely to escape his scrutiny.

'It's not so much what he has in his mind policy-wise; it is what he might choose to say about the NHS. It's no skin off the mayor's nose to lambast hospitals, ' says one London hospital senior manager.

Recently, Mr Livingstone has dropped hints about where he stands on health policy. At a speech at St Thomas' Hospital in March he claimed there would have been fewer cuts and closures if a mayor had responsibility for the NHS in London.

In the HSJ mayoral debate in April, he made it clear he felt that London was 'losing out' to the home counties in terms of funding. 'Now we have a London region and I think that should eventually come under the control of the mayor and Assembly.'

Mr Livingstone has no jurisdiction over funding allocations, or health service reconfiguration. But the mayor is allowed to 'appoint advisers on health issues if he or she wishes', in order to further the attempts to 'promote the improvement of Londoners' health'.

That could produce some interesting - and for London region, possibly uncomfortable - results.

Says one manager: 'He could take a philosophical look at the nature of healthcare - that may simply repeat the findings of other reports, but from a different perspective.

'But if he were to take a hard look at the deal London gets in relation to the rest of the country in areas such as GP access, beds per capita, funding and so on, he could be onto a real winner.'

Nigel Crisp, director of London regional office, says mayoral interest in health issues is welcome. But he adds: 'We hope that interest will be focused on fundamental issues such as public health and health inequalities rather than the NHS.'

Mr Livingstone will inevitably be drawn on health policy issues simply because as mayor he will be expected to reflect public concern. 'If someone of Ken's flair for communication were to combine with the London Evening Standard, it could make things very, very difficult for NHS managers, ' says health policy analyst Ray Rowden.

Issues such as the effects on health of transport policy will undoubtedly be on the mayoral agenda. He may back 'soft' health policy issues such as low cost housing for nurses. Private finance initiative hospitals, intensive care unit beds and winter crises will also attract mayoral comment.

The Greater London Authority 'will need to work in partnership with others to secure improvements in the health of Londoners and to reduce health inequalities in London'. It has separate powers to 'investigate specific health issues' if it wishes. It may well decide to set up a health committee.

GLA members such as Lord Harris, former director of the Association of Community Health Councils for England and Wales, could have an influential role.

The complicated political arithmetic of the Authority could also bring an interesting mix of perspectives to the debate. Labour and the Conservatives are neck and neck with nine seats each, while four Liberal Democrats and three Greens hold the balance of power.

Chief executives will have to negotiate the tricky path of working with a high profile mayor who is outside the tight lines of managerial accountability running from trusts and health authorities to London region and Richmond House. Avoiding the mayor - and the Authority - is not an option.

'I would be wanting to know GLA members on a personal level, would want them to come into my organisation and understand the issues as soon as possible, ' says Mr Rowden. 'If you look at Scotland and Wales, the smart managers are building those relationships now. It won't make a shred of difference what formal powers the GLA has. The public will write to their GLA members and the mayor about health issues, and they will take an interest.'

Mr Livingstone has some experience of the NHS from the inside. He worked as a research technician at the Chester Beatty Cancer Research Institute at the Royal Marsden Hospital for eight years from 1962. As a Greater London councillor in the early 1970s he had a spell as an area health authority member.

While an MP in the late 1980s he was active in local campaigns to save Neasden Hospital and to retain accident and emergency services at the Central Middlesex Hospital. He spoke out against proposals to merge Brent and Harrow community health councils - the proposals were subsequently dropped.

Michael Young, chief officer of Brent community health council, says: 'As an MP he is particularly strong on patient complaints, and determined to make sure patients got a response to their concerns.

'He would come to CHC meetings, and supported us in lots of ways.'

The cuttings file is thick with bitter tributes to Mr Livingstone's skills in the political black arts of 'arm-twisting and leg breaking', his apparent People's mayor: one-time health technician with his finger on the pulse.

selfishness, untrustworthiness, and egomania.

But he comes to office with massive public support. He will be a new and fascinating challenge to NHS managers.

Friends and relations

London regional office director Nigel Crisp and his chair, Ian Mills, will be at the forefront of relations with the new mayor. The region has prepared briefings for the mayor and GLA members, and the first formal meeting with Mr Livingstone will take place on 3 June.

London regional director of public health Sue Atkinson, and head of health development Hilary Samson-Barry, will also have a key role.

Virginia Beardshaw (left), London regional director of strategy and communications, is responsible for 'relationships with the GLA and the mayor'. Ms Beardshaw was director of the King's Fund London initiative in the early 1990s.

London regional office's partners, such as the Association of London Authorities, the medical colleges and the King's Fund, will also be involved in briefings and talks.