Published: 16/06/2005, Volume II5, No. 5960 Page 5

In the six weeks since she became health secretary, Patricia Hewitt has done a lot of listening. In a three-page special, she tells Laura Donnelly what she has learned - and examines the risks and opportunities of the reform agenda

The government will 'keep the foot flat down on the accelerator' of reform - in order to meet the public's 'revolution of rising expectations', health secretary Patricia Hewitt has pledged.

In her first day of interviews since taking up post six weeks ago, Ms Hewitt said current reforms must be firmly embedded and owned by staff, because continued 'flogging' of the current system was not an option. She said 'ruthless performance management' could come to an end - if the service manages to engage staff in changes, including payment by results, practice-based commissioning and choice.

She told HSJ: 'We will keep the foot flat down on the accelerator - but as we entrench and embed these reforms then targets and the performance management become much less necessary and that is part of what is a very big win for staff.' But Ms Hewitt admitted she was aware that many frontline staff felt alienated by the reforms.

'I am acutely conscious - not only because I have read this week's HSJ (Staff 'sick to death of change'; news page 7, 14 and 15, 9 June) - of the fact that a lot of staff, particularly clinicians, feel very alienated from the changes, and feel it is something being done to them instead of something being done with them.' Ms Hewitt insisted there was no contradiction between her promise to 'listen and learn' from staff, and her desire to 'keep the foot on the pedal of system reform'.

She told HSJ: 'Some people have said: 'Well she says she's going to listen and learn - but she also says she's driving ahead with the reforms.

How do these things sit together?'.' Ms Hewitt said that in acute care, although there would be listening and learning 'as we design and implement the detailed policy, ' the major decisions had already been taken, following consultation. This contrasted with the scope of debate she wanted to promote on 'healthcare outside hospitals, ' where consultation will begin in a month, with a white paper by the end of the year.

The health secretary said the consultation would give staff, patients and the public 'huge scope' to design jointly the future of care outside hospitals. She brought up a range of ideas already under discussion among GPs, while stressing that no decisions have been taken about what would be included in the July consultation. These include:

discharge planning with primary and social care before hospital admission;

personalised patient care - with the individual patient's preferences being recorded as part of their electronic medical record;

how to open up choice in primary care while maintaining continuity of care;

increasing access to diagnostics in the community.

She said the tension between choice and continuity had been one of several topics under debate at an 'inspiring' summit of 50 GPs held last Thursday (see box).

Responding to rumours that the government was considering opening up patient registration so that patients no longer registered with an individual doctor, Ms Hewitt said: 'I think what emerged as a common theme from the GPs' discussion is that registration is crucial. . . having the GP practice responsible for the patient record [so that] they in a sense become the guardians of continuity of care.'

What the doctors told Hewitt

At last Thursday's summit of 50 GPs, doctors warned the health secretary that public health and people with long-term conditions would suffer if general practice is not maintained as an individual practice list-based service and GPs' 'generalist' care of patients is not maintained.

Others were concerned that conditions such as diabetes must not be allowed to be cherrypicked by new providers as the Department of Health strives to drive plurality and open up access in primary care.

GP Dr David Haslam, who is a clinical advisor to the Healthcare Commission and the immediate past president of the Royal College of GPs, attended the meeting. He said it would be a 'disaster' if different elements of a patient's care were administered by a 'series of people only linked by a medical record'.

Hewitt's highlights In our three-page interview, the health secretary:

calls for a broad primary care debate;

is 'acutely conscious' that many staff are alienated by reforms;

admits a real risk that patients will be 'sucked into hospital' under payment by results (page 6);

says the market needs 'careful management' and a 'brake in the system' to protect key services (page 6);

is keen to go undercover in scrubs (page 7).