I spent a significant chunk of my Christmas break dealing with the 'here and now' while also reflecting on the harsh year we all face.

Challenges in the here and now arose from the wicked combination of handling winter pressures and managing 18 weeks targets while ensuring the hospital environment remained safe, clean and welcoming for patients.

Oh yes, and from making sure the reputation of my trust wasn't damaged by sensationalist headlines in the local media following a period of attrition when 40 emergency admissions in less than an hour were handled - expertly and with care - at one of our hospitals.

I was explaining all this to a friend from another industry when she asked: "Well isn't that what you are there for?"

"Yes, that's true, but there's much more to it than that!" I replied, privately feeling slightly miffed that she didn't appreciate the full breadth of my role.

Public expectations

But the more I thought about it the more I realised my friend was right. It was entirely what the public would expect from someone charged with managing local hospital services.

We all know that leading large organisations involves much more, but getting the day to day essentials right is the first test of a credible leadership.

Focusing on just the here and now is never enough; the effective leader also has to steer a course into the future.

Management guru Peter Drucker summarises this fundamental duality of leading and managing perfectly.

His research showed that the most successful executives do what needs to be done, expertly and swiftly, but are also able to devote much of their time to those things that are right for the enterprise, so preserving long term success.

Safe passage

Bearing these lessons in mind, what does this year hold when we have navigated a safe passage through the here and now, including overcoming the impact of the new payment by results tariff and the market forces factor, adjusted the balance sheet to take account of international financial reporting standards and secured our registration with the Care Quality Commission?

Whichever way you look at it there is no getting away from the fact that dealing with the impact of the credit crunch is going to be the biggest single issue we will all be facing this year, next year and probably the one after that.

NHS chief executive David Nicholson and his team have done a great job in securing such a good settlement for the health service. However, the next comprehensive spending review is just around the corner and it won't be pretty.

Mr Nicholson is rightly exhorting health service organisations to plan now for the long haul by making it clear short term solutions are not going to insulate the service from the battering the economy is inevitably going to receive.

Any self-respecting trust board should be preparing for the avalanche of efficiency savings that are going to be required to deliver the health service's contribution to bolstering the wider economic environment.

Lessons ahead

Many people have not experienced previous recessions - and this one looks as though it might be the worst yet - but the lessons are there. Minimise waste, market test services, reduce management costs and other corporate overheads, reduce staff costs, constrain pay, dispose of surplus assets and use estate efficiently.

It goes without saying that this has to be done while delivering the high quality care that patients rightly expect, but in future we will have to do it with less or at the very least with the same resources.

Yet I am sure I am not alone in thinking that the above measures will not in themselves be enough. After all, are these not the things we have been doing for the last decade?

With the vast majority of costs tied up in frontline clinical services, the route to long term success has to lie in the ability of commissioning and provider organisations - both individually and in partnership - to foster a transformation in the way that services are delivered and developed.

The touchstones for providers will be visionary clinical leadership, eradicating artificial organisational boundaries by remodelling services on patient pathways, integrating primary and secondary care services and focusing on improving quality by minimising waste and reducing errors.

Breaking ground

Commissioners will need to focus on creating groundbreaking service specifications, obtaining value for taxpayers' money and placing contracts with those providers that have the credentials for delivering leading edge services.

Taking a steer from recent events, it is vital this is done in active partnership with patients and communities.

One lesson from the banking crisis is that the focus on the customer was lost. Now, more than ever, public services can set an example by making sure the goodwill of patients and staff is not lost in these times of financial stringencies.

But it is a racing certainty that the public sector and its leaders will be under intense scrutiny from the media, especially in a year in which pay cuts and freezes are looming for millions of workers in the private sector.

Already some workers are accepting a reduction in their pay packets in order to hold on to their jobs. These taxpayers and others will be calling for the public sector to bear some of the pain and this sentiment is likely to grow as 2009 proceeds.

So we will be expected to deliver in the here and now and to the highest possible standards because that is what we are here for.

But woe betide anyone who lacks focus on the bigger picture.