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Another April revolution to transform the NHS

Published on 07/04/04 at 10:39am

For the second time in three years, the National Health Service has undergone an April revolution through the major re-engineering of how hospitals are managed, how general practitioners are paid and how the performance of every organisation in the service is assessed.

In 2002, the government chose 1 April to make the new Primary Care Trusts the most powerful NHS bodies, with the aim of devolving power to local front line staff and reversing decades of NHS management which emphasised a secondary care led system run directly from Whitehall.

Two years on, the theme of devolution and reform continues with the first ten foundation hospitals, the new GP and consultant contracts and a single NHS standards watchdog, the Healthcare Commission all coming into being on the same day.

The Labour government sees each of the reforms as vital to creating a modern health service built around improved patient services, including two increasingly central tenets, greater patient choice and local accountability. Introducing the reforms has not been an easy ride for the government, particularly foundation trusts which have been bitterly opposed by many Labour MPs and trade unions and some NHS professional bodies such as the BMA who claim they will usher in a 'two-tier' health system.

The government has gone to great lengths to distance itself from making the final assessments on the trusts itself, passing on the task to a specially appointed independent regulator.

Keen for the exercise not to be seen as a rubber stamping, chairman of the independent regulator Bill Moyes held two of the twelve first wave trusts back - North Tees and Hartlepool NHS Trust and Rotherham General Hospitals NHS Trust, citing unresolved financial issues as the problem, but indicating that these could be ironed out with more time.

Commenting on the creation of the first ten foundation trusts, Mr Moyes said: "Becoming a foundation trust offers managers, staff, patients and the local population the opportunity to decide for themselves how their trust should meet local needs." He concluded: "It's a great opportunity. I am confident that the trusts we have licensed today will use these freedoms to deliver more and better care to the patients they serve."

Foundation trusts will still be expected to deliver against key national targets -reducing waiting times and improving clinical outcomes, but will have greater freedom to raise capital and pursue plans for service development independently. Balanced against these freedoms, the trusts will be accountable to a locally elected board and can have their 'licence' withdrawn if they are found to be mismanaging their finances.

NHS primary care leaders have long been concerned that the battle over foundation trusts has detracted from the stated aim of re-focusing around general practice-based services.

Last year, the government announced that the highly successful Kaiser Permanente model of integrated care developed in the US would be piloted in a handful of England PCTs, creating a more rational, local and patient-centric system of care.

But Dr Michael Dixon, chairman of the NHS Alliance and Professor Donald Light of Princeton University say their research shows the NHS is still locked into a  hospital-centric system that prevents effective commissioning by primary care organisations.

Their joint paper published in the BMJ says inside the services "so-called integrated budgets" spanning primary and secondary care, consultants and acute trusts remain "separate and protected from the radical implications of a true partnership in commissioning."

Dr Dixon commented: "The root lesson from Kaiser Permanente is that clinicians need to run the health service. That means collaboration, not the all too common trial of strength between primary and secondary care. Until that happens, NHS reforms and their benefits for patient care will not be fully realised.

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