A radical blueprint for a service still open to all

The Report

For Tony Blair it was a new beginning "to make the NHS once again the envy of the world". The health service's condition is widely regarded as critical but the 170-page blueprint published yesterday sets out a rescue plan for the Labour Government's proudest creation that was immediately praised for its radicalism, commitment and depth.

For Tony Blair it was a new beginning "to make the NHS once again the envy of the world". The health service's condition is widely regarded as critical but the 170-page blueprint published yesterday sets out a rescue plan for the Labour Government's proudest creation that was immediately praised for its radicalism, commitment and depth.

Waiting lists

The heart of the plan is the ambitious pledge to cut maximum waiting times for hospital in-patients from 18 months to six months by 2004 with a further target of a reduction to three months by 2008. If achieved that would bring waiting times in Britain into line with those in other countries in Europe, traditionally regarded as much superior to the NHS.

By the end of 2005, the maximum waiting time for out-patients will be three months making a total maximum wait of nine months from GP referral to hospital admission.

To achieve this extra staff, extra beds and new ways of working will be introduced. Over the next four years, 7,000 extra beds will be provided, including 2,100 in hospital wards, the first increase for nearly 30 years. The remaining 5,000 will be convalescent beds provided in cottage hospitals and nursing homes, which will ease pressure on beds in hospitals blocked with elderly patients who cannot be sent home.

An extra 7,500 consultants will be appointed, an increase of almost a third on the current total. They will be required to devote their time wholly to the NHS for the first seven years of their consultant careers, before they are permitted to develop private practice.

Private care

There will, however, be a historic new "concordat" with the private sector, essential to provide the extra capacity that will be needed to meet the waiting time targets. The plan says: "The time has now come for the NHS to engage much more constructively with the private sector - ideological boundaries or institutional barriers should not stand in the way of better care for patients."

National guidelines will be published for the use of the private sector to do routine NHS operations, provide critical care beds for seriously ill patients (one step down from intensive care) and to help with rehabilitation.

New hospital units, called "diagnostic and treatment centres", will concentrate on providing routine surgery to patients who can be treated in a day or with a short stay. The plan envisages eight such centres operational by 2004, which will be treating 200,000 patients a year. A further 12 will be in the development stage. These will be designed and built in partnership with the private sector.

The concordat with the private sector is intended to be "the start, not the end, of a more constructive relationship" and that the NHS will explore the potential for further [private] investment in services.

Patients

Patients will be placed more in control than ever before. They will hold their own medical records, play a role in assessment of performance and and be given more information about their condition. Letters to GPs from consultants about patients will routinely be copied to them.

From 2002, patients who have an operation in an NHS hospital cancelled will be guaranteed a new appointment within 28 days which will be carried out in the private sector if no NHS bed is available.

By the same date, every NHS trust will have a patient's champion - the Patient Advocacy and Liaison Service (Pals) - who will act as an independent agent to settle complaints swiftly. With a national budget of £10m, Pals will have direct access to the chief executive and the power to negotiate immediate solutions.

Financial rewards for NHS trusts will be linked to the results of the annual National Patients Survey and for the first time information will be made available to patients about GPs, including their performance against national targets, accessibility and list size, to help them choose who to register with rather than taking pot luck.

There will be a national drive for cleaner wards - dirty wards are believed to be a key cause of the high number of hospital infections each year - and better food. Many hospital patients are undernourished because hospital food is unappetising. An extra £30m is to be invested immediately to improve hospital cleaning and a 24-hour NHS catering service is to be introduced with a new menu "designed by leading chefs".

New targets are set on cancer, heart disease and mental health. On cancer the plan says that survival is worse in the UK than in several European countries but by 2010 survival rates will "compare with the best in Europe".

Cancer

An extra £570m will be poured into cancer services by 2003-4 to pay for new screening programmes and extra cancer drugs. The NHS breast screening programme for women from 50-64 will be extended to women aged 65-70, involving an extra 400,000 patients a year. New screening technologies are to be introduced to upgrade cervical screening.

A new national screening programme is to be established for bowel cancer following the success of pilot studies. However prostate screening will not be introduced until "screening and treatment techniques have developed sufficiently.

A new NHS cancer research network is to be set up with the aim of doubling the number of patients in research trials. The postcode lottery in cancer drugs will be tackled when the National Institute for Clinical Excellence (Nice) issues guidance on them in summer 2001. The plan says: "30,000 people can be confident that they will receive newly licensed drugs, where clinically appropriate made available with the extra funding for the NHS."

Heart disease

On heart disease, which kills 110,000 people a year in England, an extra £230m a year will be invested by 2003-4 and the number of cardiologists will be increased by 10 per cent a year to a total of 685 by 2003-4. The number of heart surgeons will increase by 4.5 per cent a year as a result of the number of trainees in the pipeline, bringing a total increase of 19 per cent by 2003-4.

Existing targets are for an extra 3,000 heart operations a year by 2002 but with the extra investment this will now be achieved ahead of time and will be doubled to 6,000 by 2003.

There will be a new target of a maximum two-week wait for referral to a chest clinic for any patients with suspected angina (chest pain cause by heart problems) by 2003. Rapid access chest clinics will be established across the country. By the same date three-quarters of people admitted to hospital with heart attacks should receive potentially life-saving clot busting drugs within 20 minutes of admission.

Mental health

Extra staff are to be drafted in to to help GPs care for patients with problems of stress and depression as part of a £300m investment in mental health services. The 1,000 new graduate primary care mental health workers will treat common mental problems in all age groups and a further 500 community mental health staff will be employed to work with GPs and and accident and emergency departments to help people who need immediate care and attention.

Staff will shift to jobs designed around patient need rather than perpetuating occupational hierarchies. For doctors there will be major changes in the way they are trained, deployed, employed, assessed and rewarded. By shedding tasks to other NHS staff they will be able to focus on those patients who most need their specialist skills.

Nurses

Nurses will be offered new responsibilities and given new opportunities. An extra 20,000 nurses will be recruited, a 7 per cent increase, and 6,750 more occupational and physiotherapists and other health professionals. Those who have the right qualifications will be able to make referrals, admit and discharge patients, order investigations and tests and prescribe drugs.

In response to calls for Matron to be returned to the wards, the plan says senior sisters will be appointed to be in charge of a group of wards who will be easily identifiable to patients. A total of 5,500 more nurses, midwives and health visitors will be trained each year by 2004.

Doctors

While nurses are given increased powers and authority, the NHS plan effectively tightens controls on doctors, seeking to rein in the independence of GPs and end the "consultant as king " culture. Contracts are to be overhauled, private practice restricted and salaries tied to performance.

Doctors yesterday signalled that they would fight the Government over any plans which they believed threatened their freedom in the health service.

But with the stick comes a carrot of extra consultants, GPs and a further 1,000 extra medical training places, on top of the 1,000 already planned. A new consultant's contract will offer financial incentives for agreeing to work only for the NHS. Consultants will be contracted to work exclusively for the NHS for about the first seven years of their career, with a fixed eight sessions a week and extra money to compensate for the fact they will not be able to do private work. The merit award system, which can add up to £60,000 to a consultant's salary, is to be overhauled and those consultants who work hardest for the NHS may earn bonuses.

Primary care

Changes most visible to patients will be at the GP level. The public consultation on the NHS plan showed that the public's top concern was waiting for treatment. By 2002, patients will be guaranteed an appointment with a member of the GPs staff (nurse, health visitor, etc) within 24 hours and with a GP within 48 hours. At present, only half of practices achieve this.

Hospital tests will increasingly be offered in the surgery, avoiding the need for travel to the hospital. By 2004, consultants who previously worked mainly in hospital will be conducting four million consultations in GPs surgeries.

Our-of-hours services will be developed and by 2004 NHS Direct, the telephone helpline, will provide a one-stop gateway to out-of-hours care at nights and weekends. Two years before that, NHS Direct will start to refer people, where appropriate, to help from their local pharmacy, to ease pressure on GPs.

Up to £1bn is to be invested in primary care facilities with 500 one-stop primary care centres established by 2004, bringing together under one roof GPs, dentists, opticians and other health and social care professionals. Up to 3,000 GPs premises will be refurbished or replenished by 2004.

There will be a major change in the contracts for GPs with a shift from the national model to local versions - called the Personal Medical Services contract - based on meeting quality standards and local needs.

These have been piloted in parts of the country to develop new services for specific populations, such as ethnic minority communities and the plan envisages one-third of all GPs operating under the contracts within two years.

Closer integration of health and social services will be achieved with the establishment of new Care Trusts with pooled budgets and a new requirement under the Health Act 1999 for all NHS and local councils to work closely together. This, the plan says, "will bring about a radical redesign of the whole care system." In future social workers will work alongside doctors in GPs surgeries.

Targets

A new Modernisation Agency is to be set up to implement the changes and a new "traffic light" system will show how different hospitals and trusts are performing. Trusts which meet all their targets and are in the top 25 per cent of well performing organisations will be give the "green light" - and rewarded with greater powers, extra cash from a new £500m Performance Fund (by 2004) and less inspections.

"Yellow light" trusts meeting most of their targets will have to draw up plans with regional directors before they can get their hands on extra cash from the Performance Fund.

Failing trusts will be shown the red light. They will have to draw up a "recovery plan", will only be able to get extra money by applying to the Modernisation Agency and could be taken over by managers from "green light" trusts.

Bad doctors

To restore the public's faith in doctors, which has been shaken by the recent spate of disciplinary cases before the General Medical Council including that of Harold Shipman, the GP murderer, and Rodney Ledward, the incompetent gynaecologist, a new National Clinical Assessment Authority is to be set up. It will rapidly assess any doctor about whom there are concerns.

There will be tighter controls on the General Medical Council and the other health regulatory bodies such as the UK Central Council of Nurses. The plan does not signal their abolition but says they must change if self regulation of the professions is to continue.

A new UK Council for Health Regulators will co-ordinate their activities . The plan says they will need to "involve patients and the public to a much greater extent, be more transparent and develop real accountability to the public and the health service."

The poor

To tackle the health gap between rich and poor, new national targets are to be set, a measure that was called for by the Acheson inquiry into health inequalities two years ago but ducked by ministers. A new target is also to be set to narrow the gap in infant and childhood mortality.

Smokers who are on social security benefits will be helped to give up when nicotine patches and chewing gum are made available on prescription from 2001. Prescriptions are free to the poor which means that they will benefit financially as well as in health terms if they try to give up.

For children, there is to be a replacement for school milk. The National School Fruit Scheme will provide every child in nursery and those aged four to six in infant school with a free piece of fruit every day. Eating fruit is considered the second most effective means of reducing cancer, after smoking, and at five portions of fruit and vegetables a day could cut deaths from chronic disease by a fifth.