Primary care must be allowed to influence the latest round of changes

Published: 30/05/2002, Volume II2, No. 5807 Page 19

Last week the NHS took a significant step towards becoming a conceptual health provider - defined by what it does and why, not who does it or how (see news focus, pages 12-13). The NHS has always had strong values - universality, free care at the point of delivery and so on. Can they survive the arrival of foundation trusts and the 'permanent' involvement of overseas health providers? The government claims they can, though it will be interesting to see how those values are refined and reconfigured as we get down to the nitty-gritty. NHS policy is beginning to break down into three significant strands. The first is the much trumpeted primary care-focused NHS. The second concerns improving patient choice around elective surgery. The third involves nationally driven strategies to tackle perceived structural deficiencies in the system.

Foundation trusts emerge from the first two strands, the use of overseas clinical teams from the last two. However, these two ideas may both deliver the same result - the return of the independent hospital as a significant provider of emergency and elective healthcare in the UK.

Though the four (potential) foundation hospitals announced last Wednesday seem an odd bunch, you should not be misled. Four, much more obvious candidates - one in the North West, two in the West Midlands and one in London - were due to be announced last week, only to be pulled at the last minute because they were not threestar organisations. Later in the summer, the new star ratings will be announced and then things will start to motor.

Whatever model foundation hospitals adopt - public interest companies, mutuals etc - they could quickly come to resemble many of the overseas organisations being offered 'guarantees' by health secretary Alan Milburn to set up in the UK. It may be hard for anything other than an overseas 'not-for-profit' organisation to feel comfortable in this value-defined NHS.

Within the next five years and in areas of under capacity, such as southern England and the major conurbations, it is not difficult to see large numbers of 'independent' operators working hard to meet demand.

This hope is a significant part of the genesis of both ideas. While primary care trusts effect deep, grassroots change, the headlines will continue to be about waiting times and the latest cancer/heart 'scandal'. These turn off those who can exercise choice - ie go private - and whose support the NHS and the government needs to survive. The urgency with which Mr Milburn is taking direct and personal action to 'encourage' overseas suppliers to invest in the UK is witness to how seriously this is taken at the highest levels.

The mischievous would say that the use of independent suppliers and an arm's-length regulator in the commission for healthcare audit and inspection is also a useful way for government to distance itself from potential fallout. The loyalist would counter that it is often the poorest who are most dissatisfied with the healthcare they receive and if they can be helped to exercise choice within this new framework they will be better off.

If foundation trusts and overseas organisations are to be introduced into the NHS in an equitable, effective way, strategic health authorities and, most important, the PCTs affected, must be heavily involved. So far, the signs are positive on the former - NHS chief executive Nigel Crisp even said the government's mind was 'open to the idea of primary care foundation trusts' - and not encouraging on the latter. Without maintaining this local focus, those parts of the NHS not allowed to influence their own future may conclude with Kris Kristofferson that 'freedom's just another word for nothing left to lose'.