PROFILE

Published: 12/05/2005, Volume II5, No. 5955 Page 16 17

He was known as 'Tony's rottweiler', a fixer who knew or cared little about health.

But in two years as health secretary, John Reid gave the NHS space to reform and proved he was somebody the medical professions could work with. Thelma Agnew assesses his record

When John Reid was appointed health secretary in June 2003 he was, as far as the NHS was concerned, an unknown quantity.

Nothing in his career had hinted at an interest in health. He had coped well with a Northern Ireland posting, and was known to have enjoyed himself immensely during a stint at Defence. The straight-talking Glaswegian's response, when offered the top job at Richmond House, was said to have been abrupt and unenthusiastic: 'Oh fuck, not health.' No-one imagines he considered turning it down, though. If the health service community had any impression of Mr Reid, it was as a Blair loyalist, able and willing to serve in any of the trickier offices of government - even health.

Two years on and the image of Mr Reid as a Blairite enforcer, with little engagement with the health brief, is how many critics will remember him. As one commentator says: 'He has been an absentee landlord.

Policy has been initiated by Number 10 and implemented by the senior [Department of Health] team.

'Reid has had little involvement - he has been more concerned with photo opportunities. He didn't have an interest in health - he was used as the PM's 'fixer'.'

But even this critic acknowledges that after the 'horrendous pace' set by Mr Reid's predecessor Alan Milburn, a change in style - which was felt as an easing of pressure - was for many a welcome relief. 'Reid settled into a sort of avuncular GP/ father-figure role. He calmed things down after the disturbance that Alan had created, ' the observer comments.

Mr Reid never appeared to match his predecessor's famously detailed understanding of the NHS. But this apparent limitation had its advantages: he has not been tempted to micromanage the service. 'I think he's acted as chairman of the board and given space for others to do some of the detail, ' says NHS Confederation chief executive Dr Gill Morgan.

King's Fund chief executive Niall Dickson says it would be a mistake to assume that 'Tony's rottweiller' lacks subtlety or intellectual firepower: 'He is a consummate politician who works extremely well with a broad brush but has the intellect to dive into the detail at short notice and reproduce it if required. I can't remember a single occasion when [lack of detail] caught him out.

'Milburn had a forensic mastery of the detail of the brief and found it impossible not to get stuck in. For civil servants, Reid was probably easier to work with. And politically, I think he was more astute than Milburn. He played to the back benches.' Mr Dickson says that Mr Reid's 'naturally populist' touch and 'rough hue' made the reforms of the past two years - a relentless continuation of the modernising agenda set by Mr Milburn and Number 10 - easier to take. When Mr Reid pushed foundation hospitals and closer links with the private sector, he seemed to do it because of his working-class roots, and distant past in hard-left politics, not in spite of them: 'He wrapped all this stuff up in the red flag, and said this is about giving working class people what wealthy people have always had - choice.' Politicians rarely win plaudits for repackaging a predecessor's policies, but Mr Reid's skill in anchoring the 'phenomenal' changes of the past two years to core beliefs about the NHS should not be overlooked, according to Dr Morgan: 'What he brought to the complex reform programme was a restating of values - equity as an underlying principle of the service.' For Mr Reid's critics the past two years have been a missed opportunity: crucial areas of health have suffered from the his relative lack of passion for the NHS and hands-off approach.

Cliff Prior, chief executive of mental health charity Rethink, credits Mr Reid with progress in patient choice, long-term care and public health: 'But where's mental health? There hasn't been the interest [in it] or understanding. We are supposed to be having a major drive on waiting times and access - but access to psychological therapies just doesn't appear. There is not the steer from the top.' Mr Reid's commitment to the public health agenda has also been questioned - never more so than last June, when he appeared to defend working class people's right to smoke, and later when the public health white paper, published last November, fell short of setting out a full ban on smoking in public places.

Niall Dickson hopes incoming health secretary Patricia Hewitt will be 'somebody with a greater feel for the challenges faced in mental health and public health'. He suspects Mr Reid is, at heart, a traditionalist, who took a 'slightly schools and hospitals' view of health and education.

But Professor S¯an Griffiths, immediate past president of the faculty of public health medicine, roars with laughter at the idea that Mr Reid was a disappointment in the sphere of health improvement.

The Oxford University professor of public health says: 'He did a hell of a lot. He took the lead in Choosing Health and helped create a framework in which obesity and tobacco were issues which the whole of the NHS had to take seriously.' NHS Alliance chair Dr Michael Dixon believes Mr Reid was 'a sort of caretaker secretary of state'. In the early days at least, his broad-brush approach allowed 'managerialism' to dominate: 'Primary care and clinical engagement slipped down the agenda. There was a period when there wasn't strong enough leadership.

'But things have righted themselves now and the person most responsible for that is [NHS chief executive Sir Nigel Crisp]. He has made his own diagnosis and now we are beginning to see much more engagement. The real priority at the moment is to get primary care commissioning right - and that is now recognised by the Department of Health and Downing Street.' Even those who were not impressed by Mr Reid's personal contribution are generally quick to acknowledge the achievements, on his watch, of the NHS chief executive and the ministerial team.

'Reid has allowed ministers to take a more prominent role. Over the last two years [former health minister] John Hutton has suddenly come into his own: he has really got to grips with the issues, listened to what people have said, and been prepared to try and fix things.' says Dr Dixon.

Mr Reid's successor must do more to engage the medical profession in the move towards a patient-led service, insists Royal College of Physicians president Professor Carol Black. The failure to fully involve doctors in policy development and implementation, means that the 'implications' of using market disciplines to promote choice have been overlooked, she says.

'Models of service designed for choice of elective care seem hardly appropriate for acutely sick patients.

Where patients value continuity of care, as in long-term conditions, the risks of fragmentation are likely to be heightened when providers are in competition.' However, unlike his predecessor, Mr Reid proved himself to be somebody the medical profession can work with. Don Mackechnie, chair of the accident and emergency sub-committee of the British Medical Association consultants committee, thinks that the current 98 per cent target for dealing with patients in A&E within four hours is still too high; but without Mr Reid it would be 100 per cent. 'A good case was presented to him that 100 per cent was not achievable, and nor in the best interests of patients; in fairness, he listened.' One of Mr Reid's earliest successes was negotiating the new consultant contract, ending the stalemate under Mr Milburn that had led the senior doctors to threaten strike action. Health economist Professor Alan Maynard of York University says success was bought at too high a price - 'It was a disastrous settlement for the NHS and a triumph for the BMA negotiators.' But the commonly held view is that Mr Reid's concessions were a necessary piece of pragmatism.

And Mr Reid was determined to take on some vested interests, albeit via a more subtle route. He used last autumn's Labour Party conference to defend the independent treatment centre programme, bullishly claiming that the use of firms from overseas to run such centres had broken up cartels of consultants, who were resisting any attempt to shrink their private incomes.

Pragmatism is a hallmark of an effective politician, and Mr Reid is certainly that. When he arrived at the DoH 'he had no strong agenda of his own', says Birmingham University Health Services Management Centre director Professor Edward Peck. Far from creating a vacuum of leadership, it may be that this willingness to 'step back' (an emotional disengagement which Mr Milburn could not muster) will one day be judged as his greatest contribution to an exhausted health service.

Dr Morgan says that the fact that there was no 'stop and change' in 2003 is one of the 'very positive things about John's leadership'. She hope Ms Hewitt will take the same approach, giving managers and clinicians the 'space' they need.

In 50 years John Reid's name will probably not appear on a list of great health secretaries, predicts Professor Peck. But sometimes greatness is not what is required: 'He was the right person, in the right place at the right time.' .

KEY MOMENTS

June 2003 John Reid is appointed health secretary, his fourth cabinet job in a year. On his first full day in post he promises NHS chief executives he will 'press ahead with the reforms and drive them forward so our vision of a patient-centred health service becomes a reality'. Signals intention to make accident and emergency a priority by upgrading emergency care brief: it goes to minister Rosie Winterton.

July 2003 Reopens negotiations with consultants and reaches agreement on their new contract.

September 2003 Opens consultation on relaxing the 100 per cent four-hour A&E target to allow for clinical exceptions: 98 per cent target is later agreed.

June 2004 At a Labour event in London he warns antismoking health professionals and activists not to 'patronise' working class smokers: 'As my mother would put it, people from those lower socioeconomic categories have very few pleasures in life and one of them they regard as smoking, ' says Mr Reid, himself a former heavy smoker.

Launches NHS improvement plan at the NHS Confederation annual conference which promises to cut waiting times and promote patient choice: maximum wait from GP referral to operation of 18 weeks by 2008; by end of 2005 patients able to choose from four or five hospitals.

He receives rapturous applause after telling delegates he is 'sick and tired of hearing the staff of the NHS maligned and portrayed as unproductive bureaucrats... they have saved more lives and done more good than any politician ever did'.

July 2004 Announces a cut in the number central targets, from 62 to 20 by 2005.

November 2004 Promising a 'relentless campaign' on MRSA, Mr Reid commits the NHS to halving rates of bloodstream infections by 2008 at the chief nursing officer's conference.

Later, he launches the public health white paper Choosing Health.

Some critics - including HSJ - are disappointed at its failure to announce a total ban on smoking in public. But NHS managers are pleased to see it does not provide a new wave of targets, and leaves decisions to primary care trusts. And Mr Reid insists the paper is not a fudge, but a reflection of the fact that healthy lifestyles come down to supporting individual choices: 'Just because our language is moderate doesn't mean that We are not radical in intent.'