What the public said to the bishop and the peer was that they wanted an alternative to the health authority's plans. Pat Healy reports

When Bishop Mark Santer was invited to preach at a Birmingham medical conference, he did not pull his punches.

He laid into the internal market in no uncertain terms, despite the presence of the then health secretary, Virginia Bottomley, who was visibly upset.

So when, last December, Birmingham health authority took the unusual step of setting up an independent panel to examine its controversial proposals for the city's future health needs, Bishop Mark, as his staff call him, was a natural choice.

He joined a cross-section of city leaders, including councillors and ethnic minority representatives, in a bold extension of the usual consultation process.

Chaired by former NHS Confederation chief executive Lord Hunt, the panel was given a free hand in how it carried out the task, provided it met in public and took evidence from a wide range of experts and stakeholders.

Alarm was already rife. The flak was directed mainly at what would happen to hospitals.

The HA floated the idea of 'ambulatory care', swiftly dubbed 'bedless hospitals', to increase day surgery and outpatient services and reduce acute admissions.

It forecast that technological advances would mean that 85 per cent of surgery could soon be done without an overnight hospital stay.

Proposals included a new£200m hospital, funded through the private finance initiative, to replace the two hospitals run by University Hospital Birmingham (UHB) trust.

There was widespread suspicion that accident and emergency departments would close and the City Hospital, serving one of the most deprived communities, would either close or be substantially downgraded.

Few critics appeared to notice that the HA was also emphasising the need for more GPs and an expansion of primary care.

Lord Hunt says now that the panel expected to hold four or five meetings, but found it needed 20.

It took evidence at four public sessions, which were rather like parliamentary select committees, with the panel examining witnesses from HAs and trusts, community health councils, local MPs, unions and others.

The bishop proved a robust questioner, particularly of trust managers he felt might be claiming an unfair share of the cake.

He demanded to know whether Jonathan Michael, UHB chief executive and architect of the£200m PFI hospital plan, thought his trust should 'be the one where it all happens, or do you think the plums ought to be spread around?'

It was the kind of questioning that gave the panel credibility in the face of early forecasts that it would merely be the HA's poodle.

And while sceptics still charge that the panel has followed the HA agenda, the report of its findings, published last week, is giving hope that change may at last be under way.

Dr Michael remembers his exchange with the bishop as a 'robust discussion', in which he retorted that the aim of providing the best clinical services should not be treated as plums.

For him, the real question is how services can best be provided, rather than the idea of 'just sharing on a 'two for me and one for you' basis'.

Nevertheless, he says now that he found the session 'a very effective way of presenting the issues'. Like most trust managers in the city, he welcomes the report's approach. It talks of the need for trusts to be 'prepared to sacrifice some of their more ambitious plans, however painful this may be', in the interests of the city as a whole.

The bishop says Birmingham has lost out on major investment because of the lack of co-operation between trusts, which he attributes directly to the spirit of competition produced by the internal market.

The panel report, which will be considered by the HA in July, along with other responses to its consultation document, backs the idea of a new hospital, which it says has to be PFI funded because that is the only source of capital available at present. But it says£200m is too expensive, and wants a cheaper solution.

The panel also wants the City Hospital to be given a clear role as a district general hospital and as a medical school, with full A&E, paediatric and maternity services. It wants it to be the pioneer for developing the first ambulatory care centre and models of intermediate care, developed with local GPs.

But the report says primary care should be the 'absolute top priority' and urges the setting up of a taskforce.

Its development should have 'first call on capital and revenue resources', which causes a few problems for HA chief executive Mike Waterland, who nevertheless says the panel report is in line with the authority's thinking.

He is pleased with the outcome and is considering recommending action now rather than having another consultation after a new strategic plan has been drawn up.

That would not go down well with South Birmingham CHC, which welcomes the report's emphasis on primary care and services for ethnic minorities, but remains opposed to a new hospital in the city.

Chair Ursula Pearce says the report follows the HA agenda, reducing inpatient care by half and producing more cuts if the new hospital goes ahead.

She points out that Queen Elizabeth and Selly Oak hospitals, which the new hospital would replace, have had£60m invested over the past four years, which has produced 'wonderful new facilities'.

Arguments will continue, but the contribution of an independent panel appears to have opened up the possibility of change. As the report itself says, Birmingham can now 'either grasp this opportunity to build a world-class health service' or face declining health services which will fail to meet needs.

Simply the Best. From Kim Blackford, Birmingham HA, St Chad's Court, 213 Hagley Road, Edgbaston, Birmingham B16 9RG. Free.