Chris Ham, professor of health policy at the University of Birmingham, said the 'NHS recession' had come too soon for initiatives like world class commissioning (WCC) and Lord Ara Darzi's quality agenda to take root.

Rewarding hospitals to treat patients and building choice and capacity are no longer suitable, he said. 'My fear is that the NHS recession has arrived too soon for WCC,' he told the NHS Employers conference in Birmingham last week.

'PCTs are delivering improvements to services but it was always intended to take a couple of years. The funding challenges will kick in next year and the year after, at a point where WCC has yet to be delivered across the NHS as a whole.'

Lord Darzi's quality agenda, useful for maintaining standards, was being implemented at the wrong time, he said.

'Quality accounts and all the other tools in the quality kitbag are being implemented and tested, but they are fragile and embryonic, at a time when they need to more firmly embedded.'

Since the economic collapse, health ministers have maintained improving quality can deliver enough efficiency savings to rein in NHS finances. But Professor Ham said that policies created to bring down waiting times must change to suit the current economic situation.

'Choice, capacity, and rewards for hospitals to treat patients are no longer appropriate as we move to recession and address other priorities. We need to review the policy levers, as they are not fit for purpose.'

Professor Ham estimated 'the NHS recession' would last at least seven years. But the biggest questions for the future surrounded the Conservatives' GP budget-holding policy, he said.

'Why would GPs be more motivated to play their part in GP-budget holding than they were about practice-based commissioning?

'My sense of the mood among GPs is that they are no more optimistic about their alternative offer than the one out there at the moment.'