comment

Is there an air of excitement in your part of the health service today? Are great things planned to mark the introduction of New Labour's New NHS? Thought not. For all that primary care groups, clinical governance, the National Institute for Clinical Excellence and the rest mark a revolution in the organisation and, one can but hope, delivery of healthcare, there have been few signs of the hubris that this government has made its own special mode of operation.

And how refreshing that is. In a summing up of the position which might well serve as a motto for the launch of the reforms in general, Alan Carpenter, chief executive of the new Somerset Coast PCG, explained his own group's position to HSJ thus: 'We thought it better to wait until we have actually done something that the public can see before we celebrate' (see news, pages 2-3).

Health secretary Frank Dobson's New NHS revolution has been a long time in the making. Former NHS chief executive Professor Sir Duncan Nichol, who ushered in the last Conservative government's reforms eight years ago today, traces their origins to his own efforts and to those of the ministers of his day (see news focus, page 14).

There is more than self-justification in this since it is hard to imagine that a Labour government starting from the blank sheet of the 1980s would have sketched in anything like what we now see.

And even the detail has been around for some time. Back in November 1996, HSJ offered the then shadow health secretary, Chris Smith, a platform to outline his post-election aspirations.

For the first time, he talked of setting up hundreds of new GP-led mini- authorities with delegated powers to commission all aspects of care.

Such groups, he suggested, should be geographically based, include all GPs within the given area and involve social services, community health councils and other primary healthcare professionals. They might, he said, be run by health authority staff as HAs wound down their commissioning role. And he urged a clearer framework for commissioning based on evidence of need and effectiveness.

So far, so good. PCGs, clinical governance and NICE are the obvious descendants of Mr Smith's proto-New NHS.

The question is: what happens next? The repercussions of 1991 included large-scale redundancies among trust staff, a deep and abiding division between fundholding and non-fundholding GPs, and the growth of macho management techniques. None of these seems likely this time round.

But just as these were probably inherent in competition and the internal market, so the agenda of forced co-operation and compliance with national guidance on clinical as well as management issues which underlies its successor holds its own dangers.

There is, too, much in Mr Smith's speech which has yet to see the light of day (let alone the outstanding business of The New NHS white paper). The time has not yet come when we can say for sure what fate awaits HAs. Who knows whether the idea of 'a system of contestibility' instead of contracting to 'force improvements in standards' will one day become a reality?

And will the reforms really 'reduce the number of contracts or agreements required in the healthcare system to fewer than one tenth of the number in place at present'? Only time and the Department of Health will tell - and probably then only if it all works out.

As it is, untried and untested, New Labour's grand plan enjoys a hegemony over health thinking unprecedented at any stage in the history of NHS upheaval. It may not work out as anyone expects - few things ever do. But it replaces a clapped out and rejected ideology, and faces no serious opposition or rival blueprint.

If nothing else, today's ministers will be able to defend their reforms with a phrase made famous in an earlier era: there is no alternative.