Drowning, not waving

quality in the new NHS were greeted enthusiastically by managers and clinicians, hungry for fresh thinking after 18 years of Conservative rule.

Four years on, as Labour starts its second term, things have changed, as the rather mixed response from the health service to the latest reforms outlined in Shifting the Balance of Power within the NHS: securing delivery shows all too clearly.

But perhaps managers and clinicians are right to be sceptical about the proposals in Shifting the Balance. We think there are four main areas of concern:

the impact of the proposals on the ability to deliver the NHS plan;

the huge expectations they place on primary care trusts;

the unseemly and unrealistic rush with which they are being carried forward;

the lack of any real evidence to show that these proposals are what the NHS needs.

Securing delivery It seems strange that Shifting the Balance is subtitled 'securing delivery', since the massive reorganisation it presages seems likely to do quite the opposite.

In almost its opening paragraph, the document states that 'everything possible should be done to minimise disruption if the NHS is to remain focused on its delivery of the NHS plan'.

We would all agree with that, but the document goes on to outline a reorganisation that will directly affect virtually every NHS organisation apart from acute trusts.

This is unlikely to secure delivery - it will probably delay it, for at least 18 months, as tens of thousands of people change their jobs, job titles, organisations - or all three.

One good thing about Labour's first administration was its recognition that the NHS had endured years of repeated reorganisations which caused great upheaval and high financial and non-financial costs, but had often made little or no difference to how healthcare was delivered.

Ministers spoke of their intention to avoid wholesale restructuring, and to seek more meaningful ways to deliver change. That resolve has clearly weakened, and Shifting the balance signals a return to the politicians putting their faith in the 'what we need is a good shake-up' theory of improvement.

A bridge too far for PCTs?

PCTs are exciting new organisations in the NHS, with enormous potential to make a real difference to the provision and commissioning of health services. However, just as primary care groups and PCTs are getting to grips with a challenging agenda, developing local health improvement priorities, setting standards for service provision, and making a real difference to services for patients, they learn they are to assume many of the functions previously performed by health authorities.

PCTs are young and relatively fragile organisations (many do not even exist yet, in places where PCGs have yet to move to trust status) and there are already clear signs that new PCTs need to build and develop their managerial capacity just to deal adequately with their existing responsibilities.

Shifting the Balance gives PCTs a huge new programme of work, and risks overwhelming them and damaging the valuable progress they have already made.

Not only are they now expected to extend their role to cover general dental, pharmaceutical and optical services - a logical and exciting initiative - they also inherit many functions from HAs such as needs assessment, partnership working with local government, and so on. PCTs risk becoming more like mini HAs, and losing their unique ability to focus on primary care services and local issues as a result.

Already, many GPs and nurses whose involvement has been so key to making PCG/Ts a different kind of organisation are struggling to cope with the workload. If PCTs start to feel like HAs in all but name, will these practitioners want to stay involved?

What's the rush?

There are plenty of signs that Shifting the Balance is the work of a government in a hurry. Its publication was announced, then delayed, as drafting revisions continued up to the last minute. The consultation period - six weeks over the school and parliamentary summer holidays - is very short for such major proposals, and suggests that relatively little attention will be paid to the comments received.

And the timetable for implementation is very tight, with just six months to bring in the reforms, some of which, like the transfer of responsibilities to PCTs, need new legislation.

Reform in haste, repent at leisure. One risk of the current pace of change is that important functions may get lost in the welter of reform.

It is not clear what will happen to much of the portfolio of regional offices, like research and development, or specialist services commissioning. The implications of fragmenting the public health function - currently focused in HAs - across PCTs, strategic health authorities and government regional offices do not seem to have been thought through.

Another risk of rapid reform is that poorly thought-out ideas slip through because they do not get a proper reality check during policy development or the consultation period.

Perhaps one example is NHS franchising - described briefly in quite confusing terms in Shifting the Balance.No real explanation is offered as to what franchising is actually for.

Where's the evidence?

One real advance of the last decade has been the rise of evidence-based healthcare - but it is not just for clinicians.

Increasingly, managers and policy-makers are rightly challenged to provide the evidence, showing that the benefits of the changes they propose are worth the costs.

On that score, Shifting the balance does not seem to come out well. No evidence is offered that the proposals take account of existing research (indeed in some areas, like the plans for PCGs and PCTs, the proposals run counter to some findings about the size and capacity of primary care organisations).

There is no acknowledgement, let alone an estimate, of the likely immense financial and nonfinancial costs of the reorganisation to the NHS.

If these proposals were treated like a new health technology and presented to the National Institute for Clinical Excellence, would it approve them and recommend that the NHS takes them up?

Where next?

Once the juggernaut of reform has started to roll, it is difficult to stop it or change direction. Having committed itself to Shifting the balance, and with a huge majority in the House of Commons, it seems likely that these proposals are going to be implemented (though it will be interesting to see whether they get a rough ride in the Lords, where the slightest delay could sink the implementation timetable).

That does not make them good reforms, nor does it mean they will help to achieve the ambitious and laudable objectives set out in the NHS plan.

We - and the government - will find that out by 2004 or 2005, when it again faces an electorate that knows nothing about PCTs or SHAs or any of the rest of it - but does know what it wants in terms of waiting times, access to services, and standards of NHS care.

See letters, pages 22-23.

More questions than answers Will the reorganisation delay or detract from existing work to implement the NHS plan?

Is it feasible to reorganise almost completely a 'business'the size of the NHS in six months, and what will be the effects of such a pace of change?

What will the cost of reorganisation be in financial terms (for example, founding or winding up NHS organisations, moving premises, appointing and transferring staff, carrying out redundancies) and in non-financial areas (like staff morale and commitment, the loss of key managerial talent, and the effects of uncertainty and worry about future careers)?

When will the detailed implications of the reorganisation be spelt out, in areas like future responsibility for many functions of health authorities and regional offices, and the future of the public health function?

Will primary care trusts be prepared to take on their new roles, and what will be the effect on their current functions, clinical involvement, structure, size, culture and leadership?

What evidence is there that the direction of change is the right one? How well researched are the proposals, and how will their implementation and its effects be evaluated?

Kieran Walshe is a senior research fellow and Judith Smith a senior lecturer at the health services management centre, Birmingham University.