04 June 1999
Yet, as they gathered in Harrogate last week for the NHS Confederation's annual conference, the consequences of the biggest upheaval in the health service since the 1990 reforms hung heavy in the air.
Many were keen to look back on the first seven weeks of Primary Care Groups and their equivalents in Wales and Scotland, and look forward to how they will develop.
But as so often happens, plans were overtaken by events. The conference was barely ten minutes old when the 1,000 delegates were reminded by the confederation's chief executive, Stephen Thornton, of the financial problems and difficult decisions awaiting them back at their desks.
Minutes later, word filtered through of the landmark court ruling against the government's initial attempts to ration Viagra, which created unease about the service's future ability to control spending when faced with similarly expensive wonder drugs.
This was the first annual conference following the government's Comprehensive Spending Review (CSR) decision to plough £21bn into the service over three years, yet delegates were far from overwhelmed by the largesse.
Indeed, most talked of service cuts rather than expansion. Much of the £3bn the English NHS will receive this year has been earmarked for specific targets and initiatives but even these plans could be thwarted.
Thornton said that finances were so tight in some parts of the country that the government could `kiss goodbye' to its modernisation plans for the foreseeable future. The confederation had `good evidence' that more than 130 trusts were planning to cut services to patients to balance their budgets.
`Others will be forced to postpone or cancel essential developments in key government priority areas, including mental health, cancer services, emergency care capacity and primary care development,' Thornton added.
He called on Health Secretary Frank Dobson to release any funds his department has not yet allocated thought to be in the region of £100m£150m as soon as possible and without strings.
`I recognise this is likely to place constraints on service developments, but it is necessary to assure patients of the quality of treatment and care they need this coming winter,' Thornton added.
Initially, the Health Department was remarkably unmoved by the warnings. Dobson's number two, John Denham, told the conference that the government had embarked on a ten-year modernisation plan and did not expect it to be achieved in the first three years.
`I have been impressed by what has been achieved over such a short period of time. PCGs are a real achievement for the NHS,' he added.
The government's stance had changed two days later when Dobson addressed the conference. `I said on the day that the CSR was announced that, compared with the backlog of under-investment and the scale of everyone's ambitions, it was a tight settlement, and it is,' he said. `I will look to see whether there is scope for creating greater flexibility in future years.'
While the government is taking the long-term view on spending, it may have to act quickly to head off legal ambushes from drugs companies and pressure groups on the availability of new treatments on the NHS. Dobson was praised by managers, the British Medical Association and healthy academics for moving to limit the NHS prescription of Viagra.
It is possibly the first time a politician has explicitly rationed a drug or treatment provided by the health service. But the legal challenge by the drug's manufacturer Pfizer, which won a ruling last week that Dobson's restrictions were unlawful, could have ramifications for the role of the National Institute for Clinical Excellence (Nice), charged with rooting out ineffective treatments.
The High Court ruled that a circular advising GPs not to prescribe the drug breached domestic and European law.
The drug's availability is now lawfully limited under the Medicines Act, a route that could be used by Nice, but there are question marks over how non-drug treatments could be legally banned.
Public health minister Tessa Jowell denied this would be the case. `I don't think the ruling will affect how Nice operates. We have been given leave to appeal and we are not at the end of the road yet,' she said.
An appeal is likely, but so, too, is a compensation claim for up to £50m from Pfizer.
Ministers, like managers, doctors and nurses, will have little chance to pause for thought over the coming months.
PFjun1999
