Gone but not forgotten

It was a year that saw tobacco ads banned, ugliness at CHAI, Milburn stepping down, Reid stepping in, and a punch-up over foundation hospitals.Also, the weight of a 'portion'of f fruit and veg was revealed

January

The largest pay modernisation programme in Europe finally gets underway with publication of the Agenda for Change proposals.

The plans were revealed after four years of negotiation that made the Oslo peace accord on the Middle East seem straightforward - and after a premature launch of 'outline' proposals a couple of months earlier, which gave the government some good headlines but left a lot of questions unanswered. Core to the proposals are the 100-odd job profiles that give many staff the first indication of where they will be in the new pay bands.

Also in January: eight private companies win a place on the government's franchise register, along with 68 three-star trusts; health secretary Alan Milburn institutes an 'exceptional tracking exercise' to locate missing cancer cash; the Laming report into the death of Victoria Climbié is published and cites widespread organisational malaise as the root cause of the tragedy; and Department of Health human resources director Andrew Foster admits the government has had to stage a 'major pullback' from its plans to limit consultants' private work.

In the year that will see an emphasis on public health, it is at last revealed what is meant by a 'portion' of fruit and vegetables - of which we should all eat five every day. A portion should weigh 80g.

February The 'death of the directorates' is heralded as an unprecedented dismantling of the NHS's regional structure is announced. More than 4,000 jobs in the four directorates of health and social care are at risk with a 'completely remodelled department' promised by NHS chief executive Sir Nigel Crisp by April 2004.

Strategic health authorities are confirmed as 'the local headquarters of the NHS'.HSJ welcomes the move to a 'slimmed down, better focused DoH', with junior health minister Lord Hunt chairing a bureaucracy-busting committee.

The NHS Confederation says such a large-scale restructuring so soon after the creation of SHAs is 'disruptive and demoralising'.

Mr Milburn extends patient choice with the pledge that by December 2005 all patients should be able to choose their health provider at the point of referral. He also says that from July 2003, all London patients waiting more than six months would get the same choice.

Public health gets a boost as tobacco advertising in magazines, newspapers and on billboards is banned from St Valentine's day.

March As the NHS struggles towards an end-of-March deadline for tough new accident and emergency targets, HSJ reveals that trusts' performance will be measured over a period of just seven days. Progress against the milestone - to admit, transfer or discharge 90 per cent of patients within just four hours - will be determined by situation reports for the last week of March.

Critics warn that trusts will be tempted to throw unsustainable levels of resources at A&E to ensure success in the high-profile area. Sure enough, the end-ofyear target is not just achieved, but surpassed (91.5 per cent of patients were dealt with within four hours). However, the following months see a brief dip in performance until the summer.

As part of the shake-up of the Department of Health, HSJ reveals that one-third of jobs - more than 1,000 - are to be axed.

April Commission for Healthcare Audit and Inspection chief inspector Peter Homa is asked to quit by shadow chair Professor Sir Ian Kennedy because of a policy clash on how the new body was being created, HSJ exclusively reveals.

Publicly, both insist that 'personal differences' are at the root of the rift, but sources in the scrutiny world insist that differences between the pair centre on Sir Ian's determination to create CHAI 'from scratch', and his fears that Mr Homa wants to model CHAI on the Commission for Health Improvement.

CHI insiders privately admit to being furious about Sir Ian's decision to ask Mr Homa to stand down, and the way the situation was handled. And commissioners for CHAI say they were not consulted over the decision.

CHI members also accuse Sir Ian of behaving as though he were an executive chair.

CHI chair Dame Deirdre Hine says in a press release that Mr Homa was the 'obvious and ideal choice for the role... and will be very difficult to replace'.

May Relations between the DoH and British Medical Association reach a low for the year as trusts are encouraged to introduce a consultant contract that was rejected by English doctors.

Consultants voted last year to reject the negotiated contract, and despite a coup d'etat in the BMA consultants committee that results in a demand for a renegotiation of the contract, Mr Milburn is adamant that the existing deal should be introduced on a piecemeal basis.

Four SHAs are also tasked with identifying a dozen trusts within their borders to introduce a 'fee-forservice' payment scheme for consultants, but no-one bites. Nor can HSJ find a single trust willing to implement the contract locally.

Eventually the government is persuaded back to the negotiating table, and a new deal is struck in October.

June Mr Milburn's shock resignation as health secretary, due to family pressures, gives the BMA hope in renegotiating the consultant contract with successor John Reid.

While Mr Milburn's departure might have brought relief for some - including, observers speculate, NHS chief executive Sir Nigel Crisp - there are concerns that the almost all-new health ministerial team is too inexperienced.

The first challenge Mr Reid tackles is improving emergency care by moving it from a junior to senior ministerial portfolio.

But Sir Nigel does not entirely relax this month as he is irked by an Audit Commission report criticising the star-ratings system that is said to be 'quite weakly' related to performance and management ability.

Questioning the reliability of data used, the NHS chief laments the commission's 'great disservice'. But the DoH can celebrate, meanwhile, as unions agree Agenda for Change can be piloted at 12 sites.

Though Mr Milburn escapes healthcare politics, he does not avoid the spotlight entirely. HSJ hears of a friend who borrowed two valuable albums by The Jam, 20 years before. ] She will return them for 'the price of single measles, mumps and rubella vaccines' for her son.

July The first star-ratings to include primary care trusts are published, and overall they show high performances across the north of England and the South West, while central and southern areas are the main recipients of low scores.

Four hospitals lose their chance to gain foundation status in the first wave, after dropping one or more of their three stars.

Newcastle upon Tyne Hospitals trust falls from grace due to a single breach of waiting times. The trust will later meet with CHI to demand the right of appeal.

PCTs fare well in their first round of star-ratings, with twice as many receiving top marks than no stars, although London and Birmingham PCTs perform poorly.

Just one month after Mr Reid said there would be no renegotiation of the consultant contract, talks with doctors' leaders result in several concessions by the government.

Mid-summer also sees the announcement of 35 pilot children's trusts, set up following the Victoria Climbié inquiry. Pilot managers call for assurances that the trusts will not be centrally controlled.

In Scotland, meanwhile, children's health is perhaps not being treated quite as it should. Despite a£250m framework to promote healthy lifestyles, a concession stand in a Scottish hospital is reported to be giving out free Mars bars with every two purchases made.

August Three weeks after Mr Reid pledged to extend patient choice beyond elective care, the Department of Health unveils a major consultation process.It will explore what patients want from their health service in a radical exercise likened to the NHS plan. NHS chief executive Sir Nigel Crisp announces that eight expert task groups will be set up to focus on the areas of children's health, mental health, primary care, emergency care, maternity services, long-term conditions, older people's care and elective care.

Director of patient and public involvement Harry Cayton is appointed to head up a central coordinating team across the groups.

Meanwhile, it is revealed that the NHS Bank will offer financial support to trusts facing the biggest financial losses under the government's payment-by-results policy, and a consultation paper is published that contains proposals to overhaul the pay structure for chief executives and directors across the NHS.

September The DoH announces the names of seven preferred bidders for the government's independent sector treatment centre scheme.

The schemes, which cover 22 localities, amount to approximately two-thirds of the£2bn budget for the programme, which is set to treat 250,000 patients a year in purpose-built and staffed facilities. The domestic private healthcare sector fails to win any significant contracts in the first round of announcements.

The Commission for Patient and Public Involvement in Health announces the contracts for local network providers, which will provide administrative support to the new patient forums.

And the government abandons the A&E access target, stating all patients must be dealt with within four hours.

Meanwhile there is bad news for health service managers as only 27 per cent of MPs rate them as great leaders, according to a National College of School Leadership poll of public sector managers.

October HSJ launches its campaign for a radical overhaul of crumbling mental health hospitals, after managers report a growing battle to provide therapeutic care. A visit to South West London and St George's Mental Health trust finds gloomy staircases, crowded wards with beds separated only by curtains, and dirty carpets and paintwork. Replacement of the unit is expected in around five years.

'To be honest, it breaks my heart when I have to say no to the people in places like this, ' admits trust director of estates Andrew Simpson. 'Our patients and staff are the people who bear the brunt of inadequate environments.'

It is a tale repeated by mental health trusts around the country who must decide between finding the cash to refurbish crumbling estates, or gritting their teeth and waiting for a new build.

More pleasant surroundings are available at a centre claiming to be the country's first purpose-built private casualty unit.The Casualty Plus centre in Brentford, west London, offers consultations for an initial fee of£29.

During the month, the Labour Party hierarchy suffers an embarrassing defeat from its conference floor over foundation trusts. But it is probably water off a duck's back to Mr Reid, who does nothing to dispel his hard man image by introducing himself to a conference fringe meeting as 'Tony Soprano from Glasgow'.

November The gloves come off in the foundation hospitals row, as Labour rebels and loyal backbenchers alike vote against the initiative. It is a fight to the bitter end, but eventually the Health and Social Care (community care and standards) Bill squeaks through by the skin of its teeth (a 17-vote Commons majority) at the end of a game of parliamentary ping-pong.

The House of Lords eventually backs down and agrees not to reject the bill again in an eleventh-hour deal that confirms a number of major amendments, such as a patient forum for every foundation trust and the removal of trust governors' right to approve the appointment of executive directors.

The government also agrees to review the performance of the first two waves of foundation trusts once they have been in place for a year. But fears are expressed that this will merely exacerbate foundation opponents' contention that the whole idea will create a 'two-tier' system.

Meanwhile, as the new GP contract begins to take shape, some GPs take the push for the specialisation of general practice beyond the realms of conventional medicine.

County Durham and Tees Valley SHA reveals that one doctor in the region was planning to become an expert in sky diving medicine.

December Prime minister Tony Blair gives the UK's downtrodden commuters something to cheer about at last, by announcing... the renationalisation of the railways.

Well, not quite, but he does unveil proposals that include allowing patients to register with a GP near their place of work.

The plan is part of the launch of Mr Reid's first major policy paper.

Launching Building on the Best: choice, responsiveness and equity in the NHS, Mr Blair talks about finding incentives to ensure patient choice moves to the centre of primary care.

Mr Reid's paper suggests the private sector could be the catalyst to improve performance in primary care, while other proposals include allowing repeat prescriptions to be picked up at pharmacies from 2007.

Government adviser Derek Wanless questions PCTs' ability to deliver a 'consistent approach to public health' in his interim document ahead of the full report, due to be delivered to the chancellor in February. HSJ reveals that ambulance trusts are beginning to feel the out-ofhours strain, possibly as a result of the new GP contract.

Meanwhile, the soon-to-launch Commission for Social Care Inspection demonstrates that it is not afraid to flirt with scandal by holding its first media briefing in the London hotel room where BBC journalist Andrew Gilligan held a fateful rendezvous with Ministry of Defence weapons expert David Kelly.

Heroes &villains

Heroes

Lord Hunt, for resigning in March as junior health minister in protest at the government's intention to declare war on Iraq without UN approval.Supporters and opponents of war salute his integrity in resigning on a point of principle.

NHS chief executive Sir Nigel Crisp takes on the manager-bashing tabloids and their attacks on 'pen pushers', by publishing figures in June which show the proportion of NHS spending on management is falling.

In September, Robert Naylor, chief executive of University College Hospitals trust in London, launches a bid to clear the English waiting list for routine cardiovascular surgery over the next 12 months.

Villains

The 100 per cent four hour A&E target.

In January, emergency access czar Professor Sir George Alberti points out that he does not believe it is achievable or desirable.

HSJ investigates claims in July that consultants taking part in the patient choice project for cardiac patients are using the scheme to refer patients to their own private practice - leaving NHS beds empty.

A report on ambulance services by the Commission for Healthcare Improvement, in March, says more than half of ambulance services may be recording response times inaccurately.

Triumphs & disasters

Triumphs

The NHS Confederation gains an impressive 85 per cent of members'votes to change its status to an employers'organisation. In November, the council of trustees backs the move.

The Kidderminster tendency claims victory when the Department of Health's Keeping the NHS Local report, in February, gives some support to the future of small district general hospitals.

Disasters

Public health experts accuse the government of failing to invest properly in national campaigns to raise awareness of skin cancer, as a record-breaking heatwave peaks in August.

Trusts across Avon, Gloucestershire and Wiltshire SHA are told they will have to make savings totalling£60m, and borrow a further£60m in 2003-04 in the light of£219m debts across the region.The financial meltdown at North Bristol trust, within the SHA area, is described by DoH director of finance Richard Douglas in October as the 'worst in NHS history'.

Would-be foundation trusts attempt to raise public interest in their plans.While some trusts claim thousands have expressed interest in becoming members, one joint public meeting by Guy's and St Thomas' Hospital trust and King's College Hospital trust in November attracts just five members of the public - including one HSJ journalist.