Professor Alan Maynard argues for equitable distribution of recessionary pain, warning that those in well-paid jobs, including doctors, will not be immune from attention

The rate of exchange of the UK pound for the euro and US dollar has declined by thirty per cent. This is increasing the cost of imports to the healthcare sector - and the cost of living, as imported staples such as tea, coffee and sugar increase in price.

World trade is shrinking at a rate not experienced for many decades bringing with it covert protectionism in the form of subsidies to, for instance, ailing car firms worldwide. Optimists hope that there are signs of the recession bottoming out.

Even if this is so in the international context, some countries face very great difficulties and one of those countries is the UK. The dependence on international finance brought with it welcome tax flows to the Treasury. These have shrunk as the banks have tottered towards bankruptcy, and had to be bailed out by government.

The impact of this has been sharply reduced tax revenues and a sharp escalation in government indebtedness.

2010 – a good election to lose?
For a tired and increasingly error-prone government, the prospect of winning an election is quite mixed: they wish to cling to power but wiping up the mess created by Thatcher-Blair inefficiency will be a daunting prospect.

For the Opposition, power will bring with it the happy prospect of blaming their predecessors but the unhappy task of cutting public expenditure and raising taxes.

Campaigning in poetry, governing in deficit
These stark facts have had muted impact on the NHS as yet. The current Secretary of State is fighting hard to maintain some growth in NHS funding post-the 2010 election. His case is strengthened by current Conservative pledges to be protective to the NHS if elected. It seems that both parties will seek to protect the NHS after the 2010 election.

Implementing such pledges may not be so easy, as budget deficits grow and international pressure on currency markets obliges the government to bear down hard on the public sector. How can government make ends meet?

A primary target will be pay. Seventy per cent of NHS costs are pay, with nurses’ pay consuming over 35 per cent of most hospitals’ budgets. Thus a first step will be to offer zero pay increases, thereby reducing real wages as food and other items continue to increase in price.

Blessed are the poor in spirit
A second target may be “high earners”, which currently might be interpreted as the remuneration of senior managers. The Daily Mail will no doubt love to campaign for their salaries to be decreased!

However there is another group of high-earners who may not be able to avoid the limelight: doctors.

“What happens in a hospital is a product of what doctors and other clinicians do and don’t do for patients”

Whenever there is a ‘scandal’ in the NHS, it is highly-paid managers who feel the heat, being suspended and sacked with media persecution. Yet what happens in a hospital is a product of what doctors and other clinicians do and don’t do for patients.

Shooting the managers when crisis strikes, as in Mid Staffordshire, ignores the real issue behind poor-quality patient care. Such unacceptable care is the end-product of clinical choices to turn a blind eye to poor practice by colleagues.

It is the doctors who decide what care is given to patients, and it is the doctors who observe sins of omission. That they fail to act corporately to protect the patient offers a nice prima facie case for calling them to account and rewarding failures with pay cuts, pension reduction and dismissal.

It is likely that in a time of economic difficulty, such actions will be used to encourage improved practice. Hopefully, such sticks will be used with care. But perhaps a few well-publicised and well-evidenced cases will improve patient care far more that ten Darzi reports per year.

However such policies are used, the pay of high earners in the NHS - be they managers or clinicians - is likely to come under intense pressure as the government seeks not just cost cuts but also equitable distribution of pain.

Waiting for integration

” If reform is not put in place locally, the NHS may buckle and fragment “

But where else will “efficiency savings” come from? Hospital beds will have to be closed, but then patient demand will only be met if patient flow is transformed by integration of NHS, local authority and private sector home cares – integration which remains noticeable by its absence at present.

The challenges are enormous and urgent. Thinking “outside the box” to remedy well-recognised NHS problems is needed urgently. If reform is not put in place locally, the NHS may buckle and fragment.

The economic recession offers a welcome stimulus to long-required change. All patients hope that that change will be implemented in a timely and urgent manner, starting now.