29 July 2005
You wouldn't know it, but the NHS Plan had its fifth birthday this week. There were no celebrations and ministers ignored the occasion. So what ever happened to this 'once-in-a-lifetime' opportunity to reform the health service? Lyn Whitfield reports
If the NHS Plan were a small child, it would be having a miserable time this week. It has reached its fifth birthday, but nobody is celebrating.
Indeed, the government that launched the Plan as a 'once-in-a-lifetime opportunity to bring about the most fundamental reform the NHS has seen since it was created' seems intent on ignoring it.
No minister was able to find time in their busy summer schedule to talk about it for this feature. And Health Secretary Patricia Hewitt delivered a Fabian Society lecture on 'Labour's Values and the Modern NHS' last week without mentioning it once.
On the face of it, the lack of hoopla is strange, since the government could tell a good story about the Plan. Many people in the NHS still feel warmly towards it, and some of its big pledges have been delivered – albeit at a high cost.
But the silence also speaks volumes, for the Plan's reform agenda – the systems and mechanisms that were supposed to create a quality, patient-centred service – has been, if not quite abandoned, then severely battered. Few of the bodies that were supposed to implement the Plan even exist today, while the government has become much more interested in choice and 'contestability' as drivers of change.
'The Plan was a landmark,' says Baroness Neuberger, who signed up to it in 2000 as chief executive of the King's Fund. 'There was a very widespread consultation, which generated huge goodwill.
'People felt, and still feel, that the architecture behind it was right. And we had a sense that the deckchairs would not be shifted around again.
'But what has happened? We have had another huge upheaval. Why? Because the politicians felt things were not happening fast enough – and they never learn that you don't get change by moving the chairs around.'
Labour came to power in 1997, promising to 'save' the NHS while sticking to the Conservatives' spending plans for two years. In practice, it found new money for the health service almost immediately and, by the end of 1999, funding was growing by 4% a year – the fastest rate for a decade.
Despite this, the NHS endured a winter 'crisis', with the media focusing on its apparent inability to cope with a 'flu outbreak, and to treat a cancer patient, Mavis Skeet, before her condition became inoperable.
On January 15 2000, Lord Winston, the fertility expert and Labour peer, attacked the government's record, and the next day the prime minister went on TV and promised to raise health care spending to European levels. The money, it was quickly made clear, had to be accompanied by reform. A consultation, or 'listening exercise' was organised to collect ideas, and the Plan emerged in July.
Unsurprisingly, the official NHS historian, Charles Webster, calls the Plan a 'hasty compilation' – a 'portmanteau' that packed together a description of the state of the NHS with targets for expansion.
Nevertheless, it had some significant features. Labour's first white paper, The new NHS: modern, dependable, had rejected the Conservatives' internal market reforms, while promising there would be 'no return to [a] centralised command and control model.' It had also started to try and improve quality. The National Institute for Clinical Excellence, which advises on drugs and treatment, and the Commission for Health Improvement, an inspectorate, were both in place in 2000.
But the Plan went further, emphasising that the NHS had to adapt to a new, consumer world. Its vision was 'a health service designed around the patient'. Unfortunately, it did not spell out what a patient-centred service would look like, the mechanisms that would be used to achieve one or the resources that would be deployed.
In that sense, as David Hunter, professor of health policy and management at Durham University, puts it: 'It wasn't a plan at all, it was a shopping list, a wish list' of targets and new processes. Importantly, the Plan was also quite separate from the assessment of long-term resource requirements for the NHS carried out by former NatWest chief executive Sir Derek Wanless in 2001/02.
Indeed, Wanless modelled scenarios that made different assumptions about NHS efficiency and public engagement, rather than Plan policies, reviving interest in IT and public health in the process (see below).
From the Plan itself, it is possible to pick out three sets of problems that the government sought to address. These are: a lack of resources; structural problems; and a more disparate set of issues, ranging from dirty hospitals to public health, that look as if they arose from the 'listening exercise' that preceded the Plan.
The lack of resources was to be tackled with more money, more beds, more staff with new contracts, and more treatments – with less waiting.
An audit by the King's Fund shows that most of these targets have or will be met (see below), although this is an equivocal achievement. The NHS is now involved in a huge hospital building programme, even though the Plan itself envisages that more work will be carried out in surgeries and homes in future.
And it is committed to training and employing more doctors and nurses, even though the Plan itself envisages more care being delivered by multi-disciplinary teams, connected by IT.
Meanwhile, the new GP and consultant contracts, and the new pay system Agenda for Change, are proving to be hugely expensive, especially as productivity has fallen. 'New pay systems are always expensive and the government should have known that,' says Professor Rudolf Klein, NHS historian and visiting fellow at the London School of Economics.
The Plan's commitments will increase overall staff numbers by about 5% a year until 2010, according to Nick Bosanquet, professor of health policy at Imperial College, London in his report, The NHS in 2010, for the think-tank Reform. This would leave the NHS with a workforce of 1.65 million and double the wage bill; an alarming prospect for trusts already staring deficits in the face, and one that must reduce the amount of money available for other innovations.
The structural problems identified by the Plan included over-centralisation, old fashioned demarcations between staff, and disempowered patients. To tackle these, it promised a new relationship between the centre and the local NHS, with the Department of Health setting policy and standards, and NHS bodies earning autonomy by performing well against a new performance and assessment framework.
This new relationship soon soured. In the years immediately following the Plan's publication, the big complaint from the NHS was that it had ushered in an era of top-down target setting and micro-performance management.
Ministers have either forgotten that this was not the intention, or simply overlook the fact so they can tell a story about how command and control was necessary, but now it is time to finally 'let go'.
In Hewitt's Fabian Society lecture last week, she said the government's achievements had come through centralised command and control, but it was now necessary to 'embed change'.
Back in 2000, the Plan also argued that the NHS lacked national standards, clear incentives to improve and ways of identifying and supporting struggling organisations. In response, it promised to draw up more National Service Frameworks for key clinical and disease areas, to create a Modernisation Agency to advise on service redesign, and to set up a National Clinical Assessment Authority to step in when things went wrong.
The government also delivered on all these pledges; and they are seen as some of the big positives to come out of the Plan.
Stephen Thornton, former chief executive of the NHS Confederation and now head of the Health Foundation, says the Modernisation Agency, in particular, had a big impact. On the other hand, he notes: 'They've just gone and abolished the thing.'
Indeed, barely any of the organisations that were in place when the Plan was published, or were created by it, still exist. Regional offices and health authorities were swept away by 2002's Shifting the balance of power, which created strategic health authorities and beefed up the role of primary care trusts – both of which are now under pressure to restructure.
Meanwhile, the Health and Social Care Act 2003 offered acute trusts a very different sort of freedom from that envisaged in the plan – foundation status.
CHI has become the Healthcare Commission, while the National Clinical Assessment Authority and the much-anticipated Commission for Patient and Public Involvement in Health have joined the Modernisation Agency on a long list of ex-NHS institutions.
Like Neuberger, Hunter believes this is the opposite of good management: 'Structural change is very visible, it's easy to present as doing something, and it's easy to do, because managers can do it,' he says. 'But it is very expensive. It leeches expertise from the system. Staff become jaded because they've seen it all before. And you lose the narrative line of what reform is really supposed to be about.'
In the midst of all this organisational turmoil, new ideas for change have assumed greater importance. These include a much bigger role for Patient Choice than was envisaged in the Plan, linked to a new system of payment by results, which was not in it at all.
At the same time, the government is creating a more diverse set of providers, headed by independent treatment centres, which were mentioned in the Plan, but only as sources of additional capacity, not as a parallel market.
Few seasoned observers of the NHS believe these changes have come about because the government has a new commitment to consumerism and market-mechanisms. Thornton believes a wobbly government, distracted by the Iraq war and obsessed by tabloid opinion, simply lost its nerve and started drifting towards a market economy.
Others agree with Neuberger that ministers were frustrated by the slow pace of reform, while Bosanquet argues that they had to start using private sector capacity when it became clear that this year's six-month waiting time target would not be met without it.
However, there appears to be no going back. One of Hewitt's first acts as health secretary was to sign a deal worth £3bn for more private sector diagnostic capacity. And in her Fabian Society lecture she was unequivocal. 'Choice,' she said, 'is what patients want and expect' but it was also the route to a more equitable service and an incentive for hospitals to improve.
The NHS monopoly might have been 'necessary in 1948' but it has been shown to 'lack capacity and the spur to innovation and efficiency' that contestability will supply.
No wonder the NHS Plan hasn't been fêted this week. It might only be five, but it's already history – and it leaves an ambiguous legacy.
On the one hand, it helped to put quality and patient-centred services on the agenda and spurred the NHS to deliver on some big targets. On the other, it triggered some of the big 'cost pressures' that trusts are now struggling with, just as the financial climate is turning colder and its reform agenda giving way to a much more competitive regime.
Meanwhile, it is interesting that there has been no NHS Plan Mk2 proclaiming yet another 'once-in-a-lifetime opportunity' to 'jettison command and control' and lay down another 'blueprint' for reform.
'Maybe it's no longer Labour's style,' speculates Professor Klein. 'Or maybe they've decided that big plans are hostages to the future.'
Targets: hits and misses
To match European levels of spending on health care
On course. The level of expenditure on health care in the UK will reach 9% of gross domestic product by 2008, which is comparable to that of other European countries.
100 new hospitals by 2010
On course. 68 schemes are complete or under way, 64 of them via the Private Finance Initiative.
7,000 extra beds by 2004
Hit, depending on how a bed is defined. Overall, bed numbers have continued to fall, as long-term facilities have closed. However, the government has delivered 800 new critical care beds, 2,197 'acute and general' beds and 4,455 'intermediate' beds. Despite this, bed occupancy is still about 85%.
1,000 new medical school places
Hit, medical school places have increased by 52%, from 3,972 in 1999/2000 to 6,030 in 2003/04.
7,500 extra consultants, 2,000 more GPs, 20,000 more nurses, 6,500 more therapists and other health professionals by 2004
Hit or exceeded, although there are a number of caveats. The government relies on a 'head count', rather than 'whole time equivalent' figures, and it includes GP assistants in its GP figures.
Waiting lists will be replaced with booking systems by the end of 2005
Likely to be missed. A National Audit Office report found that just 63 bookings were made last year.
Waits for a first outpatient appointment to be cut to 13 weeks and for inpatient treatment to be cut to six months by the end of 2005
Likely to be hit. Roughly 50,000 patients were waiting more than six months in July.
The big picture issues
The government had published green and white papers on public health by 2000, but the NHS Plan promised further action on inequalities, with a new inequalities target and local strategic partnerships to tackle its 'fundamental' causes.
It also introduced a plethora of universal schemes and services, including free fruit for schools, the 'five a day' programme and an NHS smoking cessation service.
Despite this, government interest in public health was really rekindled by Derek Wanless's 2002 report on future health care spending, which showed this could be reduced if the public 'engaged' with their health.
In November last year, the government published another white paper on public health, but with a very different agenda to the one in the NHS Plan, focusing on how to encourage and support healthy choices in a consumer society.
The Plan promised a National Service Framework on elderly care, a National Care Standards Commission to improve standards and new measures to boost independence. In two pages, it also delivered the government's response to Sir Stewart Sutherland's Royal Commission on long-term care, and committed it to free nursing but not personal care.
A recent Panorama programme showed that neglect of elderly patients is still a problem, while a King's Fund report damned London's care market as fragmented and failing to deliver quality or choice.
The King's Fund has also asked Derek Wanless to conduct another 'fundamental review' of the trends likely to affect the demand for social care over the next two decades, and the cost of supplying it.
Problems then, problems now
According to the clean hospitals section of the NHS Estates website, the health service has invested £68m in improvements since the NHS Plan, and the Patient Environment Action Teams that it created say just 2.5% of hospitals have 'poor' or 'unacceptable' standards.
Despite this, dirty hospitals were an election issue in 2001, and the Healthcare Commission's annual 'state of the NHS report' recently criticised maternity services for 'poor standards of cleanliness' (as well as overcrowding and a lack of support).
Hospital-acquired infections have become a big issue since 2000 – although the King's Fund audit argues that intensive bed use and poor hand cleanliness may be more to blame than dirty wards.
The Connecting for Health programme has placed contracts worth £6bn over ten years to deliver a new broadband network for the NHS and electronic patient records, booking and prescribing.
The scale of investment goes well beyond what was promised in the Plan, but some of the specific pledges have not been met. Electronic prescribing and access to medical records were supposed to be in place last year, but neither has gone much beyond the pilot stage, while this year's electronic booking target looks set to be missed.
Meanwhile, a joint report by the Audit Commission and the National Audit Office recently identified implementing Connecting for Health as a major cost pressure on trusts. And while some new patient administration systems have been implemented in the North and the Midlands, the programme
is well behind schedule in London and the South, which recently lost its systems supplier.