Published: 05/12/2002, Volume112 No. 5834 Page 15

The Scots may have thought the introduction of unified health boards last year marked the end of major reform of their health system.But with a white paper imminent, they're in for a bumpy ride. Jennifer Trueland reports

Unified boards, the newest kids on the Scottish NHS block, are now a year old. But even as the candles still smoulder on the birthday cake, all eyes are on the next big thing.

Weeks after the boards had held their first meetings last October, the Scottish Executive had already announced a review of management and decision-making in the NHS.

Furthermore, officials are currently scribbling away at a health white paper for Scotland, which is now expected in February. Early predictions that the paper would pave the way for the abolition of trusts may not be right, but whatever happens, more change will be on the agenda.

These are tough conditions in which to expect the fledgling boards to take wing. Not surprisingly, it has been a mixed year for the 15 new organisations which were, effectively, set up in place of traditional health boards to bring together their management with that of the local acute and primary care trusts. There is also extensive local authority, patient and staff representation.

Privately, ministers admit that while some have made a big success of the new structure, others, such as Argyll and Clyde, which is currently being 'supported' by a Scottish Executive-appointed task force, have found the year more challenging.

NHS Scotland chief executive Trevor Jones is characteristically upbeat about the new organisations. He has been going through the annual process of reviewing the 15 boards and has been pleased with what he has found.

'The financial position feels robust, ' he says. 'A lot of that was down to us writing off trust deficits, but It is a good foundation. There are many positive developments. For example, I think NHS organisations are working better together and with local authorities. There is a real sense of progress in public involvement and I think the staff forums are working well.'

He seems so jolly about it all that it is almost a shame to ask him about the negatives. 'One or two [areas] are having problems, ' he concedes. 'Argyll and Clyde hasn't been working as well as we'd like.

But We are doing something about that, and overall I believe NHS Scotland is performing well.'

To listen to him, it sounds as though the first year has been a breeze. Those at the coalface are a little more cautious.

NHS Lothian chair Brian Cavanagh, while proud of what has been achieved in his area, accepts that there is still much work to do.

'I think it has made a difference, ' he says. 'I think We are taking a more collegiate approach. There has been less shroud waving for resources and there is more of a recognition that problems like waiting times and delayed discharge belong to all of us. The unified board is not a mythical object. It is the whole system and that has meant a change in culture.'

Most people in the Scottish health service will acknowledge that what should be one of the greatest assets of unified boards, their co-operative nature, can also be a bugbear. There are fears that a perceived lack of levers in the system could stifle modernisation.

The Scottish Executive has tried to promote quality and innovation through clinical governance and national initiatives like the performance assessment framework, against which all boards are judged. But the number of external organisations has led to accusations of 'inspectionitis'.

Mr Cavanagh sees the dangers.

'There are a plethora of organisations second-guessing from a distance. We need external national audit but there needs to be consistency of application.'

There is also the issue of who is responsible. At the moment, trust chief executives are, in law, the accountable officers for their own organisation.

'There is an ambiguity right through the system, ' says Mr Cavanagh. 'While trusts are still around, There is going to be confusion, real or imagined, over who has financial accountability for an area.'

What Mr Cavanagh calls the 'fuzziness of accountability' will be addressed in next year's white paper, which will effectively double as Labour's manifesto on health for the Scottish Parliament election in May.

More concrete ideas of the white paper's contents are beginning to filter through and it looks possible that there may be less structural upheaval than was previously on the agenda.

St Andrew's House (base of the Scottish Executive health department) has been encouraged by the changes made by some board areas, which have been achieved within existing legislation.

For example, both Borders board and Dumfries and Galloway will have single NHS organisations for their areas from next April. John Glennie, formerly chief executive at the acute trust, takes over at Borders while Malcolm Wright, formerly board chief executive, will head Dumfries and Galloway.

Other NHS boards have blurred the traditional lines of responsibility.

For example, in Tayside, Gerry Marr, chief executive of the acute trust, has responsibility for service design across the board.

'We do not think There is a single solution for the whole country, ' says Mr Jones, acknowledging that what's right for the relatively tiny Borders is unlikely to work in Greater Glasgow.

'And I am not saying It is been easy so far. But people have put a huge effort into thinking about how they can work together and I think It is paying off.' l