There may be trouble ahead

Is there an NHS crisis looming for Stephen Dorrell, or will the storm warnings prove to be unfounded?

In his first year - almost - as Secretary of State for Health, Stephen Dorrell has scarcely put a foot wrong. The great BSE crisis aside - for which he can hardly be blamed - he has proved sure-footed and trouble free. The weekly, sometimes it seems almost daily, alarums, large and small which the NHS regularly throws at any custodian of his job have all been adeptly handled. There has been strategy to Mr Dorrell's approach to the NHS as well as tactics.

But a big question mark remains. Did he, at the crucial moment of last year's spending round, take his eye off the ball? Is the NHS heading - in an election year - for a bitter winter of discontent?

The storm signals are flying in a way not seen for years - certainly not since the NHS reforms arrived in 1991, lubricated on their way by large dollops of extra cash. And it is almost certainly the worst year financially since 1987, the occasion of the last great NHS crisis. Then for want of a few hundred million pounds 4,000 beds closed, and the roof of the NHS came in - both literally as the hurricane of 1987 tore the tiles off a clutch of NHS hospitals in southern England and metaphorically as a deeply reluctant Government found itself forced into an NHS review.

Certainly the parallels with 1987 are unnerving. Then an over-tight financial settlement ahead of a general election saw the Government get through polling day only for health authorities to respond to the financial crisis in the only way they knew - closing beds early in the financial year to cut activity and balance their books. At the same time - and probably on the good political principle that it never rains but it pours - the service was hit by a series of misfortunes that were strictly unrelated to the lack of money. Unintended pay disputes - first with nurses and then with blood transfusion staff - broke out. A shortage of specialist nurses which more money alone would not instantly have solved, compounded the bed closures. And David Barber, a hole-in-the-heart baby, had his operation cancelled five times in six weeks amid legal action by his parents and a welter of damaging publicity.

Today, some of the same applies. Specialist nurses are again in short supply, compounding the problem seen last winter of too few intensive care beds for both adults and children, and over which Mr Dorrell has ordered action.

And for the current financial year - despite it being an election year - the money is very, very tight. "It is no secret that this is the toughest year financially since the NHS reforms came in," according to Philip Hunt, director of the National Association of Health Authorities and Trusts. "We have 1.1 per cent real growth and that simply isn't enough.

"Ideally, we need 3 per cent and we can manage on 2 per cent, but 1.1 per cent threatens trouble." A recent survey by NAHAT, he adds, shows the NHS to be "stretched to the limit under some of the most enormous pressures it has ever faced."

In 1987, there were essentially only two causes of the crisis - lack of cash after a series of tight settlements and the nurse recruitment crisis.

This year there are many more. There are of course the usual NHS concerns: the costs of technological advance, the ageing population and Government driven initiatives which include the extra intensive care beds to be provided from existing resources, and a drive to get more of the money into primary care and mental health services.

But this year there are a stack of compounding problems. Local authority social services departments have faced an equally tight settlement, leading to mounting worries that discharges to nursing and residential homes will be slow, blocking beds. Already, Mr Hunt says, "we are struggling to cope with the impact of delays by social services in assessing and then providing suitable support for people inappropriately staying in hospital beds."

Cuts in junior doctors' hours and a quiet revolution in specialist training has made the medical staffing of wards more difficult. The continuing implementation of local pay has left a resentful nursing workforce. And that in turn appears to be making efforts to change the mix of nursing and other skills on wards more complex, rather than simpler.

Meanwhile the rising tide of emergency admissions continues upward, for a complex mesh of reasons that leaves no one with a satisfactory explanation of the cause.

GP fundholders are reporting that the relatively easy savings from the early years of the scheme are no longer there. They too are facing the same difficulties in striking deals with hospitals that health authorities have faced this year.

And management, at a time when it faces its toughest test since the new NHS came in, is resentful at having been told to take an apparently arbitrary 5 per cent across-the-board cut.

On top of that, the run-up to the general election has left both health authorities and trusts wary over launching new "rationalisations" of services which may save money and produce greater efficiency but which tend to look to the public like cuts.

Comparisons with 1987 should not be overdrawn, however. Back then, the general management of the NHS was in its infancy. The Department of Health lacked an even half-decent monitoring system to tell it what was going on and to warn it of trouble ahead. As the crisis developed, neither political action, nor, in its absence, effective management action was taken to avert it.

Today, the flow of information is much better. Health authorities, trusts and at least some of the GP fundholders have learnt to pace themselves more smoothly through the year. Management is far better equipped to cope. And, unlike 1987, no one is pretending there isn't a problem. There remains a worry, however, that so great has been the turn-over of senior managers and health authority and trust chairmen that relatively few remain who have seen the NHS through a bad time, as opposed to the more generous settlements of recent years. Will they know how to cope when the going gets tough?

Both Alan Langlands, the NHS Chief Executive, and Mr Dorrell have both acknowledged that all is not rosy, but have argued that the service must get through. "I am well aware of the pressures which exist in some parts of the service and I do not seek to gloss over them," Mr Dorrell told NAHAT's annual conference last week.

Both have said that waiting times may have to lengthen this winter, though by how much no one is predicting. A half-decent 'flu epidemic could see them balloon. Neither for patients nor Government is this good news, particularly since one of its greater NHS achievements in recent years has been the elimination first of two year and then of 18 month waits for treatment, to the point where at the last count just 5,000 patients had waited over a year.

The NHS may indeed cope, and dire warnings that the service risks "meltdown" may prove unfounded. If they do not, however, the person for whom it might be worst news is Mr Dorrell. An NHS crisis just ahead of a general election would do neither him nor the Government any favours. Which may turn Mr Dorrell into a "let's go in October if we can" man - or lead him to bang on the Treasury door in the early autumn if by then the worst of this summer's predictions look likely to be true. Failing to do that was the mistake John Moore made in 1987. And who now remembers him?