It is a familiar message.But the government repeated it this week - and then said it again, for good effect.The NHS must modernise for its billions.
Chancellor Gordon Brown chanted the 'more resources must mean more reform' mantra as he delivered his Budget. He gave the NHS an immediate cash injection of£2bn and the promise of 6.1 per cent above inflation increases for the next four years.
But government claims that 'NHS spending'would rise to 7.6 per cent of GDP by 2003-04 were called into question. The Budget statement had failed to make it clear that the figure referred to total healthcare spending, including the private sector.
Prime minister Tony Blair took up the theme in his heavily trailed statement on NHS modernisation to the Commons, insisting a 'step change in resources must be followed by a step change in reform'.
Then health secretary Alan Milburn joined the chorus as he announced the first raft of appointments to the six 'dedicated units' - later named modernisation action teams - set up to find solutions to the five challenges set by Mr Blair (see box). The sixth team represents patients, relatives and carers.
But will the money announced be enough? Will there really be a 'step change' in reform - and what would such a thing look like?
Are the government's centralising instincts really the way to get reform in the NHS, which Unison, at least, believes is now 'drinking in lastchance saloon'?
The welcome given to the Budget's billions has become warmer as health service leaders have become convinced the money is real. Healthcare Financial Management Assoc-iation chair Barry Elliott says it is 'the best news the NHS has had for many years'.
But he warns that 'putting the NHS back on an even financial keel and relieving some of the operational pressures on the service' need to happen before 'any fresh spending commitments are made'.
Professor Ray Robinson of the London School of Economics, whose first reaction to the Budget was 'wow', also has a list of prosaic calls on the new money including:
paying for more staff: especially if the government is considering a new consultant contract that stops doctors working in both the public and private sectors at once;
sorting out the NHS's capital stock:
some of which, he says, is about to be condemned by the Organisation for Economic Co-operation and Development as 'more suited to ancient monument status than healthcare';
responding to the Royal Commission on Long-Term Care:
especially if the government accepts its call for personal care to be free wherever it is provided.
Alan Maynard, professor of health economics at York University, feels next year's£2bn should buy '18 months of tranquillity in the NHS'.He argues - without much hope it will happen - that the long-term money should target fundamental, rather than headline-hitting, issues.
'Let's have league tables for GPs so we can see who is immunising people against influenza and prescribing aspirin prophylactically, and make it so embarrassing to be at the bottom they have to do it.'
The NHS Confederation also feels a real 'step change' in reform would mean tackling professional issues. It is not clear whether this is what the government has in mind.
Conservative leader William Hague dismissed the prime minister's statement on NHS modernisation as 'cliche and waffle'.
Nigel Edwards, NHS Confederation policy director, feels this is not just presentation and that the NHS will see change in performance and the professions.
On performance 'this seems to raise the game', he says.'The hit squads and 'we will sack people'' looks like political rhetoric - we hope this will not be manager bashing and there are signs it is not - but they are serious about performance.'
On the professions, he says: 'All the things Mr Blair was talking about in his speech are about the way people practise and organise themselves:
about why doctors do not prescribe aspirin when they know they should.
'Where these are questions about management, they are about why we are not managing it.The issue is getting them (doctors) to behave in a way that is corporate.'
Royal College of Nursing general secretary Christine Hancock says she is not sure she knows whether the latest moves are presentation or real reform but feels the government's comments on professions 'sound like doctors'.
The confederation's response has raised hackles at the British Medical Association. Chair Dr Ian Bogle says: 'I do not want to continue the tone produced by (the NHS Confederation) of finding blame for particular professions.
'Mr Blair was quite careful to say variations could be caused by professional failures, but there might be other reasons, and I find that a reasonable interpretation. This is not about the professions, but the whole structure of the NHS.'
In addition to the six modernisation action teams, Mr Blair announced that he and Mr Milburn would consult nationwide on reform before putting forward four-year plans for 'the improvements we seek, the change necessary to achieve them (and) the timetable for their delivery'.
There will also be a new Cabinet committee, chaired by the prime minister, to 'monitor the standards and improvements people can expect by the end of the financial year 2003-04'.
Dr Bogle feels that the government is genuine in its attempts to draw in the professions.'There has been an amazing change in the past two or three weeks, 'he says.'I have gone from being barely tolerated at Richmond House to practically living there.'
But others fear the government's centralising tendency is manifesting itself. Jennifer Dixon of the King's Fund asks: 'Are they going to use the NHS Executive at all - or will there be some central board, possibly headed by the prime minister?'
The government's bid to modernise the health service carries risks. It carries risk for the government.Mr Blair has personally staked his reputation on modernisation. It will suffer if it fails to deliver what the Conservatives and newspapers define as success.
It carries a risk for the professions.
As Mr Edwards says, huge cash injections will remove the excuse of scarce resources.Dr Bogle adds that drawing doctors and nurses into the modernisation process so publicly will link them to its success or failure.
And it carries a risk to the NHS. Dr Dixon says it is difficult to imagine another government finding this sort of money for the NHS.
'They (the government) can see the NHS slipping away from them if they do not do something and their instinctive response is to try to run everything from the centre, ' she says.
'There is a real issue about their instincts. It might not give the NHS its best shot. . . this might not be the approach that will work.'
Blair's five challenges:
The partnership challenge: working together.
The performance challenge: to ensure that all trusts and PCGs will come up to the standard of the best.
The challenge for the professions: to strip out unnecessary demarcations and ensure more flexible working and training practices.
The patient care challenge: for hospitals and PCGs to ensure best practice.
The challenge on prevention: tackling the causes of ill health.
Welcome MAT: the modernisation teams
Prevention and inequalities: Professor Liam Donaldson, chief medical officer (chair); Rabbi Julia Neuberger, chief executive, King's Fund; Jim Johnson, chair, joint consultants committee; Professor Sir Michael Marmot, professor of epidemiology and public health, University College, London; Dr Nick Hicks, strategy unit, Department of Health.
Partnership in the health and social care system: John Hutton, health minister (chair); Christine Hancock, general secretary, Royal College of Nursing; Dr Ian Bogle, chair, British Medical Association; Jo Williams, president, Association of Directors of Social Services; Gavin Lamer, strategy unit, DoH.
Patient Care (speed of access): Lord Hunt, junior health minister (chair); Barry Jackson, president, Royal College of Surgeons; Lord Newton of Braintree; Professor Chris Ham, strategy unit, DoH.
Patient care (empowerment): Gisela Stuart, junior health minister (chair); Sarah Mullally, chief nursing officer; Melinda Letts, chair, Long-Term Medical Conditions Alliance and member of the Commission for Health Improvement; Karlene Davis, general secretary, Royal College of Midwives; Jo Lenaghan, strategy unit, DoH.
Performance and productivity: Yvette Cooper, public health minister (chair); Stephen Thornton, chief executive, NHS Confederation; Professor Mike Pringle, chair, Royal College of General Practitioners; Professor Don Berwick, president and chief executive of the Institute of Healthcare Improvement; Professor Liam Donaldson, chief medical officer; Richard Murray, strategy unit, DoH (chair).
Professions (workforce): John Denham, health minister; Professor Sir George Alberti, president, Royal College of Physicians; Bob Abberley, head of health, Unison; Professor Jill Macleod-Clark, professor of nursing and deputy dean, faculty of medicine and health, Southampton University;
Nick Ross, broadcaster; Professor John Van Reenen, strategy unit, DoH.
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