The vision: a health service designed around the patient In 1948, every dropped bedpan was to reverberate around Whitehall, according to Nye Bevan, the then health secretary. Yesterday, the NHS plan shifted that central accountability away from the government's corridors of power and out into hospital wards, GPs' surgeries, local authorities' chambers and even the patient's home.
Setting out its vision, the government said its plan was to build a health service for the 21st century, one that was designed around the needs of the patient. It wanted a "leaner more focused centre with the secretary of state devolving powers", and aimed to offer fast and convenient care delivered to a consistently high standard, with services that were tailored to people's individual needs.
"Our vision is of an NHS where staff are not rushed off their feet and constantly exhausted; where careers are developed not stagnant; where staff are paid properly for good performance; and where child care is provided in every hospital," said the NHS plan.
"Ours is a vision of a renewed public service ethos, a system that values the dedication of staff and believes that trust is still the glue that binds the NHS together."
The top-down, dropped bedpan model "failed to provide the local innovation, and the responsiveness to deliver sustained improvements in patient care".
The government admitted that it would take time to realise its vision, but said that over the next 10 years the NHS must be redesigned to be patient centred. It said that the task for the plan was to show how to bridge the gulf between the reality of the NHS today and the vision of what it should be like tomorrow.
What's wrong with the NHS?
In his introduction to the report, the secretary of state for health, Alan Milburn, said that today's NHS was not sufficiently designed around the convenience and concerns of the patient.
"The NHS provides many patients with a good and reliable service. But it is simply not responsive enough to their needs," he said. "Patients have to wait too long for treatment. Records get lost. Wards are not clean. Standards are too variable. Old-fashioned demarcations between staff, restricted opening and operating times, outdated systems, unnecessarily complex procedures and a lack of training all combine to create a culture where the convenience of the patient can come a poor second to the convenience of the system."
The report said that the NHS was a 1940s system operating in a 21st century world. It criticised old-fashioned demarcations between staff which meant some patients saw a procession of health professionals to whom they often had to recount the same details. Information was not shared and investigations were often repeated.
The report said the fault line between health and social care which had existed since the service was created in 1948 had inhibited the development of services shaped around the needs of patients.
It criticised the NHS for doing too little to prevent ill health in the first place. "The health gap between the better off and the worst off in society has widened in the last 50 years. The gap between health need and health services remains stubbornly wide."
The relationship between service and patient was too hierarchical and paternalistic. The NHS was also criticised for inadequate levels of modern equipment, and IT investment had been "too slow and too patchy".
What will happen in the future?
The public's main concern about the NHS was waiting times, and the plan said that these would be cut.
"The traditional waiting list for surgery will become a thing of the past. There will be waits of weeks rather than months. The uncertainty of not knowing when your operation will happen will be replaced by the certainty of a booked date."
The government said that, by the end of 2005, waiting lists for hospital appointments and admission would be abolished and replaced with booking systems. The maximum waiting time for an out-patient appointment would be three months, and for in-patients, six months. It was hoped that by 2008 the maximum wait for treatment would be cut to three months and 75% of operations would be carried out on a day-care basis. By 2004 patients would be able to have a GP appointment within 48 hours.
As a result of the plan, there will be 7000 extra NHS beds by 2004 along with a substantial investment in NHS buildings. Between now and 2004 there will be 7,000 more consultants, 2,000 more GPs, 20,000 more nurses, and over 6,500 more therapists and other health professionals.
Patients
The plan said that too many patients felt talked at, rather than listened to, and that this had to change.
A patient would have the right to fair access and high standards wherever they lived. They would have greater power and possession of their illness, their choice would be strengthened and they would have more rights. Eventually they would have smart cards containing medical records. These electronic patient records would enable nurses, therapists and doctors to maintain continuity of care and knowledge of patients.
Appointments would be pre-booked to suit the patient, and tests and diagnosis would be carried out on the same day. Patients would have proper redress when operations were cancelled and would have access to patients advocates and advisers, a service that would be set up in every hospital.
By 2001, the patients' charter would be replaced by the NHS charter, which clarified the NHS commitment to patients and their rights.
Better, faster services
The plan said that waiting times in accident and emergency departments would be drastically reduced; no one should wait more than four hours and most should be seen within 75 minutes. The proposal meant big changes to the way casualty departments worked, and patients with minor injuries would often be treated by nurse practitioners.
The role of NHS Direct would increase to try to unplug choked areas of the system, particularly accident and emergency departments. The plan said: "By 2004 a single call to NHS Direct will be a one-stop gateway to out of hours healthcare, passing on calls, where necessary."
The government promised better out of hours pharmacy services and to make available a wider range of over the counter medicines.
Newer, cleaner hospitals and better food
The government promised to build a new generation of state of the art hospitals with more intimate ward bays or rooms rather than the old style Nightingale wards. Eventually each patient would have their own television and telephone.
Over £30m would be allocated immediately to hospital trusts to improve hospital cleaning, and a nationwide clean-up campaign would start immediately. All patient areas, visitor toilets, outpatients and accident and emergency units would be thoroughly cleaned and maintained. Each hospital would have an unannounced inspection of its cleanliness in the next six months, and the results would be made public.
The plan said that the NHS provided more than 300m meals each year and the food was "variable in quality, is not provided in a way which is sufficiently responsive to patients, and too much of it is wasted as a result".
By 2001, there would be a 24-hour NHS catering service with a new menu designed by leading chefs. Half of all hospitals would have new "ward housekeepers" in place by 2004 who would ensure the quality of meals and that patients were able to eat them. An extra £10m would be provided for improvements in hospital food.
Better pay
Improvements would be made in pay for NHS staff, the plan said. There would be more help with accommodation costs, and the concept of staff hotels would be evaluated.
The national recruitment campaign would be extended, and the way NHS employers treated their staff would be linked to the financial resources they received. Every NHS Trust would receive £25,000 to be spent on improving the working environment for staff, and childcare provision would also be increased.
Changing role of health department
The role of the department would change so that it would champion the interests of patients by applying both pressure and support.
By 2004, there would be a new relationship between the government and the NHS and devolution would have taken hold. The same year, the share of NHS spend on management costs would be cut so that a higher share of every pound went into frontline patient care.
Consultants
A move from a consultant-led to a consultant-delivered service would provide a clear career structure for doctors. Contracts would be overhauled; the issue of consultants' private practice would be addressed and performances would be reviewed; and two-thirds of consultants would get a superannuable bonus. The financial reward to new consultants would be increased, but they would not be allowed to take up private work for seven years.
Nurses
Nurses would be empowered to undertake a wider range of clinical tasks, including the right to make and receive referrals, admit and discharge patients, order investigations and diagnostic tests and run clinics and prescribe drugs.
By 2001, 23,000 nurses would be able to prescribe a limited range of medicines. Staff would be given training if they wanted to take on new roles. Support staff would each have access to £150 from a learning account.
Cancer
The plan stated that the provision of extra investment, improved prevention and changed ways of working would mean that cancer services would improve. It would invest an extra £570m by 2003-04. The breast screening programme would be extended from ages 50-64 to ages 65-70. Cervical cancer screening would be upgraded, and there would be an expansion in cancer screening drugs. An end would be brought to the postcode lottery in the prescribing of cancer drugs.
Coronary heart disease
A £230m investment by 2003-04 would be accompanied by the establishment of rapid access chest pain clinics across the country. Clot-busting drugs would be available within an hour of calling for professional help, and ambulance response times would be improved.
New equipment
New equipment would also be introduced: 50 magnetic resonance imaging cancer scanners; 200 CT cancer scanners; 80 liquid cytology units to improve cervical cancer screening; 450 new and replacement kidney dialysis machines and 3000 automated defibrillators, which would be placed in public places. Up to date information technology systems would be introduced for which the NHS Plan would provide an extra £250m by 2003-04.
Modernisation and scrutiny
A modernisation agency would be created to help local clinicians and managers redesign local services around the needs and convenience of patients.
The NHS would be made subject to independent scrutiny, and local government would also be given power of scrutiny.
Concordat with the private sector
The government plan outlined a concordat for the relationship between the NHS and the private sector, which it said would not compromise the principle underpinning the plan. It said: "Under our proposals a patient would remain an NHS patient even if they were being treated in the private sector."
Improving health and reducing inequality
The report said that the gap between health needs and health services remained stubbornly wide. The plan aimed to tackle the specific needs of differnt groups as well as disadvantage in all forms. The government would set a target to narrow the gap in infant and early childhood mortality and morbidity between socio-economic groups. By 2002 it would develop a new health poverty index. The plan said that the "inverse care law" still applied to too many parts of the country. There would be a new way of distributing resources to address iniquities in poorer areas.
Reducing smoking and eating fruit
For the first time, a quitting service would be provided on the NHS, with nicotine replacement therapy available on prescription from GPs.
A new national school fruit scheme would be introduced, whereby every child in nursery aged four to six would be entitled to a free piece of fruit each school day. This would coincide with a programme to get the public to eat five pieces of fruit or vegetables a day.
Mental health
Extra investment would bring 500 more secure beds and 1,000 new graduate primary care mental health workers, as well as 500 more community health staff.
The plan would also see early intervention to reduce the period of untreated psychosis in young people, with 50 teams established over the next three years.
The plan said: "By 2004 all young people who experience a first episode of psychosis, such as schizophrenia, will receive the early and intensive support they need."
Support for carers
By 2004, there would be 7,000 more staff recruited to provide relief to carers and reduce the risk of social isolation.
New health targets
• Maximum waiting time for an operation to fall from 18 months to six months by 2005 and to three months by 2008
• Maximum waiting time for outpatient appointments to fall to three months by 2005
• Maximum waiting time at accident and emergency to fall to four hours by 2004. Average should fall to 75 minutes
• If an operation is cancelled on the day of surgery for non-clinical reasons, the hospital will have to rearrange for a date within 28 days. Or it must pay for the patient to go private at time and hospital of patient's choice
• Maximum waiting time to see a GP will fall to 48 hours and to see a primary care professional to 24 hours by 2004
