Health Policy Insight welcomes back associate director Tom Smith, with this timely and thoughtful instalment of Health Policy Today considering the health secretary wannabe election debate

"Andy", "Norman" or "Andrew"? Which Health Secretary wannabe can make omelettes without breaking eggs?

The men who would be health secretary gripped adjacent lecterns on a stage at the King's Fund yesterday. It took place nine hours before the party leaders kicked off a debate with a much greater influence on the outcome of the election.

Yet what this debate lacked in influence it made up for in sparks between the individuals, being heavier on policy, and in Sue MacGregor, having a host who gathered difficult questions from a knowledgable audience.

Much agreement about healthcare
There were notable differences between the three - on the role the private sector should play in reform and on how public health should relate to the NHS - but what was much more interesting were things they agreed upon.

All three think the NHS budget should be protected. They agree the NHS will have to save money and improve productivity. They believe savings can be achieved and care revolutionised without effecting frontline jobs.

"Norman" Lamb will cut the quangos. "Andrew" Lansley will banish local bureaucracy. "Andy" Burnham will focus the NHS on prevention, tackle demand, and cut management costs. They will all get rid of ineffective management.

They were speaking in front of an expert audience who were given the chance to ask questions.

The head of the RCN asked about "future staffing levels and workforce numbers". "We saw 22,000 posts lost and training ended when the NHS last had a deficit crisis in 2006. Cutting jobs is often seen as the quickest way to save money so how can you guarantee to improve patient care in this financial crisis?"

Andy agreed with the questioner. The managers had made the wrong decisions in 2006 (oh, if only they'd told the government!). "I remember that the NHS, in places, did not handle the situation well and lost the confidence of staff at that time ... The handling, the management, of these issues is going to be crucial".

The health secretary seemed to suggest that Labour would handle the reforms better than the Conservatives would. Norman also remembered "all the wrong things were cut in 2006 - cuts to staff training, public health and mental health ... Our choice now is whether you slash and burn services and lose staff and training or alternatively redesign the way the money works in the NHS to make it more efficient."

Andrew said the Conservatives will increase the NHS budget in real terms but would save costs in back office administration.

Bye bye, unnecessary management
All three leaders said they would get rid of unnecessary management.

Hello, heated debate
Then, with exquisite timing, John Ashton, Director of Public Health in the north west, stood up and said he had seen a recent circular which noted that Directors of Public Health could be seen as senior managers NHS managers that could potentially be cut. Did the three think that was right?

"Listen", said Andy. "I can't mandate the public health head count from Whitehall ... I've said before we must not make the mistake of cutting public health resources. I've said that promoting physical activity should be the core business of the NHS. What more can I do? My challenge to you is for you to take these arguments to your PCT." Andy was suddenly interrupted ...

"Every day, every week", shouted John, the questioner. "I do that every day, every week" and it makes no difference".

Andrew stepped in and saw a chance to emphasise a difference from Andy. "As you will know, John, for five years I have said there should be a separate budget for NHS and for public health initiatives."

Heckled about where it would come from, Andy replied: "this would come from within the total envelope".

The next question asked, "doesn't your rhetoric on efficiency hide the fact there will be job losses?"

Norman said he "wouldn't protect the quangos related to the NHS ... We will cut the spending on qungos by a third ... We could cut the DH in half ... The critical thing is that you don't cut jobs that really matter".

Andrew felt "the question betrays the problem in the NHS ... We do need to improve efficiencies and in the private sector the idea of achieving 5% would be seen as standard but in the public sector people assume it means taking a percentage of services out ... We can use resources in improved ways ... We've had ten years of tiers of management and frankly it is going to have to change".

Andy said there wouldn't be any implications for jobs but "there are implications for pay". He also said some people might have to change the way they work: "we might ask people to work in different settings".

Peter Carter from the RCN said he was worrried specialist nurses would not be replaced when individuals retire. And then a student nurse asked, "when I qualify, will I have a good job?"

Andy said a good thing about the NHS is that it offers good job security (none of the nurses, managers or public health directors laughed). "I think we need more specialist nursing. We need to see them managing long-term conditions and this is the route to improved productivity in the NHS".

Andrew said, "all of us have been saying, if we can change the increase in management then there is no reason why we can't be talking about increased numbers of opportunities". Norman is "really concerned about mental health and that it will be a target for PCTs, because tariffs and targets don't apply to mental health. "If you reduced administration and management in trusts to 2005 levels you would save £800m.

'Understandably, they were keen to show they understood the NHS had to change to save money, and that real savings had to be achieved. But none of them would acknowledge that any local difficulty was likely.'

I almost gave this piece a different title - '5 minus 3 equals 8, the would be health secretaries unlikely to become future chancellors'. During the debate, Andy regularly accused Andrew of "riding two horses" - but they all did, to be fair.

No trouble ahead, apparently
Understandably, they were keen to show they understood the NHS had to change to save money, and that real savings had to be achieved. But none of them would acknowledge that any local difficulty was likely.

Norman, Andy and Andrew all brushed off the difficulty of changing local services - i.e. closing some hospitals and services and relocating others.

According to recent polls, health is the second most important issue in this election behind the economy. Few people will vote according to the different health policies of the parties. They will more likely vote according to the overall approach presented by the party leaders during the TV debates.

To be fair they would get a reasonable view of the party positions on health.

Labour promise to protect the NHS. So do the Conservatives and Liberal Democrats.

The Conservatives will tackle back room waste, unnecessary bureaucracy and cut management significantly. So would the Liberal Democrats and Labour.

The Liberal Democrats say that changing the way we work can use our current resources more effectively. So do Labour and the Conservatives.

This is a worrying consensus for the audience before them. All three potential health secretaries believe cutting management and increasing local responsibility will support the NHS to achieve even more while spending less. At a time when the NHS needs to be challenged to change, they would take away the people ordinarily paid to try that.

While emoting and stating their passion for local control, they all suggest a change that would make central decisions the main levers for change, be it through incentive, imploring, tariff, targets or dictat.