An SNP victory in next week's Scottish elections would take a hatchet to a host of Labour's NHS reforms north of the border, writes Jennifer Trueland
Few managers would deny that reconfiguring services can be a bruising business, both professionally and personally.
So imagine getting to the point where decisions have been signed off, then being told that it's not going to happen after all. This is the scenario facing managers in Scotland, should the Scottish National Party win the Scottish Parliament elections on 3 May.
The SNP, which is leading in the polls, has promised to reverse decisions to close two accident and emergency departments and to introduce a 'presumption against' centralising core hospital services.
In health policy terms, there are few major differences between Labour and the SNP. Both manifestos propose shorter waiting times, although with different methodologies to achieve this. Both want an emphasis on public health. but it's the centralisation issue that sets them apart.
During the last parliament, all parties in Scotland signed up, in principle, to the National Framework for Service Change, better known as the Kerr Report. There was also support for the Scottish Executive's response, Delivering for Health. Both make it clear that some degree of reconfiguration is inevitable, although they want healthcare to be as local as possible - and this is the path Labour is still following.
'The SNP has taken a populist line on saving accident and emergency departments,' says Institute for Public Policy Research senior research fellow Joe Farrington-Douglas.
'But whether they will be able to end reconfiguration, taking into account clinical and financial drivers, remains to be seen, especially if there's less money about.'
This May's election could lead to uncharted territory, not just for Scotland but for the UK as a whole. After years as the main party of opposition, the SNP is poised to take the largest number of seats, although it is unlikely to win an overall majority.
If that is the case, there will probably be a referendum on independence at some point - although the SNP manifesto doesn't trumpet this too loudly, presumably aware that most Scots do not want to leave the United Kingdom.
Independence would, of course, give even greater powers to the Scottish Parliament as it would take over responsibility for health matters currently reserved for Westminster, such as abortion law.
But even without independence, an SNP victory would be a test of devolution because, for the first time, there would be different administrations at Westminster and Holyrood. Although SNP leader Alex Salmond has said Scotland and England would be 'best of pals', there would undoubtedly be clashes as the nationalists fought their corner in negotiations with the Treasury or the Department of Work and Pensions.
The same scenario, incidentally, could result following the next Westminster elections if David Cameron's Conservatives form the government. If one thing is certain, it is that the Tories will not win in Scotland, which would again mean administrations from different parties.
Mr Farrington-Douglas believes there are challenges ahead for the Scottish NHS, whoever wins the election. 'I think we could see a new debate on funding. The comprehensive spending review will be decided in London by Gordon Brown or whoever is chancellor. Nobody seems to doubt it will be a tight settlement that will have an impact on the Scottish NHS.
'Until now the Scottish Executive hasn't been complaining that they've not been given enough money, but if there is lower spending as a result of the spending review then the SNP, if they win in May, could complain that the NHS in Scotland is underfunded because of decisions taken by the chancellor in London.'
The potential for both Westminster and Holyrood to play a blame game would also rise with different parties in control.
'And it could work the other way as well,' says Mr Farrington-Douglas. 'Health spending is historically higher per capita in Scotland but if people in England see that Scotland isn't having reconfiguration, while England is, there might be a feeling that the money should be cut.'
Devolution has already led to divergence, with Scotland rejecting England's more market-led model for health services, preferring a partnership approach.
An SNP victory could, however, have implications for private finance deals, although again it's not clear how this would work in practice. The party has long been loud in its condemnation of private finance initiatives and public-private partnership deals - leading some campaigners to hope that it might be abolished should they come to power. The manifesto is much softer, saying instead that public bodies would be allowed to choose how projects should be funded and that it would introduce not-for-profit trusts to 'crowd out' PFI and PPP.
Professor Allyson Pollock, head of Edinburgh University's centre for international public health policy and a leading critic of PFI, hopes the election will provide an opportunity to take stock. 'Servicing PFI debt is already having a financial impact in Lanarkshire and Lothian and there are big plans for PFI projects elsewhere in Scotland.'
Workforce issues have also been treated differently. For example, the Scottish Executive broke with the UK to give healthcare workers this year's pay award in full, and has announced a more generous resolution to junior doctors applying for specialist training under Modernising Medical Careers. But BMA Scotland chair Dr Peter Terry calls this 'small-scale stuff'.
'The big differences are that the NHS in England is performance managed, usually through financial systems, while the health service in Scotland is run much more on partnership. I'd hope that consensus building would continue whoever is in power.'
Potentially the most interesting manifesto comes from the Liberal Democrats. Although extremely unlikely to win the most seats, the party could well form part of the ruling administration if a coalition is formed after the election.
As Labour's coalition partners in the first two sessions of the Scottish Parliament, the Liberal Democrats were highly successful in achieving on key commitments. It was the Liberal Democrats who pushed free eye and dental checks for all, and they were prime movers behind the decision to fund free personal care for the elderly.
There are no real blockbuster headline grabbers like that in their manifesto this time, but there are some pretty serious commitments. These include 200 extra dentists, 2,000 extra nurses and 100 new and refurbished local health centres. They also want to see a new waiting-time guarantee setting out maximum waits for access to primary care (one day), for a full consultation with a GP (five days), for diagnostic tests (90 days) and treatment (a further 90 days).
In 2003 the Liberal Democrats won a reputation for hard bargaining when the programme for government was hammered out with Labour. It's unlikely to be different this time.
So what will happen come May 4, if we have an SNP-led government?
Will Alex Salmond be fairy godfather to those ardent local campaigners and reverse decisions to close the A&E departments in Ayr and Monklands in Lanarkshire? In the latter case he would be an unlikely bedfellow of home secretary John Reid, who campaigned to keep his local A&E open.
Mr Farrington-Douglas believes there will be challenges. 'The idea of devolution was always to try out a variety of different models in different countries then share experience of what has worked well and what hasn't,' he says. 'So far there's been a lot of diversity but not much sharing. I think if we have administrations of different colours there will be even more difference but less sharing. It might mean that the health services will have to do the work themselves on that with managers north and south of the border making sure they talk to each other and collaborate on learning and experience.'
Whatever happens in the future, Dr Terry is optimistic. 'Clearly if there are different parties in power north and south of the border England could make things difficult for Scotland, but I see opportunities. If at a strategic level they are mired in constitutional matters then maybe we on the ground can just get on with running the NHS.'
The Welsh perspective
If Labour wins control in Wales next week, health service managers can look forward to increased scrutiny - and a 'get tough' approach to costs.
In its manifesto, the party has promised to commission an independent analysis of managerial capacity and administrative costs in the Welsh NHS and use its findings to underpin a drive to move as much money as possible into frontline services.
This pledge took on more resonance as the campaign unfolded. Last week, for example, research from BBC Wales was forecasting a£33m NHS overspend for the last 12 months, added to historical debts of£84m.
It's unlikely, however, that Labour will win overall control. Indeed, if the polls are to be believed, they'll be struggling to be the biggest party in the next Welsh Assembly.
The most likely outcome is a coalition government, but there is no certainty about how it would be formed. Labour and the Liberal Democrats would be the most likely partnership, but there could be a three-way coalition between Plaid Cymru, the Liberal Democrats and the Conservatives. So the manifesto pledges will presumably form the basis of much argy-bargy and deal-making after May 4.
This is likely to have an impact on health services. The Conservatives, for example, are likely to cling to their key policy of replacing the existing 22 local health boards with an all-Wales commissioning body to develop secondary and tertiary services.
The Lib Dems want to bring healthcare and well-being services together through 'health hubs' and introduce nurse-led walk-in centres.
Plaid wants to stop current proposed closures to hospitals and services and require LHBs and local authorities to share budgets to cut bed-blocking.
But perhaps all should take heed of Labour, which wants services to be based on co-operation, not competition, something they will have to remember in coalition government.