The report by consultancy McKinsey revealed in this week’s HSJ spells out the pain of cuts and change the NHS needs to endure to find £20bn of savings.

The report is a prosaic summary of the tough choices needed to get the healthcare system through the financial storm.

The management challenges it throws up are extreme, not least stripping out around 137,000 jobs. It paints a picture of an NHS in which senior hospital managers will be held to account for unacceptable variations in performance measures such as staff productivity and readmission rates.

They have given the DH a mass of data and options; it is now up to ministers and the NHS leadership to transform it into a policy

The dry numbers and analysis imply wide ranging criticism of management and clinical practice - facilities lying unused, overstaffing, patients having operations they do not need.

Its recommendations are tough and direct.

For example, the report rightly calls for swift action to cut the number of medical school places to prevent a looming glut of medical graduates. Timely and effective action like this will make a significant long term difference.

But it also recommends reviewing plans to increase staffing and investment for the national stroke strategy. While reviewing is always an option, it would be reckless to undermine the hard won improvements in stroke care, which was until recently a disgrace in many parts of the country. This is an example of where ministers and managers are in peril of resorting to old fashioned, ill thought through cuts which harm patients.

McKinsey claims up to £1.5bn is wasted on ineffective clinical interventions. Saving a significant slice of this would depend on presenting treatment choices to patients in ways that lead to fewer opting for surgery and other procedures. Hip replacements and hysterectomies are cited. But delivering this would depend on changing the incentives for hospitals to operate and changing the way doctors communicate with patients - both are controversial and difficult.

Overall, the NHS of 2014 will need to have fewer people going into hospital and staying fewer days, served by fewer, more efficient staff providing a better patient experience.

The consultants were not asked to provide a politically nuanced document. They have given the DH a mass of data and options; it is now up to ministers and the NHS leadership to transform it into a policy which manages to cut staff while achieving wider goals such as moving more care out of hospitals and continuing the quality drive.

All this has to happen in the run-up to the general election, when the urgent need for tough, fast reforms and cuts will be stymied by the short term political expediency of a government desperate to avoid a crushing defeat at the polls. For example, will Labour want to hand David Cameron the campaigning gift of cutting medical school places? If the government does not have the courage to go down this road then in five years there will either be unemployed medics minicabbing or too many doctors costing too much for doing too little.

Managers should not wait for ministers to tell them what to do. The most important changes will happen regionally and locally, not nationally. Local NHS leaders need to act as a counterweight to political inertia. Valuable months of preparation for the funding downturn must not be wasted.

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DH is told 137,000 NHS posts must go in next five years