Tony Blair is said to be frustrated by the pace of change in the health service, so how must the public feel? Lynn Eaton reports

The clock is ticking on Labour's pledge to modernise the NHS. It is a year since the Health Bill had its first reading in the House of Lords, more than two years since The New NHS white paper - setting out the government's plans to reform the health service - was published, and it could be just a year until the government goes to the polls.

Nearly three years into a Labour government, how is it measuring up? Has New Labour managed to change the face of the health service sufficiently to convince voters that it is not only safe, but cherished, in Labour's hands?

'The NHS, ' promised prime minister Tony Blair, 'will get better every year so that it once again delivers dependable, high-quality care-based on need, not ability to pay.'

In a month when we have had the Shipman case, the Bristol inquiry is still trundling along, and a doctor in Scotland has been amputating perfectly healthy limbs from disturbed patients, things aren't looking too good.

True, there has been a rash of potentially votewinning initiatives - walk-in centres, NHS Direct and a reasonable nurses' pay deal among them. But does Joe Public realise the internal market has been abolished?

Or have any idea what a primary care group does?

Probably not, says Simon Williams, assistant director of the Patients Association.

'Generally, patients will pick up on the bad news we all hear in the press and expect the worst. In terms of PCGs and the National Institute for Clinical Excellence, patients won't know much about the changes.'

But if these are key to the new-look NHS, how does the government expect to sell concepts which are so difficult to dish up in easy soundbites for the general public's consumption?

Take PCGs, which came on stream in April 1999, and the primary care trusts launching this April. A patient visiting their local GP's surgery is unlikely to have in the service they receive as a result of the change.

In fact, the government announced last week that it was to set up a project monitoring their work and coming up with good news initiatives in an attempt to highlight what they do.

'Of course, it is a 10-year project, ' says Dr Michael Dixon, chair of the NHS PCG Alliance, admitting that it will be some time before inroads are made in the overall health of the local population. As for the equality-for-all philosophy behind PCGs - replacing the have/have-not divide of fundholding with a co-operative system - that too will be a long way off.

'Some practices are losers, some are winners, ' says Dr Dixon. 'But the idea of everything levelling up is not realistic. What is happening is levelling out.'

He believes the biggest change patients will see is in their access to hospital treatment or local initiatives which eliminate long hospital waits. Like having a community psychiatric nurse working with primary care to deal with young people who would otherwise wait 18 months to see a child psychiatrist.

But last week's Audit Commission report on PCGs said most were 'struggling with limited staff' and 'facing barriers to success'.

They suffered from poor data and information technology and were finding it difficult to resolve the conflict between local initiatives and central targets.

Another much-trumpeted reform, NICE, was launched in April 1999. But its recommendations on 20 different medical technologies - from treatment for schizophrenia to having your wisdom teeth removed - are not due to be available until March at the earliest. Will its recommendations arrive in time to influence voters at an election?

John Sussex, associate director of the Office of Health Economics, doubts that, even if the reports are done quickly, they will have much impact. 'I'm not sure NICE is a vote-winner, ' he says. 'The real issue is how much money the health service has got to spend.'

What about the Commission for Health Improvement, then? It, too, will have had little time to prove itself - it only starts work this April.

Director Peter Homa says CHI was briefed to produce high-quality work as soon as possible.

'Certainly, by 2001, depending on when the election is called, CHI will have completed a number of important pieces of work, ' he says.

Nigel Edwards, policy director at the NHS Confederation, doubts whether CHI, NICE or any of the other initiatives will, on their own, be vote-winners.

'We have to see it in the larger context of improving the patient's experience of the NHS and maintaining public confidence, ' he says. 'Public perception is perhaps, at the moment, quite poor. The government is worried about losing it.'

Mr Edwards says he has 'heard from a number of people who get to speak to Tony Blair' that the prime minister is becoming increasingly frustrated at the pace of change in the NHS.

'Tony Blair wants to know why, if there is good practice, is the idea not being picked up and implemented elsewhere.

'The service is not in a good position to explain that.'

Former health secretary Frank Dobson rashly predicted in January 1999 that 'one of the most noticeable changes that patients will see is the introduction and deployment, over time, of 21st century technology'. The reality is still a long way off.

He promised that, by the end of 1999, all computerised surgeries would be hooked up to NHSnet. But in August 1999, the government announced that connecting all GPs was 'not strategically practicable'. By the end of the year, only 2,500 surgeries out of a possible 9,000 were connected to NHSnet.

He said pilot projects allowing patients to book hospital appointments from their GP's surgery would be under way by the end of 1999. They were, but a report from Birmingham University health services management centre revealed that only four of the 24 pilots had any plan to give booked dates for inpatient treatment. Most could only book outpatient clinics or day surgery.

Online prescribing has been 'rolled out' with between 3,000 and 3,500 surgeries having access to the Prodigy computer prescribing package, estimates the Department of Health. But that is still only a third of all possible GP surgeries.

Mr Dobson had hoped that hospital test results would be sent by computer direct to the doctor's surgery by the end of 1999, but this has been delayed by nine to 12 months to decide on a suitable encryption service to keep records confidential.

And plans for prescriptions to be sent by computer direct from doctor to chemist by the end of 1999 are also delayed. A project linking GPs to community pharmacists is not now due to start until 2001.

Work has only just begun on replacing the old 'Lloyd George' wallets for patient notes with electronic patient records. The DoH is merely at the point of selecting 'demonstrator communities' for a pilot due to start this spring.

Among many other provisions, the Health Act introduced a duty of partnership between health and local authorities. Has anybody noticed a difference yet?

John Ransford, head of social affairs, health and housing at the Local Government Association, believes that many councils are getting on with it anyway, legislation or not.

'A lot of key measures don't come in force until April. And we haven't even seen the detailed regulations yet, ' he says.

Councils saw the draft in the autumn. 'We were concerned that too many projects needed special approval from the health secretary.

'But at least having a statutory requirement will make working in partnership the norm, rather than the patchy provision we have now.'

So is the new NHS going to be the modern, dependable service the public has been promised?

Certainly, Tony Blair is getting impatient. And Alan Milburn is making 'get on with it' noises. In last week's speech to the King's Fund, he pushed the now frequent message that investment and reform was key to the sustainability of the NHS.

'If we poured in extra billions and still failed to meet modern public expectations of the NHS we would run the risk of fatally wounding the public's support for a universal, tax-funded health service, ' he warned.

At the moment, the need to restore public confidence is the greatest need of all, argues Alan Maynard, professor of health economics at York University.

'All of it is going to be a big focus on quality, ' he warns. 'Trust was cheap. Managing an effective monitoring system is going to be very expensive.'

What the Health Act did for the NHS abolished fundholding;

set up a structure for primary care trust finance and organisation;

established the Commission for Health Improvement;

gave a duty of partnership between health and local authorities;

introduced new price checks on the pharmaceutical industry;

introduced measures to tackle NHS fraud.

Source: Audit Commission. The PCG Agenda: early progress of primary care groups in The New NHS.