Published: 22/07/2004, Volume II4, No. 5915 Page 12 13

The NHS plan has been described as a catalyst for monumental change.Now, four years after its launch, the plan's signatories comment on what it meant then and to what extent it has fulfilled its original promise, as well as casting light on some of its shortcomings. Mark Gould reports

They would make strange bedfellows, but iconic Old Labourite Aneurin Bevan and smoothly pragmatic New Labour moderniser Alan Milburn have much in common.

Mr Bevan created the NHS and Mr Milburn, despite all his dalliances with the private sector at home and abroad, can be seen as its saviour.

Mr Milburn, then health secretary, was the main architect of the NHS plan, launched on 27 July 2000. It was presented to an ailing NHS battered by years of underfunding, hospital closures and structural musical chairs.

According to those who signed up to the 10 core principles in the preface to the NHS plan it has been a roadmap to success that stays loyal to the founding principles ofMr Bevan - equal access and free care at the point of delivery.

The preface was signed by 25 people representing almost everyone with a stake in the NHS. Four years on, HSJ asked them all for their views and received replies from 18.

The respondents all agreed with varying levels of enthusiasm that the plan has been a success and would happily sign a similar document tomorrow. There was a strong feeling that the plan was a rallying point for those who supported the NHS but wanted to see it evolve away from the tribalisms that beset Bevan.

Professor Jenny Simpson, chief executive of the British Association of Medical Managers, said it was a 'catalyst for monumental change'.

'It addressed the things that had hardly been spoken or written about before - changing cultures and changing the way we do things on the front line and further up. It was everything I had been working towards for 15 years.'

Stephen Thornton, then chief executive of the NHS Confederation, says: 'The NHS plan was a good document, not just because of its content but because it brought all the key players of the NHS together to reach a consensus.'

NHS Alliance chair Dr Michael Dixon stepped off a pedalo on holiday in Brittany to take a call from a Department of Health official asking him to sign up to the core principles. He says it was a 'brave, almost defiant plan to save the NHS when most health professionals thought that it had had its day'.

Dr Dixon says the plan's focus on hospital outpatient and inpatient waiting times, waiting in primary care and heart and cancer care were issues that patients and the public felt were the most important.Of course, such priorities also generate headlines and win votes.

While Mr Milburn was unavailable for comment, one of his closest advisers at the Department of Health, Simon Stevens, said the NHS plan set out to provide four things: a diagnosis, an identification of broad priorities, some new change mechanisms and a bigtent coalition.

He said its diagnosis was 'ground-breakingly honest about NHS under-funding, and rightly paved the way for large taxfunded increases'. And he says its priorities (building capacity, improving responsiveness and dealing with the major killers) 'are still correct' - although he admits that chronic disease has 'only recently' been emphasised.

But support for the plan only goes so far. Many of the signatories feel it was not strong enough on commissioning, mental illness, public health or long-term conditions. Local Government Association vice-chair Sir Jeremy Beecham echoes many when he expresses regret that the role of local authorities in the social care agenda promoting health and well-being was missing.

Mr Thornton, now chief executive of the Health Foundation, says there was insufficient recognition of the critical importance of engaging patients. 'It is interesting to see June's NHS improvement plan saying much more in this regard, such as extending the expert patient initiative, ' he comments.

National Association of Primary Care chair Dr Peter Smith has two major reservations about the plan.

'The IT objectives have proved woefully difficult to implement, ' he argues, 'notably the target that by 2004, 75 per cent of hospitals and 50 per cent of primary and community trusts will have implemented electronic patient record systems. I give the plan 10 out of 10 for vision [in this area], a kind four for effort and two for achievement.'

He also warns that, despite delivering promised changes to patient representation in the NHS, the plan did not achieve true patient empowerment and involvement.

He adds that in the vital area of self-care, 'commitment and progress have been slow'.

Barbara Meredith signed the plan for Age Concern London.

Now speaking in a personal capacity she agrees that a patient-centred NHS is a long way off. She chaired the working group advising on implementing the commitment that clinician letters be copied to patients. She is disappointed that the commitment seems to have disappeared. 'I hope the Department of Health will reinvigorate this important policy.'

Health Development Agency chief executive Paul Streets, who signed as chief executive of Diabetes UK, hopes the improvement plan signals a move away from vote-driven waiting initiatives that promote 'over-investment in physical infrastructure at the expense of community-based and prevention investment'.

Royal College of Midwives general secretary Dame Karlene Davis is disappointed that the plan did not stress choices. 'The RCM would have liked to have seen more commitment to diverse models of maternity care.'

Influential former British Medical Association chair Sir Sandy Macara, who signed for the National Heart Forum, is happy with the plan overall and says treatment and care of heart disease has seen 'genuine improvement'.

But he would have liked greater commitment to public health and joint working with local authorities. 'I tackled Mr Milburn about what was going to appear when he had a meeting of all the modernisation teams when a draft of the plan was being put together. I got the impression that there was rather less support for improving public health and more obsession with improving the acute sector.'

Melinda Letts, who signed for the Long-Term Medical Conditions Alliance, says that with hindsight she would have wanted more consultation. 'The plan didn't take a lot of what [the modernisation teams] had written into account.'

Carers National Association signatory Diana Whitworth was concerned that while the government has made a real effort to improve mental health services, doing so without earmarking money has led to a 'huge gap between government priorities and local priorities'.

Harry Cayton signed the plan as chief executive of the Alzheimer's Society. Now speaking from within the NHS as director for patients and the public, he says the plan has proved durable as a framework for building a patientcentred service.

He was critical at the time of the decision to exclude the recommendations of the Royal Commission on Long-Term Care that personal as well as nursing care be funded for people in care homes.He is still worried.

'I was concerned that this was unfair and that the nursing care assessment would fail to pick up the mental health needs of people. I know the Alzheimer's Society is concerned at the number of appraisals being considered by the ombudsman.'

But Royal College of Surgeons president Sir Barry Jackson's reminder should serve as the last word on the plan's anniversary.

'Remember, It is a 10-year plan, not a four-year one. Progress is being made, but [there] is still a long way to go.'