The same, but different

Welsh Office officials faced a problem as they drew up the health white paper that was finally launched last week.

The government has said it wants a 'national' health service, one which is recognisably the same institution across the UK.

Yet the background against which NHS Wales operates is different to that in England and Scotland.

And it will be even more different once the Welsh Assembly is up and running in about 18 months' time.

Journal sources indicate that this led to 'an amazing amount of running around' in Cardiff before agreement could be reached with London on how different the NHS in Wales would be allowed to be to take this into account.

In the end, the 'thrust' of Putting Patients First is the same as The New NHS, as a note from Welsh Office health director Peter Gregory told the service it would be.

There are the same promises to scrap the internal market, give GPs and primary health professionals a bigger role, improve cancer services, quality and openness, and set national standards for services under the direction of two new bodies - the National Institute for Clinical Effectiveness and the Commission for Health Improvement.

But there are also significant differences. For a start, there will be no primary care groups in Wales, even though these organisations are at the heart of the English reforms. Instead, Wales will have local health groups.

The New NHS talks about primary care groups 'typically serving about 100,000 patients' and starting 'at whatever point' on a spectrum from advising health authorities to running primary care trusts 'is appropriate for them'.

Putting Patients First is much more definite about how local health groups will be established and what they will do. They will be coterminous with the 22 unitary authorities established in Wales in 1996 and will have a governing body 'which reflects the range of health professional interests within the locality'.

They will be set up as 'sub-committees' of HAs and only 'over time' and 'as (they) gain experience' will they be given cash-limited budgets for a full range of health services.

It also seems unlikely that local health groups will be encouraged to become primary care trusts.

Putting Patients First carefully notes 'legislation will be brought forward which will provide for the creation of primary care trusts'.

But, it says, 'decisions in this area will be for the assembly in the light of experience, local circumstances, demonstrable evidence of managerial, financial and risk management competence across the participating players, and the patient benefits intended'.

This is a tough test in itself, but it is not the only obstacle.

The major programme of trust reconfiguration already underway in Wales is likely to result in the merger of many community and acute trusts, so there will be few, if any, community trusts for GPs to 'combine' with.

Privately, officials also see problems in making trusts run primarily by GPs accountable - a problem which has still not been resolved in England.

One explained that, while in England 'bits' would be 'lopped off' trusts for GPs to run, in Wales trust boundaries would be 'permeated' by GPs running a few services.

HAs, then, are to be given a major role in the development of local health groups. They are also the 'winners' in Putting Patients First in other ways.

The white paper says they will get an 'overarching role to ensure that the NHS locally works together for the benefit of the populations they serve'.

They will do this by drawing up health improvement programmes which 'set a clear agenda' for improving the health of local people and setting a 'pattern of local service configuration which takes account of clinical, accessibility and affordability considerations'.

HAs will monitor the implementation of these plans and step in 'where the actions of either local health groups or NHS trusts go against the grain of health improvement strategies or are obviously failing'.

They will be able to 'retrieve functions delegated to local health groups', decide 'which facilities will become surplus to requirement' and, notably, 'require their agreement to new developments, including key permanent posts in NHS trusts'.

Officials indicate the 'key permanent posts' will include consultant and senior nursing appointments, and the move is being seen as an attempt to stop trusts expanding their services to pull in work from other hospitals.

HA managers claim over-expansion of services has contributed to the current cash crisis in Wales, where trusts are expected to be at least pounds21m in the red by the end of the financial year.

Trusts, meanwhile, will be required to produce annual plans showing how they will meet the objectives set by HAs and local health groups. They will also be made responsible for providing quality services.

Putting Patients First devotes a chapter to quality, and says legislation will be brought forward to ensure trust chief executives 'carry ultimate responsibility for quality in their trusts, just as they are now accountable for the proper use of resources'.

But in the medium to long term, there is a question mark over the future of the five Welsh HAs.

The white paper says the Welsh Assembly will eventually 'monitor the health of the Welsh population and respond with policies to promote health and tackle ill-health'.

The assembly will also 'identify and promote good practice in health services', hold NHS bodies to account for their performance and ensure services conform to seven new values for NHS Wales: fairness, effectiveness, efficiency, responsiveness, integration, accountability and flexibility.

Privately, managers say the assembly could take on many of the current HA functions and that HAs could be axed or reduced in number.

Launching the white paper, Welsh health minister Win Griffiths claimed the changes would generate pounds50m to 'spend on patient services'.

But Putting Patients First says that 'this should not be allowed to become a crusade against management in the NHS', and that 'the government does not propose to establish further arbitrary targets or cuts in management costs'.

Mr Griffiths said most savings would come from GP fundholder management allowances and the trust reconfiguration programme, which the government claims will save pounds5m-pounds10m a year.Putting Patients First. The Stationery Office. pounds12.50.