New health secretary Andy Burnham’s second stint in the Department of Health is, like the first, defined by financial crisis.
Three years ago the then junior minister was grappling with deficits - “knee deep in turnaround” as he graphically describes it in his interview with HSJ this week.
He calls for the lessons learned during those tough months to be remembered as we head into the new storm. But that should not be read as encouragement to react in the same way.
Last time, short term crisis management led to ward closures and rushed staff cuts. This time, with months of warning before the cuts start to bite, Mr Burnham is positioning the Darzi reforms squarely in the context of delivering sharp improvements in productivity and efficiency.
Despite the straits the government is in Mr Burnham’s tone was upbeat. For example, he stressed the progress primary care trusts had made on innovative approaches to improving public health since he was last in the department.
But he let slip the risk the NHS faces as it takes the pain of spiralling public sector debt - admitting that his arguments with the Treasury in coming months would stress the danger of reversing the huge gains the service has made under Labour governments. Presumably every other Whitehall department will be pleading the same.
There can be few experiences more frustrating than having the ostensible power of a Cabinet minister, but compelled to wield it in the dying months of a collapsing government which is running out of money. Little can be achieved beyond the grubby business of trying to claw back votes.
Mr Burnham at least has the luxury of steering the Health Bill through Parliament, at a time when MPs are debating little of substance apart from their own avarice. It was he who recommended a constitution for the NHS last time he was in the DH. As well as getting the legislation right he now has the chance to encourage patient advocacy groups and others to use it as a vehicle to drive service improvement.
Resuscitating the debate around the future of social care should be a priority for him. It is central to the financial and social challenges facing us over the coming decades, and will be a key determinant of the ability of the care system to manage demand for hospital beds, but DH hyperbole last year about bold decisions over social care policy has come to little.
The DH says the long overdue social care green paper will finally dribble out before July, months late and more than three years after Derek Wanless exposed the choices facing us about our old age. The Health Bill legislates for personal budgets; these are a trivial detail which will do virtually nothing to address the big issues. The green paper needs to be followed by policy proposals which are up to the task. Mr Burnham has the chance to ensure Labour’s social care legacy is not years of dithering over hard choices.
In a report published for its annual conference this week the NHS Confederation has offered him another opportunity to make a difference. It has highlighted the stupidity and futility of a regulatory system where 47 core standards related to recruitment, training and skills are monitored by 25 separate bodies, but which still fails to prevent hundreds of deaths in scandals such as Mid Staffordshire. Making a determined effort to give management and clinicians the space to focus the NHS on what matters to patients without the distraction of duplication and pointless controls would be a legacy worth leaving.