How will yesterday's "radical reform" of the national health service be judged a decade from now? If all goes well - and with such good groundwork, it should - Tony Blair may even come to be named along with Aneurin Bevan as co-architect of a truly effective 21st-century health service. There is room for caution, of course. Charles Webster, the NHS historian, issued a timely warning about radical reorganisations in our Society section this week. Both the 1974 and 1991 reforms were disasters, the first burying health care below multiple levels of bureaucratic administration, the second introducing a sharp-elbowed internal market, pitting hospital against hospital and introducing a two-tier system of primary care under GP fund holding.
This reform will certainly not go down as the most radical bid for change. That prize must go to Margaret Thatcher's cataclysmic market option. But several elements in it suggest it could be by far the most successful since Aneurin Bevan launched the service in 1948. First the structure, which is sound, stays in place. There are big changes, true, but they apply to working practices, partnerships and professional demarcation barriers. Second, it has what earlier reforms fatally lacked: a massive injection of funds.
Health spending will increase in the next four years by 35% in real terms: the largest sustained increase in NHS history, at last allowing managers to look and plan beyond the short term. Third, four intensive months of seminars, taskforces and consultations by ministers have paid off. The medical profession is on side. Of course they all have caveats. But 24 leading medical, nursing and managerial names have signed up to the plan's core principles.
The importance of the increase in resources cannot be overemphasised. Historically, this has been the fatal flaw in the NHS - still one of the most efficient systems in the world, but held back by politicians unready to provide a sufficient amount of taxpayers' funds. Even with this record increase, advances in medical technology will ensure that the gap between the possibilities which modern medicine offers and the resources available to pay for them will still be there. But serious modernisation can now begin. More than money is needed, as ministers will know from reading the recent report on orthopaedic surgeons: spending 50% up in the last decade, and yet a decline in the number of patients treated down to a mere six operations per surgeon per week, when there are 250,000 on the waiting list!
Few will argue with the need to make the NHS more patient-centred. Typically patients see their GPs six times a year. No one needs to tell them how patient-unfriendly the present system can be. Many have to wait days before they can even get an appointment to see a GP. Even under the new plan, it is going to be 2004 before patients are guaranteed an appointment within 48 hours; 2005 before booked hospital appointments replace current waiting lists; and 2008 before the maximum waiting time for any stage of treatment is reduced to three months. Big increases in medical manpower are in the pipeline - 7,500 more consultants, 2,000 extra GPs, 20,000 extra nurses - but it takes three years to train a nurse and six years to produce a doctor.
One potentially serious error has been avoided: this is not just an acute hospital plan. Nine out of 10 times when people use the NHS, a hospital is not involved. Primary and community services are also being improved, with 3,000 GP premises being modernised and 500 new one-stop primary centres (bringing together GPs, dentists, and opticians under one roof ) opened. Far more consultant outpatient appointments - 4m by 2004 - will take place at GPs' surgeries and 1,000 GP specialists will take further strain off hospitals. Even so, we needed more GPs, and fewer hospital doctors.
The plan goes a long way towards meeting the set of principles which the prime minister called his "six 'p's". For partnership, the answer is new pooled budgets between health and social services to deal with the 5,000 elderly people blocking hospital beds. For fewer professional boundaries: a radically enlarged role for nurses, allowing them to admit and discharge patients, order tests, run clinics and prescribe drugs. For a more even performance: national standards and a new monitoring system placing units into three grades, the top being given "earned autonomy" with the other two getting help and supervision. For more prevention: new targets to reduce health inequalities and more action on smoking. Finally, for more patient access, and more patient rights: a champion to take up complaints in every hospital.
The biggest disappointment is long-term care: elderly people will now receive free nursing care in local residential or nursing homes but not the free personal care (bathing, feeding, dressing) which the royal commission recommended. The toughest job will be that of the nurses who have to decide which particular services are "personal" and which "nursing". Even more troubling for the government is what can be done by election time. Banishing dirty wards, inedible food, and grim grey corridors would be a quick - and cheering - start.
