LOOKING ASKANCE

The NHS plan was systematically leaked before its publication, contained few surprises and has potential. Whether this can be translated into systematic reform is uncertain.

The style is frothy, lots of words and good intent. The pearls among this manure have to be teased out - for example, the death of regional chairs and the demise of community health councils as we know them. However, the central issue is that, even with the enhanced budgets, this agenda cannot be afforded. Once again, the government's propensity to promise wondrous change has accelerated way past its capacity to create such miracles.

The government has waited for the completion of the NHS plan before it commits all the funding for 2000-01.

As a consequence perhaps as much as£700m awaits disbursement. In the months ahead there will be a stream of announcements of 'new' funding badged to particular wheezes. The challenge for chief executives and boards is to guess the nature and timing of announcements so that they can bid swiftly and coherently.

Boards in marginal constituencies should be on their toes as loot may be directed at them, at the expense of equity.

Managers will inevitably have to take risks, anticipating what ministers will do and perhaps leaping before our leaders have got their act together. While this should be exciting, the price of failure might be high. Some regional directors are already desperate and admonishing their chief executives in flowery language which doubts their ancestry.

They all fear that come April 2001, many places will miss their waitinglist and other targets and underspend. This 'double whammy' is promised to lead to the disembowelment of 'failing' managers and what is known in the financial trade as 'hide your surpluses now'.

There are a series of issues which the plan hints about but which lack detail and will be costly. First, sweeteners for doctors are essential to ensure their support and to increase activity. Earlier in the year the government put more money into primary care: pouring cash into a system which is a black hole of inefficiency in terms of its incapacity to manage demand (hospital referrals) and prescribing (the cost of which is rising by 12 per cent annually). Primary care trusts lack the skills and incentives to remedy these well-defined problems swiftly.

The second remarkable increase in the subsidisation of inefficient primary care was the decision, four years after the evidence was published (the chief medical officer is such a slow learner), to vaccinate the over-65s (previously over-75s were the primary target group) and highrisk groups. This shift has been reinforced by the payment of£6.40 for every person vaccinated. What a nice little earner for general practice.

The immediate problem for hospitals is raising their activity, and two significant obstacles are blocked beds and consultant productivity.

With many local authorities shifting cash from social services to education budgets, the funds for bed blockers are inadequate. To use the cute American term, acute hospitals are having to 'warehouse' elderly folk who would be better served by care in the community. Thus in the medium term it is attractive to establish separate diagnostic and day facilities, as these can be ring-fenced against the blockers.

While the plan signals this for the future, what about the next year? Lots of 'red traffic lights' seem inevitable - the obvious will be identified but not resolved.

The government is tiptoeing around the consultant issue. The proposal to prohibit new consultants from doing private practice for seven years has delighted the boys in practice as it enhances their income for monopoly inflated fees. Their trade union, the British Medical Association, is screaming in ritual protest and will no doubt extract a high price for this gesture.

More fundamental reform of the consultant contract is essential but the government fears the electoral consequences. Thus incentives to get the consultants to achieve shorter waits for patients by getting them to control GP referrals will be costly, as will rewards to increase their activity rates.The resources likely to be needed to incentivise doctors may make a large inroad into the unallocated funding for the service in this financial year.

Such reform will bring with it the performance management heralded in the plan. Trusts will have to monitor and manage consultant team activity by identifying variations in practice and 'communing' with comrades when their work is not what the doctor ordered! One hopes this will be accompanied by a decision to allow employers to dismiss medical staff with due cause. Again, the BMA will extract a high reward unless ministers exhibit an unusually high degree of resolution.

The absence of detailed proposals to remedy bed blocking and medical activity is either cunning guile (unlikely) or lack of agreement in Whitehall village about how to proceed. The mandarins have, no doubt, given the ministers the options, and there is some evidence that they want to deal with some of these issues radically.

But they have little freedom of movement, as the prime minister, in his presidential way, is controlling policy. Focus groups show that doctors remain the most highly respected group of tradesfolk in the country despite Shipman, Bristol, Neale and Ledward.

So the prime minister has some nice choices to make.

The NHS plan is an ambitious agenda which requires greater political courage and careful prioritisation.

In 1997 Blair refused to have a NHS policy because the focus groups showed he would be elected without one. In 2001 he will have many policies, mostly undeliverable by managers, who cannot perform instant miracles, but will be blamed.

What a pity ministers have never managed so much as a whelk stall in their jolly lives.

Alan Maynard is professor of health economics at York University.