The first 100 days of the coalition government

The coalition government has moved quickly in its first 100 days to set out its plans for the NHS in England. Although ministers have stressed that these plans build on Labour's health reforms, in reality they are much more radical. Tony Blair's policies may have paved the way for choice and competition to play a bigger part in the NHS, and Ara Darzi laid the foundations for quality of care to be taken seriously, but neither sought to do so at the speed and the scale now proposed.

The new government's plans are genuinely distinctive in their intention to give general practices almost all of the responsibility for commissioning as primary care trusts are phased out. To persuade general practitioners to take on this challenge, the government will have to negotiate a revised contract with the British Medical Association (BMA), and this will take time. The need to reassure the Treasury on how GPs will be held to account for the use of budgets may be a further brake on progress.

Previous reforms have relied on general managers to act as the shock troops of change, most notably in the internal market introduced by the Thatcher and Major governments in the 1990s. The coalition government's distrust of managers and its commitment to significantly reduce management costs mean that this option is not available this time round. Ministers have placed enormous faith in the ability of entrepreneurial GPs to make change happen and it remains to be seen whether this is justified.

So while the health White Paper has set out a clear direction of travel, it is far from a done deal. The history of NHS reform is littered with examples of bold government plans that have been amended and compromised by the politics of health care and the difficulty of implementation. Often, it has been the power of doctors, both nationally through the BMA and locally through their role in influencing change, that has limited the impact of policies in practice.

The next thousand days will determine the fate of the government's plans and their effect on patient care. Ministers and their officials will need to exercise consummate skill to negotiate the political and policy minefields that lie ahead as the hard work of implementation and delivery now begin.

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#212 Dr Paul Worthington
Project Manager
Hereford PCT

Interesting very perceptive comments. However, we also need to bear in mkind the parliamentary arithmetic. The consultation on the White paper closes mid-October, and indithere are suggestions that DoH has booked legislative space for November. If that's the case, draft legislation is almost certainly being prepared already, and the timescales for taking on board consultation responses and views generally will be significantly circumscribed.

#213 WENDY

Will carers be remembered in the White Paper?
Will the fact that carers save the country £87 billion a year have any bearing?
Carers can't afford any more cuts!
Carers need more help!

#214 Mary E Hoult
community volunteer

During March 2006 PCT reconfiguration to reduce the number of PCTs to one our local MPs wrote to the SHA/DOH to say they were disturbed to learn that the savings from that reconfiguration would not necessarily be recycled into the city's health economy and regarded the situation as totally unacceptable.Our health arena is not overfunded and faces major challenges in terms of addressing the historic imbalance between community and hospital services,it is therefore essential that these new arrangements explain how savings will made for the benefit of our local community as they are not clearly defined within the white paper.Who's responsibility will it be to do this?and how will it be reported back?I know NHS IC for information for health and social care has a large part to play,I have attended their meetings for over a year and feel they will need to be more patient focused both in their reporting and planning..

#242 paul johnson
retired to Thailand clinical physiologist
advisor to Thai health policy

Professor Ham brings a new overview to the KF, the white paper, and a range of other topics confronting the health of the nation – not just patients. In mentioning the legacy of failed reforms –in fact over the last 40 years –he mentions the role of the medical profession in obstructing progress (true) but no mention is made of the massive role of the population in overwhelming the NHS with a pandemic of lifestyle-related (avoidable and preventable) diseases that now account for 2/3rds of acute and chronic diseases and the same proportion of direct and indirect health costs (which exceed direct costs by 4 to 5 fold). With less than 1% of the NHS budget spent on primary prevention it is clear that there is still no thought or action being taken to Securing good health for the whole population (Wanless 2004) which laid out in the clearest of terms the stark choices facing healthcare in the UK (indeed in western influenced global healthcare). His report gave clear guidance and solutions which has been totally ignored. Instead we are being offered a US version of integrated care which is a hijack of the term and only another version of focusing on the failure of attempting to integrate a sick service –integrated care pathway for the patient – which has besotted UK health thinking for over 30 years. Has anyone noticed where the US languishes in the world league of health outcomes with the highest real and GDP expenditure on sick care? Instead look to the Thai government policy of integrative care which is a genuine cycle of promotion - prevention – cure – rehabilitation –where the population is urged to return to primary self-care with a genuine holism of mind and body care. Instead the UK is spending trivial amounts on the mindless (literally) approach to exercise and diet as if these will reverse Europe’s worst trend in lifestyle-related diseases. Even the Canadian government has recognized (2009) what the Thai government recognized in 1978 that the best ‘health service’ can only account for 17% of a nation’s health –real change is a societal decision beyond healthcare. Mr. Cameron asked the electorate to share the responsibility of societal reform –well now is the hour - we do not have another 1000 days to see what happens with the latest health reform - unless the promise of real increase in health spending is not simply going to be swallowed up in meeting the society’s self inflicted pathway to more ill-health. By the way where is the medical leadership on the nation’s health –wasn’t this the brief of the CMO?

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