According to the Kübler-Ross model there are five stages of grief – denial, anger, bargaining, depression and acceptance. Elizabeth Kübler-Ross said her model described the stages people go through when dealing with grief and tragedy, particularly the death of a loved one or the diagnosis of a terminal illness. But it could be applied to a potential loss of employment. At the HFMA primary care trust annual finance conference in Birmingham last week, delegates displayed most of the stages when asked how they were feeling about their future job prospects.

With the government set on paring down PCTs’ responsibilities to little more than public health and some residual commissioning, most had gone through denial and accepted change was going to happen. There was a little anger – but more at the contempt shown to finance staff and administrators in general (as well as a belief in their disposability) – but no bargaining. It was pointless, as no-one believed the government could be swayed from its path.

There was some mild depression, but perhaps more accurately described as anxiety about the future fuelled by uncertainty. All may be revealed in the white paper (more of which later), but then again it’s unlikely to go into details about numbers of finance staff, grade and skill mix, so it is probable a whole new set of questions will be generated once the white paper is published.

The final stage is acceptance, which many at the PCT conference had already reached. Of course, some had got there in double-quick time by looking dispassionately at the government’s plans for commissioning. But the tougher management cost reduction targets – which soar to more than 50% over four years for some PCTs – have clearly made the threat of job losses much more real within finance departments and other support functions.

Of course finance will have to make its contribution to this, although it is not completely clear where the savings will come from. At the transactional level, many efficiencies have already been driven out either by outsourcing to a provider such as NHS Shared Business Services or through local shared services arrangements. There is likely to be more mergers of other financial activities and wider support services (even if PCTs themselves stay separate).

Many of the finance managers at the PCT conference seemed level headed about the changes. PCTs have been here before – okay perhaps without such extreme external pressures. But many will be reasoning that primary care commissioning bodies, whether they are multi-funds, consortia or PCTs, will always need financial facilitators and financial support. One delegate acted as spokesman for those with a positive outlook when he urged PCT finance staff to embrace the change. ‘There will always be work for us,’ he added.

Another delegate even mused that the creation of consortia could support the push on management costs. Commissioning support would come out of PCT management costs, but then (depending on how the management cost issue is defined) the consortia could be exempted from management cost cuts. After all, they would be new organisations that needed business support to get them on their feet. Cynical or naïve? Who’s to say? But it’s certainly not beyond the bounds of possibility.

Some formal body will presumably be needed to receive the acute commissioning budget, which even very rough estimates would put at over £100m (say £50bn across 500 consortia) – the budget of a small foundation trust. Many would be much bigger. They will need robust governance and finance structures to ensure there is proper public reporting and accountability, to ensure financial controls and discipline are in place and to drive better value from resources. Even if some of these roles stay at the PCT – charged with providing the necessary support services - the roles and functions themselves can’t all be eliminated.

Rumours that PCTs may have to wait longer to know their fate could be good news for finance staff. There is speculation that the white paper has been delayed by the Treasury having cold feet over handing billions of taxpayer pounds to consortia with few control mechanisms. Of course, the Treasury may be doing nothing more than applying its regular checks and balances on spending department plans, so there may be nothing to see here. However, if it is insisting on greater local oversight, finance will play a key role and for many finance staff anxiety could turn to relief.

With no major funding announcement, George Osborne’s 22 June Budget could have been very dull for the NHS – in truth levels of personal taxation set in the set-piece affair are usually the only items of interest for the service; the main action normally takes place in autumn’s pre-Budget report. However, two of the chancellor’s proclamations will have led finance managers to check not only their personal finances, but also the impact on their organisation.

Chancellors rarely give with one hand without taking with the other, and so it proved for the NHS. While it gained on the swings of the planned two-year freeze in public sector pay, it will lose on the roundabout of the 2.5% hike in VAT from next January. Of course it’s hard to say how much the freeze will save the service, though we know that each 1% rise for staff on agenda for change (AFC) contracts costs around £300m a year.

The impact of the increase in VAT to 20% is clearer. According to the King’s Fund, it will cost £200 to £300m a year – not dissimilar to the cost of the 1% rise in employers’ national insurance contributions planned by Gordon Brown’s government, which will not now go ahead (though David Cameron plans to press on with his proposal to create a cancer drugs fund using the money that would otherwise have been spent on NI increases).

With potentially similar sums being taken out as being saved, it would be tempting to say the Budget has roughly no overall impact on the NHS, but (as said above) there are other costs to be considered, as well as expenditure avoided (every 1% uplift in salaried doctors’ pay costs £100m a year, for example).

Leaving this aside, one question remains – will the pay freeze apply to the increments for which most staff on AFC contracts are eligible every year? NHS Employers have played a straight bat on this question, saying only that they would be discussing the matter with the government soon. However, we know the potential cost of increments is significant – in its submission to the NHS pay review body for the current year Employers said 70% of AFC staff would be eligible for incremental pay rises in 2010/11 and this would likely add 1% (£300m) to the pay bill.

The chancellor reiterated his commitment to protecting frontline NHS spending and increasing it in real terms, but this has set him at odds with some of his own backbenchers. Some, including Tory grandee Lord Lawson, came out recently to call such protection untenable when other departments were being cut by 25%. It will be interesting to see if such opposition develops as we go through the comprehensive spending review, the results of which will be announced on 20 October.

The Budget wasn’t the only show in town as health secretary Andrew Lansley continues to expand on his vision for the NHS in England. Again, this left more questions than answers – answers that should be supplied in the upcoming white paper, due in the ‘coming weeks’ according to the taciturn Department of Health press office.

The main questions surround the plans for GP commissioning consortia, some of which were raised in a recent report by six national healthcare organisations, including the King’s Fund, the Nuffield Trust and the Royal College of General Practitioners. Estimates on their number vary from 150 to 600, putting the average number of GPs in a consortium at between 240 and 60. Would these numbers be workable – even 50 or 60 GPs offer ample scope for infighting or disagreement. Even so, many GPs will be happy to be led by the enthusiastic few, some of whom will be veterans of GP fundholding, probably organised into a board. Will a chief financial officer sit on each of these boards? Certainly, with each consortium potentially in receipt of hundreds of millions of taxpayer pounds proper governance and financial stewardship will be vital. Where will the Audit Commission stand in all of this – will each consortium have an external auditor? The answer to all these questions should be ‘yes’, but it illustrates the level of detail that must be worked through.

How will funding be allocated to the consortia? We currently have a funding formula that allocates money to 150-odd primary care trusts, but there are questions over whether it will be sufficiently robust to fairly apportion funds to smaller populations? There is an alternative – the ‘fair share’ formula used to allocate indicative budgets to practice-based commissioners, but even the Department of Health has acknowledged this is not without its failings.

What happens if consortia overspend? Or underspend? Will there be a top-sliced pool, perhaps held at a regional level, to cover overspends? Will there be financial incentives, or even clear directions in the operating framework, to underspend? Will there be a failure regime for GP consortia?

Providers will also have many questions for the future. At the recent NHS Confederation conference, the health secretary spent a lot of time addressing the future of payment by results. ‘If the peak of Everest is a payments system that supports precisely what the commissioners are looking for and that patients need on every occasion, then I’m afraid we’re still at base camp’, he said.

The future system would have benchmark pricing, allow contracts to run along care pathways and switch between primary and secondary care (no mention of community care or mental health, but I am sure this was an oversight). It would focus on ‘outcomes not episodes’ and incentivise quality. ‘I want to see a system that rewards performance and is tough on poor quality – a payment system that works for clinicians and patients, rather than the other way round – a system which stimulates innovation,’ he added.

There’s a lot of work to get through to make Mr Lansley’s vision a reality by April 2012, the implementation date he has reportedly given to Department officials. At the confederation conference the message on timing appeared contradictory, with Mr Lansley insisting there be no delay, only for NHS chief executive Sir David Nicholson to later firmly pooh-pooh notions that it could be achieved in less than two years.

Many interpreted this as a gaffe by Sir David; others that he was standing up to his new boss. But perhaps it was a twist in the time-honoured good cop/ bad cop routine, enabling the civil servant to keep managers onside – remember 46% of the 2009/10 management costs are due to be cut by 2011/12. Ouch. But will such swingeing cuts be achieved at a time when so much support will be needed for the new commissioning groups, particularly in the areas of finance and governance? What the government saves on the swings it might have to spend on the roundabouts.

 As spring turns to summer, most people’s thoughts will turn away from the election and its aftermath to the weather, summer holidays, the weather, the World Cup and the weather. Inside the air conditioned offices of Whitehall, civil servants and policy wonks will be working hard on delivering the coalition’s health policies.

Almost a month after they received their ministerial portfolios, the coalition health team will be pretty confident they know what they are doing – especially as many of them had the health brief in opposition. In Simon Burns’ case he was a health minister in the Major government. But what about the rest of us?

In terms of funding and the impact of the new government’s efficiency programme, we know there are two important dates. First, George Osborne’s first Budget on 22 June, and second, the comprehensive spending review (CSR), which is likely to report in the autumn, possibly at the same time as the pre-Budget report. The CSR will likely set out health spending for the next three to five years and, as health secretary Andrew Lansley has hinted, whether the NHS in England will be required to generate efficiency savings greater than the £15bn to £20bn that has already been targeted. In the meantime, the coalition has committed to real terms increases in health spending for each year of the Parliament and to cut administration costs by a third.

Policy-wise, we know that reconfiguration plans are on hold, Strategic health authorities are likely to be downgraded and primary care trusts may get directly-elected representatives on their boards. GP commissioners could be offered hard budgets rather than the current indicative sums – a move that could increase management costs.

Like all new governments the Conservative – Lib Dem coalition is going over Labour’s policy documents with a fine tooth comb. This includes the current year’s operating framework, policy on payment by results (PBR), management costs, programme budgeting and costing. (It should be said that all statutory regulations and guidance remain in force while the ‘update’ is taking place.) But given the wafer thin differences between the Conservatives, the Lib Dems and Labour on PBR, for example, how much will really change when the government’s own tariff policy documents and guidance begin to appear?

Some interesting embellishments of the coalition’s health policy have emerged. The proposal to make Monitor an economic regulator with some influence over price setting, for instance, is an attention grabber, particularly as there will be an independent board set up to (among other things) allocate resources to commissioners. Will the Department of Health sit in the middle squaring the circle between funding and prices? There are even unconfirmed reports about wholesale changes to the GP contract – scrapping PMS and GMS in favour of a new contract held centrally by the new NHS board.

The new regime at the Department is also keen to be seen as transparent. That is how it explained why it published on 2 June the McKinsey report into the fiscal future of the NHS. Why now, one might ask? The report is the best part of a year old and Mr Lansley has rejected its recommendations because they set a top-down agenda. The previous government, which commissioned the report, had also binned the consultants’ proposals.

Is the health secretary saying, ‘Here are examples of things I don’t want you to do’. Or, a cynic might ask, does Mr Lansley want local health economies to take the ideas, toss them around for a bit and then make them appear to be their own?

Either way, the NHS would appreciate some clarification and the end of this nudge-wink style of management.

Now the fun and games begin. The predictions of a hung Parliament with the Conservatives holding the most seats proved to be correct and over the next few days the political horse-trading will take place in Whitehall before the puff of white smoke emerges.

A Conservative/ Lib Dem pact (I think they would be loathe to call it the Con-Dem alliance) is not out of the question, nor is a minority Cameron government propped up with support from various shades of Northern Ireland Unionist. Labour will try to woo Nick Clegg, along with the nationalists from Wales, Scotland and Northern Ireland (together with the first Green MP, Caroline Lucas).

What this means for the NHS is anyone’s guess. We know that frontline services would be protected and funding should at least be at the level of inflation, whether Labour or Conservatives are the major players in the new government. And the focus on efficiency and quality will sharpen.

However, some questions spring to mind. Would a minority Tory party be able to push through their planned early public sector savings (remember, they pledged to make savings in the current financial year) in a summer Budget? Would the Lib Dems demand the scalp of strategic health authorities as part of a wider programme of ‘cuts in bureaucracy’, if it enters a formal coalition with Labour or the Conservatives? Is the planned rise in national insurance dead in the water, even if a Labour MP has the keys of Number 10? Would the support of Unionist and nationalist MPs in Northern Ireland, Scotland and Wales have to be bought with better financial deals for those devolved administrations?

What is clear is that it was a bad night for Labour’s health team. Mike O’Brien, Gillian Merron, Phil Hope and Ann Keen all lost their seat to the resurgent Tories, meaning health secretary Andy Burnham is the only member of the team that will return to the Commons. All the shadow health ministers and Liberal Democrat health spokesman Norman Lamb retained their seats.

In Wyre Forest, Independent MP Richard Taylor, the consultant rheumatologist who swept into the Commons in 2001 on the back of a campaign to stop the downgrading of Kidderminster Hospital, lost his seat to the Conservatives.

The dust is settling. Over to you Mr Cameron, Mr Brown and Mr Clegg.

It's all over, bar the shouting. The combatants have criss-crossed the country like manifesto-spouting Tasmanian devils for the last time before arriving at their constituencies.

The last few days of the campaign mean hammering home the message (although Labour did get in a bit of a spin over tactical voting), so Gordon Brown warns of the danger of NHS cuts under a Cameron administration, while Nick Clegg promises to rid the service of waste.

On Tuesday (4 May) David Cameron denies his plans to squeeze spending in the current financial year, should he win power, would lead to cuts in frontline NHS services. Though he acknowledges the scale of the cuts will be greater than seen for many years, he refuses to go into greater detail.

He returns to this theme later in the day as he visits Northern Ireland to give his backing to the electoral pact the Conservatives have made with the Ulster Unionists (who have agreed to take the Tory whip if elected).

Potentially, the Ulster Unionists could give Mr Cameron the majority he seeks in the Commons, and the local party has been criticised by its opponents for being in cahoots with the Conservatives. This is particularly acute when Mr Cameron seems to suggest that Northern Ireland, together with Wales and Scotland, will have to make do with less.

'There is no way Northern Ireland will be singled out over and above any other part of the UK', Mr Cameron says, leaving ample wriggle room.

Bad news for Mr Cameron on the eve of the election (5 May) as X-Factor Svengali and trouser model Simon Cowell backs his campaign (in the interest of balance, it should be pointed out that fellow talent show judge Piers Morgan has voiced his support for Mr Brown).

Visiting Bradford on 5 May, Mr Brown is asked about mental health funding. Reporters are too shocked by the specific nature of the question to record his response

As the parties’ leaders make their way home, they will perhaps be reflecting on the gaffes, the first televised leaders’ debates, the rise of Nick Clegg and how many votes the Zombie party will get (ok, so maybe not the last one).

But will they also be thinking about the health service – the dog that didn't bark in this election campaign. This is my fifth election as a health reporter and I can’t think of one where the NHS has been on the agenda less. Yes, there have been vague promises to 'protect the frontline' and the sport of manager-bashing was pursued for a few minutes in the first televised debate, but little beyond that.

Certainly, Labour has neutralised the NHS issue that has dominated some recent elections – waiting times. But there has been little discussion about the scale and type of efficiencies that will have to be made in the next few years, whoever is in the hot seat at Number 10. Maybe this is intentional as the parties seek to keep their message positive, knowing the electoral can of worms that would be opened by such a debate. And, as noted in previous blogs, the money is not available to fund great swathes of reform.

The polls point to no outright victor, and in the event of a hung Parliament there could be days or even weeks of horse-trading before a government is formed. Of course, Scotland has been getting by well with a minority government in recent times, but history tells us that where there is a hung Parliament at Westminster another election often follows soon after. Happy voting.