1997 and all that: Blair remembered

The NHS has transformed remarkably since Tony Blair entered Number 10 in May 1997, reinvigorating a struggling monolith with record investment.

With successes in waiting times and failures in deficits and PCT reorganisation, Blair's reforms have always been controversial, marked by a determined pursuit of market mechanisms.

As he enters the final days of his premiership a number of key players including managers, clinicians and one of his closest advisers look back on his time at the top.

Mark Britnell

My memory of Tony Blair that stands out is his visit to the Queen Elizabeth Hospital, Birmingham, in May 2001 on the day the general election was announced. Many will remember him being barracked by a woman whose partner was suffering from cancer. She complained about the timeliness of care, the ward environment and her partner's transfer from one ward to another due to bed shortages.

The story sums up how I feel about the prime minister. Go to the same hospital now and you will find good cancer waiting times, a brand new ward, new equipment and drugs for leukaemia and bone marrow transplantation, as well as a redesigned care process that has boosted patient and staff morale. You wouldn't recognise the place.

Patient satisfaction for the NHS remains high. In a sense, Blair helped stop a 30-year decline and gave the NHS hope. It's a shame that over the past few years the language of necessary change has alienated some, but we should not underestimate the importance of the 18-week target, which we will achieve during the 60th anniversary of the NHS. But like all things in modern life, there will be more to do and more that could have been done. That is Blair's NHS legacy.

Mark Britnell is chief executive of NHS South Central.

Julian Le Grand

Tony Blair's principal contribution to the NHS is twofold: his understanding of market-oriented reforms, and his commitment to driving them through. The understanding came from an appreciation of the failure of the model that characterised Labour's early years of government in England: one that relied on an uneasy mixture of trust, command and control and middle-class voice, and resulted in increased waiting lists, little increase in activity and service distribution that favoured the better off.

He realised it was essential to embed incentives for improvement in the system, and that gave more power to the patient: hence the drive for competition and choice.

Also crucial was his perseverance in the face of powerful opposition. This is his successor's greatest challenge. The default position of the NHS is centralisation coupled with command and control: the slightest relaxation, and it will snap back.

If his successor does take his foot off the reform pedal, he will preside over a service where long waits reappear, activity and outcomes stagnate, and inequities mushroom.

Julian Le Grand is Richard Titmuss professor of social policy at the London School of Economics and Political Science. He was senior policy adviser to the prime minister from 2003-05.

Nigel Edwards

The NHS is in a very much better state than it was in 1997. There has been an emphasis on quality and waiting-time reductions that would have been unthinkable in 1997. We have learned that targets can work, but for a limited range of things.

There is a long list of positive innovations and achievements including national service frameworks, the National Institute for Health and Clinical Excellence, and the development of regulation.

With hindsight there was a lost opportunity from 1997-2000,. and then the money probably arrived too fast. There have been far too many rushed, top-down reorganisations.

There are a number of areas where his legacy will persist. Perhaps the most significant will be a shift to a mix of health policy using market mechanisms, plurality, regulation, incentives, transparency and the change in status of trusts to bring the English NHS in line with other European systems.

There are significant challenges for his successor, not least the fall in the level of growth, the need for a more effective approach to health inequalities, and poor relationships. Creating the patient-focused system we want will require local leadership - but the system has a habit of relying on hierarchy. A key lesson is not to revert to command and control just because things are getting tough.

Nigel Edwards is policy director of the NHS Confederation.

Pam Garside

The scale of investment in the NHS almost goes without mention as a lasting legacy for our publicly funded health system, but beyond that Tony Blair tried very hard to 'modernise' the NHS in England.

He took an underfunded and undermanaged service with archaic customs and practices and introduced mechanisms to get the patient at the centre of care.

Market dynamics have shaken up surgical and procedural medical services and despite the howls of opposition we are probably thinking and behaving differently towards patients and their agents.

The government has actually asked patients what they think in planning policies. It hasn't all worked but there has been a shift. in view.

An unresolved issue is measurement in its broadest sense. Ten years ago we didn't count much, never mind apply sophisticated analysis. We did not know who our patients were, the nature of our balance sheets or in some cases how many staff we employed.

We still have a long way to go. We deserve a world-class electronic patient record linking all aspects of our service. We have started on the road to outcomes measurement. and we need to bed that in with routine and detailed measurement of clinical outcomes, starting with doctors.

Pam Garside is senior associate at Cambridge Univerity's Judge Business School and co-chair of the Cambridge Health Network.

Carol Black

By 1997 it was well known that the quality of healthcare and the outcomes of care varied widely across the country. But there were few measures against which that quality and performance could be judged, or excellence or failure identified.

The most important contribution to emerge from reform is the dominant focus on the quality and safety of care. We now have explicit and measurable standards for NHS healthcare. The performance of every health organisation is monitored against those standards.

We have a powerful instrument to support change and improvement. When demonstrated at the level of individual patient care, the notion of patient 'centredness' becomes real.

Many problems remain unresolved. Perhaps the most difficult in a changing, market-oriented culture is how to ensure that we retain, in a new form, the professional commitment, trust and advocacy that has been an enduring characteristic of the NHS for almost 60 years.

The new professionalism must now be welcomed and embedded into the health service. Unless this happens the high continuing aims of reform will be hard to achieve.

Professor Dame Carol Black is chair of the Academy of Medical Royal Colleges.

Niall Dickson

The Blair years will be remembered for a remarkable growth in investment years when the excuse or explanation of underfunding as the cause of underperformance became less and less tenable. Some of the extra resources were not well spent and his government stands accused of organisational vandalism in its obsession with finding the right structure. But it was funding with a purpose. Blair and New Labour understood, better than the professionals or the managers in the service, that without faster access to treatment and care public (especially middle class) support for the tax-funded health service was at risk.

The transformation of waiting times in England, the faster access to accident and emergency and cancer and heart treatment have not been without cost, but they are real achievements.

The same can be said for the creation of a set of structures for ensuring more uniform and higher standards across the country NSFs, NICE and the Healthcare Commission, or something like them, are here to stay.

The greatest challenge now is in a sense the same as in 1997 how to transform a health service that is relatively inefficient, reactive without being responsive, and still too dominated by provider interests.

The aim should be to achieve a service that really does help us all to keep as healthy as possible no matter what our current health status may be. We need to continue to devolve decision-making, free up providers, invest in commissioning, re-engage the professions and ensure the incentives are powerful enough and consistent enough to deliver the changes in provision that are needed.

We are still some way from achieving all this but contrary to Harold Wilson's assertion, even 10 years is not a long time in politics.

Niall Dickson is chief executive of the King's Fund.

Tim Kelsey

Giving patients the right to choose where they are treated is one of Tony Blair's best achievements. Although choice has been in the vocabulary of the political classes for a while, it was Blair (and former health secretary Alan Milburn) who made it happen.

This single initiative will guarantee the survival of the NHS in an increasingly consumer-led society. And despite what the cynics say, choice improves the quality of the health service. It will empower patients and their advocates.

The key requirement for Blair's successor is information. Although the government has taken real steps to improve the availability of information on NHS standards and services, there is still a very long way to go. The proposed new online information service NHS Choices [A DoH joint venture with Dr Foster Intelligence] may well turn out to be a landmark.

Tim Kelsey is chair of Dr Foster Intelligence.

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