Election

If Labour sweeps the polls today, there are interesting times ahead for the NHS - from the official end of postcode prescribing to innovatory use of staff; from dramatic cuts in HAs to a boost for the private sector.But what shape would the service be in by the end of a second term? Alison Moore looks into the future The year is 2005. Tony Blair, his hair now streaked with grey, has called an election, doubtless hoping that his son Euan's success with the latest chart-topping boy band will win over the youth vote. Health secretary Alan Milburn - topping the polls since he discussed his waistline battles on Kilroy - is facing John Humphrys on Radio 4's Today to defend the government's track record on the NHS.

But what will he have to say?

Almost certainly Mr Milburn will be able to point to massive changes in the NHS since Labour entered its second term in 2001. If the government pushes forward on all its manifesto promises and those already planned, we will see health authorities reduced in number to 30, regional offices abolished, the Department of Health shaken up - to say nothing of some pretty major changes in primary care, with primary care trusts established everywhere.

'It seems to me that we are not in for a period of stability, ' says NHS Confederation chief executive Stephen Thornton. 'The next session will see some turbulent times, particularly in relation to the medical profession. We have still not got a new consultant contract, we need a new GP contract and then There is personal medical services.'

The structural changes are unlikely to meet much opposition, although GPs may be outraged at being forced into PCTs after a government 'promise' that they would only go ahead where there was professional support.

And PCT amalgamations - especially if some are seen to be failing - will lead to accusations of distant bureaucracy and interference. Cynics may think this sounds awfully like GPs' relations with HAs.

Renegotiating contracts for both wings of the doctors may cause headaches, but nothing a newly elected government with a substantial majority can't handle.

What is likely to be more problematic is the continuing shortage of nurses and doctors. Although the government is increasing medical student numbers dramatically, it will take at least the next term to affect the situation on the ground. And attracting sufficient young men and women to become nurses will remain a difficult task.

So we are likely to see continuing influxes of nurses and doctors from abroad, and perhaps more attempts at using staff imaginatively to cover the gaps. Mr Thornton suggests this may happen in the new ambulatory care and diagnostic centres, especially if they are run by the private sector. Nurse anaesthetists and operations carried out by people other than qualified doctors (but under strict supervision) could be two areas of innovation.

But more doctors and nurses are also needed to relieve the pressure on existing ones, and improve morale. 'The assumption is that we need more doctors and nurses to treat more people but we actually need them so that the existing ones are not rushed off their feet, ' says Mr Thornton.

That is not just being nice to NHS staff - it is about coping with rising public expectations and patients' expectation of spending more time with their GP or nurse.

'The big unanswered question in all of this - for any government coming in - is that however successful they are at managing the health service, will public expectations have grown faster still?'

says Mr Thornton.

The Bristol Royal Infirmary inquiry report is due very shortly.

It could be out as soon as next month, and its conclusions will add to the picture of future regulation of the medical profession.

Tackling doctors on this issue will probably be an easier task for the new government than it would have been previously. But it is likely to run into trouble on the details of some of its proposals.

The plans for setting up a national patient safety agency, for example, have concerned many doctors. But at the end of a decade of horror stories about the medical profession, they may find it hard to put up an effective fight.

The chances of GPs resigning wholesale from the NHS seem remote, despite the British Medical Association's ballot.

The role of the private sector in providing 'contract' services to the NHS seems certain to increase, despite the qualms of many commentators. 'The issue seems to be whether private management will do better - and There is no evidence of that, ' says Alan Maynard, professor of health economics at York University.

'I think they are naive if they think the private sector is going to have the experience or even the capacity, ' warns David Hunter, professor of health policy and management at Durham University.

Certainly, Mr Milburn will have to tread carefully between his desire to carry out more operations (and rid future health secretaries of the spectre of waiting lists) and locking himself into a long, costly contract.

The Independent Healthcare Association has said the private sector could do 1 million operations for the NHS over the course of the next parliament - the most recent figures suggest it is currently doing about half that.

But will the government commit to putting that amount of business into the independent sector? Or will it try to use its facilities as and when needed, with no longterm deal? The second scenario would be cheaper but would not encourage independent providers to invest in new facilities.

Private providers have already shown a lot of interest in running the new ambulatory care centres.

But IHA executive director of public affairs Dr Tim Evans says they may prefer to use existing facilities rather than building afresh.

Ultimately, private healthcare operators will be calling on the same pool of doctors and nurses as the NHS. The NHS Confederation's fears about private sector involvement are therefore focused on potential staff poaching and whether private operators will be able to match or exceed NHS productivity. If they can't, then overall, fewer operations may be done.

Opposition from the unions is bound to mount, points out Steve Dewar, a fellow at the King's Fund.

'Some of the healthcare unions may have been hesitant about engaging in that debate at the time of the election, but may want to add their tuppence-worth later, ' he says. Anxiety about union reaction may be behind Labour's election pledge to look at ways in which staff in private finance initiative hospitals can remain within the NHS.

So what will the NHS look like in 2005?

IfLabour is successful, it will be beginning to deliver the kind of service envisaged in the NHS plan.

This will cost money. The threeyear NHS funding deal will be up for negotiation within the next two years. Continued, sustained investment is needed, Mr Thornton points out.

Almost certainly, more NHS work will be done in the private sector - although not without disputes with the unions on one side and the independent providers on the other.

By 2005, the NHS will also begin to look pretty standard across the country, with PCTs in control of three quarters of NHS spending but tightly constrained by national 'guidance'.

Postcode prescribing may have disappeared as PCTs are forced to adopt National Institute for Clinical Excellence guidance, but the flip side to this is that there is little leeway for individual PCTs to set their own priorities - although there may be more experimentation in how services are delivered.

There will be little cash left for PCTs' pet projects, once they have funded the growing number of national service frameworks, adopted NICE guidance and tried to hit other centrally determined targets.

Ironically, given the stress in the Labour manifesto on decentralisation, the NHS looks set to be more centrally run than ever.