The disagreement between the National Institute for Health and Clinical Excellence and primary care trusts over guidance on saving money presages a big debate facing the NHS over the balance between central and local power in the recession.

NICE is resisting growing pressure from some PCTs for explicit guidance on what they should stop spending money on.

For many years NICE has highlighted treatments it believes are ineffective or poor value for money, but it does not want to go the extra step and specifically recommend disinvestment.

PCTs have countered that clear recommendations from NICE would help them overcome resistance from clinicians, interest groups and hospitals.

The fact that PCTs - many of whom have been pushing for more autonomy - are now in effect asking for more central control is a measure of how worried managers are, not just about finding the savings but about how to win the arguments with the public and their own staff.

There are risks in this approach - PCTs should always be out in their communities, winning the arguments themselves, not relying on NICE or anyone else - but the debate at least shows many PCTs understand the scale of the challenge they face.

As the service stands it is not equipped to deliver the £20bn of savings required by 2014. To get there the system needs to run faster. Develop its leadership talent, create workplace cultures where clinicians can propagate ideas, ramp up commissioning and procurement skills, improve clinical pathways, get better at prevention and much more besides - all that needs to happen in months.

To do this, the NHS needs to determine what decisions should be taken at which level in the structure.

For example, disinvestment guidance and decisions could come from any or all of the Department of Health, NICE, the strategic health authorities, a region’s PCTs, specialist commissioners, lead clusters of PCTs, sub-regional consortiums or 152 individual organisations. What should happen where?

The focus of this debate will be the consultations for the 2010-11 operating framework, which will begin after the summer in preparation for publication before the end of the year.

Managers cannot sit back and wait for the outcome - this consultation is likely to be the bedrock of NHS management practice for the years of the public sector’s recession.

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