Four years to save the NHS

20 May 05
NIALL DICKSON | New Health Secretary Patricia Hewitt has inherited an improving NHS in England.

New Health Secretary Patricia Hewitt has inherited an improving NHS in England.

The huge amounts of money pumped into the service over recent years have delivered faster treatment, better facilities and more staff providing better care. Tough targets and performance management have made a difference.

There is a clear strategy too - repeated in the manifesto - that commits the NHS to further cuts in waiting times, improving care for people with long-term conditions and giving patients real choice over how and where they are treated.

Ministers are also committed to using the private sector more, not just to provide extra capacity but to promote competition and help improve quality and efficiency. As an added bonus, the government has promised that Whitehall will be less interfering.

This week’s Queen’s Speech featured a number of health measures - from a clampdown on dirty hospitals to new measures for patients who wish to redress any problems with their health care. This is an administration that seems to have little doubt about where it is going or what it wants to achieve.

So, with a reasonable record and a clear agenda, what is there to worry about? Well, quite a lot actually.

First, money. Record sums have gone in but most of it is already committed. New pay deals, combined with reduced working hours, rising pension and drug costs and clinical negligence claims, have left precious little for new tasks. As we have seen in recent months, parts of the NHS are running large deficits.

Worse, the boom days of big spending are numbered. The Treasury is warning Richmond House to expect much smaller rises beyond 2008.

In the meantime, Hewitt and her new ministerial team will have to oversee the new system of ‘payment by results’, where hospitals will be paid by the number and nature of patients they treat against a fixed national tariff. They might not say this very loudly but the aim is to encourage more competition for patients.

All this in turn is intended to encourage tighter cost controls and make hospitals and other providers more responsive to patients. However, it is high-risk stuff. Apart from various technical problems, there is no strategy for what happens when a service fails and, as yet, it is not clear how or if it will work for people with long-term conditions. There is a danger, too, that choice, the other great mantra of the moment, will do most for the able and the articulate. This must be prevented.

We heard rather a lot about targets during the election. In spite of the criticism, the government has lost none of its enthusiasm for setting them. One major challenge will be ensuring that by 2008 no one will have to wait more than 18 weeks from referral to treatment.

If everything is a priority, nothing is. But it is too easy to neglect lower profile areas. Mental health has been allowed to slip away and that must be reversed. Public health, too, must be at the forefront of policy, given the rise in sexually transmitted disease, binge drinking and smoking-related illness.

The NHS also needs the right numbers of staff to make the government’s vision a reality, but we are still relying on too many replacements from overseas. And a survey from the King’s Fund this week found that more than four out of every ten overseas nurses working in London were considering leaving to take up posts in other countries.

How well Hewitt and her team manage to re-engage NHS staff - especially the doctors - with the process of change will go a long way to determining how successful the government’s reforms are.

Finally, there is a strong possibility of more Labour backbench revolts around contentious issues such as private sector involvement and handing more freedoms to foundation hospitals.

It is a measure of this government’s commitment (or is it the prime minister’s?) to a radical third-term agenda that it is willing to dispense with another essential ideological tenet of the NHS — that it should be state-funded and state-provided.

While all sections of the Labour Party now talk about pragmatism, the medical profession and others remain suspicious. Despite this, there is no good reason for holding back with reform. We have seen the start of some significant improvements but there is much more to do. If services are to become more responsive, we need both stronger incentives at local level and less central control.

So it is clear we are heading into choppy waters and, with more elderly people with more complex needs, the demands will keep on coming. None of this presents an impossible agenda and Hewitt has already ruled out wholesale reorganisation.

But, at best, the health secretary has less than four years to prove that a reformed NHS is the right health model for this century — a few years to save the service for a generation.

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