'Admitting that the NHS does not always offer a 'world-class service' is a high political risk'

When strangers ask what I do for a living, I sometimes hesitate before answering.

It's not just because explanation lasts rather longer than the casual questioner's interest ('yes, it's health journalism; no, not about nips, tucks and six-packs; no, it's not medical; yes it's about NHS management; no, a thousand times no, it's not run by the Department of Health').

It's probably more to do with the fact that one isn't always in the mood for a heated debate about health reform, NHS managers or, on a very bad day, what kind of parasite would make a living from writing about them. (That's not why I have decided to make this my last regular column - I've just run out of opinions, at least for now.)

So last week, when I clambered into a cab after a night celebrating the very finest in health
management, courtesy of the HSJ Awards, and found myself being asked how I had spent the evening, I may have sighed before answering the question.

With a 10-mile journey ahead, honesty seemed the best policy. And, a few minutes later, as the driver uttered the phrase: 'I'll tell you what the problem is with the NHS', I braced myself.

'I'll tell you what the problem is: they put all this money in but they didn't change enough about the way things are done. So now, nearly 10 years since Labour came in, we've got all these rows about closing casualty departments. The way I see it, if they needed to change the way hospitals are run, they should have done it as soon as all the money came in.'

On he went: 'And as for choice, what's all the fuss about giving people a choice of hospital, when most people hardly ever go there? What they really want is a choice of GP, and some way of knowing if the one they've got is any good or not. Sorry love, can you tell me the way to the Lea Bridge Road?'

I looked up, that suspicious gap in the Knowledge reinforcing my growing suspicion that, in its desperation to speed the reform agenda, the government had resorted to commissioning Mori's finest to moonlight as cabbies.

In fact, the basic thrust of the conversation somewhat echoed many conversations held earlier that evening with managers working in all types of different NHS areas.

But amid a lingering sense of regret that tough decisions weren't taken a long time ago, there had been some constructive ideas about what would help that process now.

At the start of this financial year, I suggested that the NHS needed hope, leadership and clarity. Eight months on, signs of both hope and leadership are encouraging. Chief executive David Nicholson's pronouncements on reconfiguration have been largely helpful, the new generation of leaders have made a confident start and initiatives such as the involvement of veteran NHS manager Sir Ian Carruthers in a 'sanity check' of reconfiguration plans have brought in a welcome injection of wisdom and experience.

I am writing this a few days before the DoH publishes its operating framework, when some hopes remain that the government will have something good to say on the issues of historic debt and resource accounting budgeting.

No operating framework can keep everyone happy, but the document's timely publication - a month earlier than last year's - at least recognises the importance of planning time, and the road testing of the payment by results tariff shows the DoH is prepared to listen as well as eat humble pie over last year's fiasco.

One subject much under discussion during the awards was the need for NHS organisations - primary care trusts in particular - to take a more businesslike approach to decision-making. When it comes to reconfiguration, this means setting out both a clear business case for the requirement to change and the risks attached to a failure to do so. In business, this is usually represented in pounds. In the NHS, it can also be measured via the more precious states of life and death.

Last week, the government embarked on a media offensive, lining up the czars and chief medical officer to flank Tony Blair and several ministers in setting out the case for reconfiguration.

The arguments are not new (the documents themselves feel rather like a 1950s skit - read all about Benny and Betty and a game of golf that went horribly wrong), but the government recognises that clinicians offer a credibility that neither ministers nor managers can muster.

Meanwhile - and somewhat more controversially - its favourite think tank was at work. The Institute for Public Policy Research trailed a report due out this month which will suggest that the survival of many district general hospitals could result in more than 1,000 deaths a year. Its analysis draws on research on the best treatment of heart attack patients and those suffering severe injury, and sets out the case for specialist centres.

Associate director Richard Brooks suggests that 'on the strength of the evidence, people should be out on the streets campaigning for changes to NHS services, to protect the health of their families, not to keep services the way they are'.

There is of course a reason why the IPPR is articulating the argument, not Mr Blair. Admitting that the NHS does not always offer a 'world-class service' is a high political risk, especially for a government that has spent almost a decade in power. But it's an issue that NHS managers and senior clinicians need to explore and face head-on with local communities.

One reason for public lack of faith in 'consultations' on change must surely be the tendency of those running them to make statements that fatally undermine each other: services are acceptable but change is vital.

Frightening as it is to concede that some services are not worth saving, the alternative may be more frightening still. Happy Christmas.

Laura Donnelly is news editor of HSJ. A new regular column by healthcare analyst Anna Donald will begin on 25 January.