HSJ's review of 2008: diamonds, debt and Darzi

The year of the NHS’s 60th anniversary began with both main parties scrabbling to wrap themselves in the blue and white flag. Conservative leader David Cameron headed to Trafford General - the Manchester hospital where Nye Bevan launched the NHS in 1948 - while Gordon Brown put the NHS at the centre of what everyone apart from Downing Street referred to as his “New Year relaunch”.

New Year goodies on offer from the prime minister included a greater emphasis on prevention, improved access to primary care and an NHS constitution enshrining patients’ rights and responsibilities.

But staff at the Royal Marsden specialist cancer hospital (some of whom had apparently been less than enamoured with the frequency of the hospital’s emergency fire drills) had a rude awakening to 2008, when they had to put their training into practice with stunning effect when a major fire broke out at the site. Seamless working with staff at the nearby Royal Brompton Hospital ensured the safe transfer of around 80 patients, some still intubated from surgery.

On 17 January HSJ leaked a terse letter revealing the strained relationship between regulator the Healthcare Commission and the government over the handling of fatal C difficile outbreaks at Maidstone and Tunbridge Wells trust. Commission chair Sir Ian Kennedy told health secretary Alan Johnson there was no basis for claims his organisation had failed to keep the Department of Health informed about events at the trust.

The British Medical Association battled to save the nation from the twin perils of new surgeries and longer opening hours, claiming such government policies would “harm patients”. By mid-February relations between GPs and ministers - never an example of mutual love and respect - plunged further after BMA GPs committee deputy chairman Richard Vautrey encouraged members to ignore primary care trust requests for information on practice opening hours.

Meanwhile the antipathy between NHS chief executive David Nicholson and Monitor executive chair Bill Moyes was laid bare with the publication of a series of letters in which Mr Moyes accused the DH of threatening the independence of foundation trusts. The dust-up was triggered by a letter Mr Nicholson wrote to hospitals in the aftermath of the Maidstone and Tunbridge Wells scandal. Rebutting the charge, Mr Nicholson said: “I must admit that I do not fully grasp your point.”

February ended with much weeping at Confed Towers as “supremely effective” NHS Confederation chief executive Gill Morgan headed back to her native Wales to head its civil service. The oft repeated refrain by inconsolable Confed staff that “we’ll never be able to replace Gill” has proved true; 10 months later the post is still vacant and the organisation has yet to decide what the role of her successor should be. “Acting” chief executive Steve Barnett has been acting for so long that they have dropped that bit from his title while the hunt for a new head continues.

By April cracks started to appear in health minster Lord Darzi’s blueprint for reforming healthcare in London, which he drew up before becoming a health minister but were widely expected to give insight into his overall review of NHS services. NHS London board papers revealed the serious risk of the plans being derailed by insufficient leadership capacity in PCTs.

Dirty words

David Cameron used a speech at the King’s Fund to reveal the Conservatives’ big idea for the NHS: a service built round the needs of the doctor. GPs should be free to choose their own opening hours, he argued.

Still on GPs, the P-word (polyclinic) was already a dirty word in the media. As BMA petitions against them popped up in GP practices across the land, The Independent on Sunday derided them as “medical megastores” while the Conservatives claimed their introduction could lead to the closure of more than 1,700 GP surgeries.

That same month eating disorders services received a surprising boost to their profile when former deputy prime minister John Prescott bravely admitted wanted to sell lots of copies of his autobiography revealing he had suffered from bulimia. Visiting a consultant for the condition, he had found the waiting room full of young women. “I felt a right twerp,” he said.

In May, in a moment of schadenfreude for the DH, BMA staff’s own union, locked in a bitter pay dispute, accused doctors of trying to impose a performance pay system they would never accept for themselves. A confidential BMA staff survey leaked to HSJ delivered an excoriating verdict on the doctors’ trade union’s leadership, honesty, openness and politics.

Clinically led

Lord Darzi moved to neutralise public protests against service reconfigurations such as accident and emergency unit closures by insisting any changes were clinically, not managerially, led. If they will not save lives or improve outcomes, don’t bother, was the message.

Quango grandee Baroness Young became a major force in healthcare when she was named as chair of new super-regulator the Care Quality Commission. “Outspoken” and “upfront” were two of the adjectives colleagues used to describe the former NHS manager.

East of England won the race to become the first strategic health authority to unveil its regional strategy as part of the Darzi review. The peer lavished praise on its content, claiming it was “as ambitious as Bevan’s vision 60 years ago”.

The South West meanwhile brought a Mediterranean flair to its report, promising to secure the highest levels of fruit and vegetable consumption in England - a target its chief executive Sir Ian Carruthers later admitted might be tricky to measure.

Surplus games

In primary care, HSJ analysis of PCT accounts revealed they were stuffing chunks of their surplus down the back of the sofa before the Treasury could get their hands on it. Ploys included “proactive asset reviews” and ramping up provision for payments to non-NHS bodies such as hospices.

David Nicholson unveiled Developing the NHS Performance Regime , a plan to replace management teams at failing trusts with teams from the private sector or the health service. NHS Confederation policy director Nigel Edwards scoffed that the plan employed “anti-management rhetoric”, warning managers would be “mad” to take over a “basket case trust”.

In June the Audit Commission and Healthcare Commission joined forces to accuse the government of failing to deliver its plans for reforming the NHS. While they praised shorter waiting times and improved quality, they also said the introduction of foundation trusts, patient choice, payment by results and practice based commissioning had not necessarily brought benefits to patients.

Overwhelmed by media pressure, including stories of patients denied “life-saving” drugs depending on how willing their PCT was to pay for them, Alan Johnson ordered cancer czar Mike Richards to review the ban on patients making top-up payments for expensive treatments not available on the health service.

The next stage

On 30 June, the beginning of the NHS’s 60th anniversary week, Lord Darzi unveiled his long awaited next stage review. It aimed to make the service clinically led and patient centred. A constitution for the health service would enshrine the rights and responsibilities of the NHS, staff, patients and the public. Clinicians were promised more power, providers were told to publish annual quality accounts, with financial incentives and penalties planned to encourage better outcomes, and personalised care was promised for patients with long term conditions.

Gordon Brown told HSJ: “People can look forward with confidence not only to a health service that is better at curing disease and illness, but a health service that is better at preventing health problems.”

Three weeks later NHS West Midlands chief executive Cynthia Bower was named as the first chief executive of the Care Quality Commission. Months later she was still the only full-time member of staff.

BME survey

In August HSJ revealed research from the South East Coast region which showed black and minority ethnic staff got a worse deal on promotions, pay and grievances. Further research by HSJ later in the year showed a similar pattern across the country.

The same month the National Institute for Health and Clinical Excellence was at the centre of yet another media storm, this time over its draft decision not to approve use of four drugs for kidney cancer. An oncologist referred to NICE’s “bloodstained portals”, while Panorama waded in after the newspapers with a poorly balanced programme on the infamous postcode lottery.

It was announced that none of the first wave of London’s much vaunted polyclinics would deliver services from a new, standalone building. Instead, existing services would work more closely together - although to the untrained eye these so-called federated polyclinics might have looked like business as usual.

Hart attack

In September health minister for Wales Edwina Hart announced she had found the perfect person to run the country’s health service - herself. In a plan with more than a whiff of Stalinism, she axed the internal market and put planning and funding in the hands of a national advisory board that she would chair and whose members were government appointees. Regional chief executives and chairs would report to the board. Her Tory shadow, Jonathan Morgan, accused her of “politicising the NHS in a way I never thought possible”.

By mid-October it had become painfully clear the credit crunch was going to hit NHS funding. While the government continued to claim the bank bailout plan would not affect public spending, it was obvious such statements were at odds with reality. The NHS’s£1.7bn surplus was too tempting for the Treasury to ignore. At that time the£38bn cost of the bank bailout plan seemed vast.

Over the following weeks the pre-Budget report and the operating framework for 2009-10 began to reveal the true impact of the crunch. Trusts were effectively stripped of£1bn of surplus and the NHS was lined up to be the biggest contributor to a cut of£5bn in existing spending plans for 2010-11. At the same time, hospitals face having to make efficiency savings to stay out of deficit. As the operating framework spelt out, managers enter the new year facing “a huge leadership challenge”.