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New faces at the top, but will there be change at the coalface?

18 September 2007

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Tom Brownlie
AMSPAR Chief Executive

In recent months there have, as always, been a number of significant changes in the health sector.

In May, NHS Chief Executive David Nicholson set the ball rolling with a number of structural modifications and appointments. These include the creation of three posts: a director general for commissioning and systems management; a director general for finance and performance; and a medical director for the NHS.

In the words of Mr Nicholson, the role of the director general for commissioning is “to manage the environment in which providers and commissioners operate. It will also develop policy for new provider organisations, which the strategic health authorities will implement.”

He also said: “The post should not be interpreted as a move away from the purchaser/provider split, but a recognition of the distinctive role the department plays in having oversight of the system as a whole.”

New names, old policies?
Of course, at the very top there was also the much-heralded handover, as Gordon Brown took the mantle from Tony Blair as prime minister. Patricia Hewitt also stepped aside to be succeeded by Alan Johnson as health secretary. Many questioned whether this may mark a shift in policy. Early indications are that this may be possible with a review of health policy being announced immediately.

However, will this really result in significant change? It is unlikely that Brown and Johnson were not involved in discussions on Department of Health (DH)/NHS restructuring. The speed with which Whitehall departments were restructured – websites were up and running within hours of the new cabinet being announced – was breathtaking. If only such efficiency was endemic …

The review of the NHS will be led by Professor Sir Ara Darzi, a practising surgeon and new health minister. Professor Darzi will report to the prime minister, the chancellor and the health secretary before the 60th anniversary of the NHS in July 2008, with an interim report to be produced in October this year.

Wide-ranging review
Professor Darzi will examine how the NHS can provide better access to safer, high-quality care for all, while delivering value for money for taxpayers. His aim is to establish a vision of the NHS for the next decade, which is based less on central direction and more on patient control, choice and local accountability.

Professor Darzi would like to ensure that the NHS is clinically led, so he will work with NHS staff to ensure that clinical decision-making is at the heart of the future of the NHS. He will also be consulting patients to ensure they receive improved care in a dignified, clean environment.

Alan Johnson says of the review: “Doctors, clinicians and nurses complain that they are fed up with too manytopdown instructions, and they are weary of restructuring. They want a stronger focus on outcomes and patients, and less on structures and processes.

“As Secretary of State, I am determined to establish a new, closer, more robust social partnership between patients, practitioners and policymakers, based on trust, honesty and respect. That is why Professor Darzi is leading this review – supported by a team of leading clinicians across the country. He will engage directly with frontline staff, not just the great and good of the health world, but those working in every primary care trust and hospital trust up and down the country.”

Alike minds
The review itself was already well mooted. Indeed, the British Medical Association (BMA) was ahead of the game with the publication of a discussion document a month before the announcement. Titled A Rational Way Forward for the NHS in England, the document makes 24 recommendations as an alternative way to deliver better services to patients while safeguarding the core values of the NHS.(1)

At the launch, the-then BMA chairman James Johnson said: “The time has come to look at a much more independent framework for the NHS, to allow greater flexibilities for health economies to develop care systems and to find ways of increasing local accountability.”

Arguably the most significant of the recommendations is that of increased independence for the NHS. This would see Parliament establish and appoint an NHS Board of Governors. The board would be responsible for ensuring compliance with an NHS Constitution and be accountable to Parliament.

Gordon Brown is rumoured to have in mind ideas not a million miles from this, which could be comparable to his first-day decision as chancellor to give the Bank of England independence to set interest rates. Former health adviser to Tony Blair and now Professor of Social Policy at the London School of Economics Julian Le Grand commented: “Almost anything that would insulate ministers from having to stand up in the House of Commons and defend everything that goes on in the NHS is a good idea. There is a case for having ministers dealing with the strategic objectives, and leaving the day-by-day operations to someone else.”

Business as usual?
The above is all very well, but what does it mean down in the practice? Probably nothing much. Practice-based commissioning will continue. The push for more independent treatment centres will go on. Our Health, Our Care, Our Say will be used to press ahead with the shift from secondary to primary care, and enterprise will be encouraged. This is evidenced by Professor Darzi’s report into reforms of the NHS in London, which many interpret as a template of a national rollout.

What practices need to do is ensure their voices are heard as the review takes place, so that it is not simply paying lipservice to the dedication of the hardworking staff in the sector. And, above all, there has to be a plea for some element of stability in order to allow reforms and structures to be implemented properly and allow them time to find their feet.

In the last week, a notice has gone out to all NHS staff entitled “The Day”, which encourages frontline staff to send their thoughts on the review via email ([email protected] for those who are interested!). It concludes: “Your views matter: we can only develop a robust social partnership between patients, practitioners and policymakers, which is truly underpinned by trust, honesty and respect, with your involvement.”

Let’s hope they listen. After all, who knows better than you?


1. British Medical Association. A Rational Way Forward for the NHS in England. A discussion paper outlining an alternative approach to health reform. London: BMA; 2007.