Delivering results

It was in the NHS' 60th year that Gordon Brown made his first major speech concerning health and healthcare since becoming Prime Minister. What would he say? Would we see a lurch back to the left, as some Labour and NHS 'die-hards' anticipated, or some variation on the 'third way' of his predecessor? On January 7, 2008, I tuned in to hear our leader's speech...

He started off by congratulating the NHS for caring for tens of millions of people, and saving lives, and highlighted "its unique offer of healthcare free at the point of need" – news to me when I last went to the dentist or my GP gave me a prescription, but let's not be churlish. Perhaps prescription charges are important – at least politically. In Scotland and Wales there are commitments to abolish them, and even the PM has committed to removing charges for cancer sufferers.

In the same year, Brown also introduced the principle of 'top-up payments' for certain medicines. Is it just me or is there a shade of inconsistency emerging here? Indeed, as health policy increasingly diverges across the UK, do we any longer have a UK NHS? I think not.

But back to the big speech. We had the usual rehearsal of improving safety and cleanliness, a quick reference to matrons (presumably who hark back to the Hattie Jacques school of nursing) and then on to the meat of the speech. Next, and the choice of words was interesting, the PM spoke of a personal service; one dominated by patient power with people "engaged and taking greater control over their healthcare too". He didn't use the word choice, but rather "personalisation" and, for a moment, I thought the old market ideas were going. After all, in the NHS public monopoly of Scotland, choice has given way to personalisation. But then Brown went on to preview the much-vaunted Darzi review and set the agenda for Alan Johnson this year. In fact, he did more than set the agenda, he declared exactly what Johnson and Darzi would be doing and saying in 2008. Commitments were given on:
• New access to check-ups that empower patients and their clinicians
• New access to screening and preventive vaccines
• Millions – especially older people – making choices to become part of active patient programmes (ah – choice was back – and reinforced later on in the speech)
•  Primary care far more open and convenient, with new providers, and more weekend and evening access (a huge challenge to general practice and more marketisation – this time in primary care)
• New and decisive action against failing services, whether in hospitals or primary care (are we about to address market exit at last?)
• A new statement – through an NHS constitution – of rights and responsibilities in healthcare
• New help for individuals and families as they strive to lead healthier lives.

What the PM was saying is that he's now taking health policy into the third and critical stage of matching increased diversity of supply with an ability to respond to the new diversity of demand in preventive and curative medicine – tackling the underlying causes of health inequalities as well as providing the best care. He was moving from illness treatment to health promotion and as my public health colleagues nodded and thought "about time too," my mind was turning to the affordability of all of this and how one disinvested or decommissioned service to secure real upstream investment in preventive health and health care. Remember, this was before the credit crunch hit.

Gordon Brown then went on to disappoint his own left wing and those who wanted a return to the old NHS. He was quite clear that the pace of reform and change was going full speed ahead and that he would even grasp the tough decisions that have eluded politicians down the years. He said: "We will reject the views of those who say the NHS must put a moratorium on change and reject those who oppose further reform... we must be prepared to listen to the clinicians and the public and take the tough decisions which will save lives."

So far we had a commitment to personalisation and choice, and an indication that the reform programme was going to continue, so was there anything new?

Yes there was. Having reviewed the growing burden of illness associated with an ageing and more demanding population, the PM committed to a new direction of health promotion and a preventive service. In this massive move upstream he promised to:
• Give everyone in England access to the right preventative health check-up
• Give men over 65 a simple ultrasound test to detect early abdominal aortic aneurysm
• Introduce on the NHS a series of tests to identify vulnerability to heart and circulation problems
• Extend the availability of diagnostic procedures in the GP surgery
• Extend screening – for example, for colon cancer and for breast cancer
• Make available to everyone any recommendations for a new form of screening on clinical grounds made by the National Screening Committee.

His next move was to reinforce the patient power aspect – committing to personal care plans, personalised budgets, patient views affecting the income of individuals and hospitals, and opening up choice to all NHS-funded care. This was a truly radical vision for the future, and one which didn't just continue the Blair reforms, but outstripped them in terms of pace, radicalism and intellectual rigour. It made a health-oriented NHS a reality and not just the regional sickness service which emerged from 1948.

Has he delivered?
So has he lived up to his word in the last year? What are the current challenges facing the NHS? Did he get them right? Will the NHS survive to its 70th birthday and beyond?

Well, the last year has been interesting for health policy and Darzi was the big news of the year. But, when you look at the Darzi reforms, with their commitments to quality, personalisation and clinical engagement, all they really do is flesh out the Brown agenda set out on January 7. In fact, the important part of the Darzi report may well turn out to be the process adopted: hundreds, if not thousands of clinicians involved in local reviews. Johnson, a shrewd political operator and a self-confessed novice on health, has delivered on the Brown agenda and avoided the faux pas of his predecessors. Johnson has gone on to beat up the BMA (to get more value for money from contracts – particularly GPs) and the industry (PPRS renegotiated to achieve a price reduction); announced screening programmes, and launched the NHS Constitution. All along he has managed to still keep smiling, like your friendly postman with a cheery Christmas message to the NHS. A remarkable performance from a wily and safe pair of hands which, of course, is why Brown appointed him in the first place. 

Bottom line: Brown is in charge and is delivering on his commitments. But is he hitting the right buttons? Well, yes and no. Better brains than mine have argued that there are nine key challenges facing health policy going forward, namely: widening inequalities; variable quality and safety of services; lack of upstream investment; buying things that don't work; costs increasing faster than income; lack of public confidence; complex systems difficult to navigate; clinical engagement and public responsibility.

We can see from the Brown speech that the commitment is there to try and address most of these, but performance has not matched commitment since the "24 hours to save the NHS" speech made by Blair and New Labour on the eve of seizing power from a discredited conservative government. Arguably, inequalities have widened, we still have trouble making the big upstream investments, and there remains a lack of public confidence in a system that is difficult for patients and clinicians to understand, never mind play a part in.

Moreover, the NHS still seems to be part of a massive national machine that fails to make itself accountable to local communities. Whose NHS is it anyway? This goes to the heart of the Brown dilemma. I believe he has the right policies, and the groundwork is set, but his problem is one of taking hearts and minds with him, and one of implementation. Real implementation requires a fundamental culture change in the NHS and one rooted in localism, with local accountability for clinicians, managers and communities – a tough act when the case for change is not always accepted. Perhaps there are just too many vested interests?

All of this will become an even greater challenge when one factors in the economic situation. After all, if the NHS has not been able to do it in times of plenty, how will it do so when times are hard? The key message from the PM is that he hasn't yet got the 'loose-tight' relationship between the centre and the local NHS right, and he must do so to make his vision a reality. Tory leader, David Cameron, must watch and listen carefully, as the conservative policy for the NHS differs little in substance, but they do seem to have caught the public mood on presentation and may have a more enabling style of political management – arguably easier in opposition than in power.

Ongoing survival
So will the NHS survive these trials and tribulations? Of course it will, for two good reasons: firstly, it is the political icon that politicians would dismantle at their peril. Secondly, and perhaps more importantly, it represents the most effective and equitable way of pursuing its key goal of improving population health. But let's be clear, in the corrupted words of 'Bones' from Star Trek, in 10 years time, it may be the NHS, Jim, but not as we know it!

The Author
Michael Sobanja is a former NHS chief executive is currently chief executive to the NHS Alliance and a health consultant to a wide range of public and private sector organisations. He writes here entirely in a personal capacity.
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