COMMENT It is time to digest the challenges that accompany the celebrations

Published:25/04/2002, Volume II2, No. 5802, Page 15

How did you feel when you woke up last Thursday morning? Most NHS managers would have been forgiven for celebrating the chancellor's largesse, but more sober reflection over the past week will have raised more painful thoughts on the practicality of delivering what the government has promised on their behalf - as well as the public and private price of failure.

At first sight it would appear that the Bevanite ideology of a tax-funded NHS has reasserted a vice-like grip on the delivery of healthcare in the UK. Nothing could be further from the truth.

The chancellor, who yearns for equality of health provision, and the prime minister, who wants an NHS middle England can believe in, have nailed their futures - and that of their party - to this particular mast and have provided the funds to 'ensure' that their vision is delivered.

If the cash does not achieve what they want, no sensible politician will ever assume such a stance again. The opponents of a primarily tax-funded NHS know this, and as targets are missed and inefficiencies revealed - as we know they will be - they will lose no time in pointing up this expensive error in judgement.

One of the many ironies of this Budget is that it has significantly increased the chance of the UK introducing some form of health or social insurance scheme in the next 10 years. For by opting so emphatically for a continuation of a tax-funded service, the consequence of failure can only be a seismic shift to an alternative model.

In addition, even those who broadly accepted the thrust of the Budget called for it to be accompanied by root-and-branch reform. HSJ readers who have spent the last two years involved in one of the most wide-ranging and significant restructurings of the NHS in a generation will have raised a hollow laugh. Most newspapers' leader writers called for less cash and faster, bigger reform. The opposite is more likely to deliver results, especially in the short term.

Irony number three is the change in the balance of power between NHS managers and their political masters. Yes, the new inspectorate will have an 'edge' and the targets are coming even faster - and tougher - but the health secretary must know that his fate is, to a large extent, in the hands of those who manage the health service. Of course it is doctors and nurses who will provide the healthcare, but it will be managers who put in place the service's new structure and ensure that it serves the needs of clinical staff and patients.

We hope and believe that the health secretary recognises this - especially as every extra penny spent on management, or managers, will be derided as 'waste' by the NHS's critics. We also hope that Alan Milburn will be a little more vocal in his support of managers, though his 'tribute' to 'ancillary staff ' in his Commons address and the omission of all mention of managers from Delivering the NHS Plan hardly suggested a readiness to grasp this particular nettle.

He should guard against the understandable inclination of politicians to hang managers out to dry every time the media unearths a juicy 'scandal'. Managers, every bit as much as doctors, suffer from poor morale.

Yet more irony was provided by a Labour government choosing to tackle bed blocking by hammering local government. The money given to local authorities is clearly inadequate to tackle the problem, and the blunt instrument of fines is likely to drive a further wedge between two wings of the public sector that need to work together much more closely if the NHS reforms are to succeed.

Finally, there are the vociferous calls from the health unions to boost their members' pay packets, thereby diverting funds away from the service delivery they rightly say is paramount.

Justifiable pay rises for health service staff will improve recruitment and retention, giving the reforms the best chance of success; inflated claims will kill them stone dead.

The first challenge for the government and managers is to hold their nerve. Significant change within the health service - as experienced by patients - is likely to take a couple of years at the very least. Life for those working in the NHS is likely to get tougher on almost every front - despite the money - before it begins to get better. Make no mistake: last week's Budget provided the funds to do the job. Managers will understand the scale of the task and the determination needed to carry it through. l