Almost everywhere you look, it is possible to see the NHS equivalent of electricity transmission losses

Almost everywhere you look, it is possible to see the NHS equivalent of electricity transmission losses

My three-year-old son spent much of Christmas working his way through a succession of AA batteries that powered his various new toy cars, model planes, speaking books and other testaments to the miracle of Chinese manufacturing. But they haven't cracked batteries: the time between new battery and flat one was frustratingly short.

It later set me thinking about similar 'voltage drops' in the health service and the risk in 2007 that the necessary energy behind recent reforms is not sustained. Two contradictory sets of images came to mind.

The first was the complaint often heard in Whitehall: that high-voltage health reforms are 'plugged in' at 240V AC but somehow, by the time they emerge at the NHS front line, they are only a flickering current on par with a fading Duracell battery.

Two examples at random:
why are patients across the country not all being routinely copied in to the letters written about them by consultants as promised over
six years ago in the NHS plan?

And what happened to the commitment in the much-heralded Our Health, Our Care, Our Sayhealthcare outside hospital white paper a year ago to tender for primary care provision in 30 underserved primary care trusts?

Almost everywhere you look, it is possible to see the health service equivalent of transmission losses
as electricity flows from power stations through the national grid to people's homes.

There is an alternative set of images that implies there is a different understanding about energy losses in the healthcare system.

This starts from the assumption that there is a reservoir of latent commitment widely distributed - between patients, professionals, managers and, yes, private sector providers - and then asks the question: what causes energy to dissipate? What drives the process
of entropy?

Such an analysis would start
with the apparent inability in many parts of the NHS to tackle professional attitudes that are self-serving while also - crucially - creating a climate of possibility and entrepreneurialism for those many clinicians who long to get organisational backing for innovation and improvement.

(This is the kind of environment that the British Association of Medical Managers might foster if it were given the chance to run some of the nation's hospitals.)

It would point to the reorganisation fatigue on the part of managers working in the so-called 'intermediate tier' of health authorities and PCTs.

It would deplore the fact that the NHS wastes too much of the potential energy of its voluntary and private sector partners, who are prevented from getting on with the job of making improvements in the real world as they divert endless weeks and months into long, drawn-out discussions and half-baked, half-hearted procurements.

Above all, it would recognise that rather than viewing patients as 'demand', they should be seen as
'co-suppliers' with all the revolutionary consequences that would have for the organisation of care.

Get these things right, goes the argument, and there would be no shortage at all of improvement energy across the NHS.

Of course you get a different sort of analysis from many of the media pundits as to what lies at the heart of the NHS's current difficulties, with large pay awards and/or large funding increases frequently getting the blame.

It is hard to disagree that the health service would probably have performed better had it received steady real growth of say 4.5 per cent per year over the past decade, rather than the famine/feast funding swings it was subject to between the 1990s and the 2000s.

It was the prolonged underfunding, well into the current government's first term, that produced huge pent-up demand for wage increases, infrastructure updating and new treatments, and which in turn meant large funding increases matched by large pay rises were in practice politically unavoidable.

To compound matters, the ability of the NHS to absorb the sharp increase in investment it then received would have been enhanced had the implementation of the reform programme set out in the NHS plan of 2000 (and more particularly the 2002 white paper Delivering the NHS Plan) been funded earlier rather than later on.

This means that some elements of the new policy mix will not be in place fully until after 2008, perhaps even the end of the decade. Which takes us back to the 'voltage losses' experienced in the reform programme implementation.

While it was my son's Christmas presents that set me off on this train of thought, for Rudolf Klein - the doyen of health commentators - it is the fast and furious bobsleigh events in the winter Olympics that best describe what NHS reform will feel like in 2007: 'Riders hurtle down the icy track at great speed. There is nothing they can do to change direction. If they were to brake suddenly disaster would strike,' he says.

'The policy-makers engaged in transforming the health service are in a similar position - once the government had decided on the new three-part model for the health service, the course was set.

'In turn, the logic of the model - competing providers, active purchasers, and money following the patient - drives policy, and allows for no deviation or delay [in] any element [which] puts the whole model at risk.

'This interdependence of the various strands of policy explains the relentless pace of change, with ministers deaf to all pleas for adopting a less hectic pace for fear of derailing the whole exercise.'

Simon Stevens is president of UnitedHealth Europe and visiting professor at the LSE.

See feature, pages 22-25.