NEWS FOCUS: It is easy to dismiss Labour's manifesto pledges on health as all too familiar. But beware - they contain more than meets the eye, says Maura Thompson

Labour's election manifesto may at first glance throw up little new in terms of its pledges on health - 10,000 more doctors, 20,000 more nurses, health spending to increase in real terms by 6 per cent, maximum waits for outpatient appointments of three months. . . been there, heard that.

With promises built very firmly on the foundations of the NHS plan, the pragmatic document contains few shocks.

And yet the thinking behind what look like throwaway lines in the 44-page manifesto makes it very clear that Labour is staking out the centre-middle ground in preparation for a second term.

Indeed, as one source close to the party puts it: 'There are no throwaway lines in this document - the thinking behind it is very clear. '

That big-tent approach already apparent would become even more transparent during another Labour term, and the implications for the NHS are very clear - we love our public services, we want everyone in our NHS family to be happy and do a good job.

But if you do not like our approach and you do not do things in the way we want, then There is a price to pay. Tough but caring, firm but fair.

And so, according to HSJ sources, a new Labour government would quickly introduce legislation to deal with two of the thornier issues - community health councils and the soaring costs of clinical negligence.

As one source says: 'Time was running out before, but CHCs will be replaced - as it stands there are two different bodies with the same rights in terms of things like referral to the secretary of state. '

With a new patient body established and patient forums on statute, Labour is determined CHCs will go. Sources are privately surprised that the Association of Community Health Councils for England and Wales didn't play a smarter hand in the dying days of the last parliament when Lords amendments would have granted concessions.

'There were lots of people who thought 'this is as good as it gets' but they let it go, and what you get at the end of a parliament is very different to what you get at the beginning, ' the source warns.

The manifesto promises a 'review of the clinical negligence system' - which would not necessarily mean consideration of a no-fault compensation scheme, despite its appeal in some quarters.

Government sources, as well as managers, are frustrated that such a high proportion of NHS money currently ends up with lawyers, and are planning a green or white paper early in a new parliament.

There is a clear consensus that ways have to be found to protect the NHS from the escalating cost of claims and to give trusts some element of control over it. One option may be to set a tariff for particular circumstances so that the NHS pays out if there is clear evidence that negligence has occurred.

One other element the Labour government has been concerned about is the apparent 'double payment' - lump-sum awards are made to victims of medical negligence as if they will receive future treatment from the private sector, but they then receive ongoing care from the NHS, so It is as if the NHS is paying out twice.

A flying start for managers?

The manifesto says repeatedly that failing hospitals could be taken over by successful ones. Yet this will not mean one trust assuming responsibility for running another, a source says.

'It doesn't mean you get rid of one management team and bring in a management team of another hospital, but good managers have got to be able to spread their expertise. '

Rather, the idea is to use the pool of management talent in the NHS to help improve standards. One scenario is to have whole management teams which can review and improve problems - a kind of flying squad rather than hit squad.

The idea is still to have management peers help improve problem services in that developmental way the Modernisation Agency has championed, but also to create more flexibility across NHS management.

This would also create 'structural'opportunities for innovative and talented managers who do not want to move jobs but who can share their expertise.

Health secretary Alan Milburn, who looks a safe bet to stay in the role to continue the work he started, has described it as 'franchising the NHS'.

A cautious concordat?

Media speculation on Labour's second term has paid a great deal of attention to its plans to move ever closer to the private sector. One brief and apparently rather vague line in the manifesto says that a Labour government would 'seek ways'to ensure that staff working under public-private partnership arrangements could remain within the NHS.

One source argues that the wording was in fact 'quite precise'and acknowledges that while that is 'not a guarantee', there is a belief that avenues will be found to make sure staff stay part of the public sector.

In the week when Unison finally threw in the towel in Dudley, it is clear that Millbank policy is based on an assumption that the principle of PPP has now been established and accepted in the NHS. The task is to make it work as best it can and to get down to the nitty-gritty of negotiating arrangements such as staff employment issues.

The new fast-track surgical units Labour envisages would be very much along the lines of the original ambulatory care and diagnostic centre at London's Central Middlesex Hospital - units linked to existing services in the NHS which are undergoing development or refurbishment, or making use of private-sector spare capacity to carry out all planned procedures.

Behind the scenes there are suggestions that the private sector may have over-estimated its future role in running 'failing'hospitals. 'The voices off have said It is about private-sector management taking over failing bits of the NHS, but It is not - It is about using NHS talent, 'says a source, adding that when some private providers struggle with running routine services in a 100-bed unit, there is no question they will be brought in to run an accident and emergency unit.

Such reassurances may be needed, for concern about the scale of potential private-sector involvement in a second term has been widespread. The King's Fund warns that evidence from the US shows privately managed services are no more efficient than publicly managed ones and that private-sector involvement could produce only 'marginal change'.

Supporting the idea of investment in - and freedom for NHS managers to pioneer - service improvement, a spokesperson warns that 'use of private management teams. . . risks the Balkanisation of the health service'.

A decade of change The NHS has moved a long way since 1997. The manifesto gives a glimpse of how very New Labour it could become in another four years. The staff numbers promised in Labour's manifesto are the same as those outlined in the NHS plan but the base is higher because it begins and ends a year later. Now the timetable for having an extra 10,000 doctors and 20,000 nurses has been moved forward to 2005. For GPs, personal medical services will remain locally agreed - so whatever happens with the British Medical Association's ballot of GPs Labour is confident many individual GPs will opt to negotiate local contracts.