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The full picture

After winning a historic third term in office on a platform of economic competence and public service reform, the NHS may be improving on paper but public perception is not keeping step

After winning a historic third term in office on a platform of economic competence and public service reform, the government has all eyes turned towards it watching to see whether it can really deliver the needed changes to the NHS.

Despite the media glare on the Iraq war and immigration, the predominant focus of the electorate during the campaign was on public services. During the build-up to the general election, Times pollsters, Populus, asked voters what had been the single biggest influence on how they voted; party positions on public services like the NHS lead the way.

Tony Blair has a firm and distinct reform agenda for health, as he does for education, but much will depend on whether he can persuade an angry parliamentary party to sign up to his still controversial support for a degree of market-oriented reform.

First move

The new Health Minister, Patricia Hewitt, is a smart operator and a Blairite who understands business and appears committed to reform.

Indeed, her first move as Secretary of State was to announce a major new wave of contracting out of services to the private sector. An extra 1.7m NHS operations will take place in the private sector in a deal worth £3bn over five years.

This is a bold move in the right direction and continues the government's strategy of creating extra capacity in the NHS by guaranteeing high volume, low cost deals with private providers, who must compete to secure new contracts. Those on long waiting lists have the most to gain from this.

Yet, success in reforming the NHS will depend as much on patient or public perceptions of improvements as it will on actual reform. For now, as far as patients are concerned, the Prime Minister is still under pressure.

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When he appeared on BBC1's Question Time during the election campaign, Blair appeared flabbergasted by complaints that patients were unable to make an appointment to see the GP they wanted, when they wanted. Despite the official targets appearing to be met, in as far as patients must be seen by their GP within 48 hours, the system is not working out quite so well on the ground.

As a direct result of the targets, many surgeries now only allow appointments to be booked on the same day or a day before. Patients who wish to book, say, a week in advance are told to call back nearer to the time, which actually makes the system less convenient for many people, especially workers and those with small children who need to plan ahead for childcare.

It also affects patients with chronic conditions who need regular, repeat appointments and those who wish to seea specific doctor.

How does this tally with the government's commitment to providing patient choice and a patient-centred NHS? Yes, some people are being seen faster, but the overriding impression is that appointments are still arranged at the convenience of the system rather than at the convenience of the patient.

Unfortunately, according to a major piece of public opinion research conducted by the Stockholm Network in 2004, this issue tops the list of public concerns.

As many as 98 per cent of those polled felt that the time between diagnosis and treatment was an important part of the health system, yet only 18 per cent felt that the NHS was good at delivering such a feature. Following closely behind, 91 per cent felt that being treated at a time and place to suit them was important but only 25 per cent felt that this was done well by the NHS - a `delivery deficit' of 66 per cent.

Poor public perception

Although the NHS is believed to be improving on paper, according to reports from independent analysts this perception does not appear to be shared by the public.

Thanks to the huge amounts of money that have been pumped into the service over the past four years the NHS is beginning to deliver faster treatment, better facilities and more staff providing better care. However, the speed at which this extra money has arrived has not been matched by noticeable improvements for patients, perhaps because of the slow pace of institutional reform.

New policy innovations such as Agenda for Change, Foundation Trusts and payment by results are just 13 months old and, in some cases, are not due to be extended nationally for another three years.

Both Labour's manifesto and the recent Queen's Speech commit the NHS to improvements, be they further cuts in waiting times, improving care for people with long-term conditions, giving patients choice over how and where they are treated or, crucially, addressing the hot topic of MRSA infections and hospital cleanliness, which has become a major public concern.

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What will it take for the Prime Minister and his government to turn things around? A key element will be staffing and getting the medical profession on board behind its reforms. Yet, this area too looks problematic.

A recent survey from the King's Fund, a health think tank, found that more than four out of every 10 overseas nurses working in London were considering leaving to take up posts in other countries.

How well Patricia Hewitt manages to re-engage NHS staff - this includes disgruntled doctors - with the process of change will go a long way to determining how successful the government's reforms are and how fast patients can be seen.

Even with careful and tactful negotiation by Hewitt, there remains a strong possibility of more Labour backbench revolts around contentious issues such as private sector involvement and handing more freedoms to Foundation Hospitals.

Blair has already faced calls for his resignation and these are likely to resurface at regular intervals, especially when the parliamentary party feels it is being bounced in a market-oriented direction it feels instinctively goes against its core values.

Since he is likely to step down before the next election, the Prime Minister now, however, has nothing to lose in pursuing a bolder, more radical agenda. Without it, he will struggle to manage key issues such as the GP appointments fiasco, since politically-driven targets and freedom of choice for patients are a poor mix.

If reform is to succeed it will rely on convincing sceptical patients that by paying more for the service they will get more. This means moving to a decentralised model where GPs and other providers have control of their own destinies and can set their own targets, and where money follows the patient.

This alone will allow enough flexibility and sensitivity to make scheduling an appointment with the doctor as simple as making a booking with the hairdresser. Now that really is a radical thought.

2nd September 2008

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