New foundations for the health service

By Karen Allen BBC Health Correspondent

It's been a year where health has continued to grab the headlines daily.

Midway through the government's ten year plan, and the opinion polls show that on an individual basis patients believe the NHS is serving them well.

Some hospitals now have greater freedom

But collectively the view is that much more needs to be done.

April marked a radical re-structuring of the health service with the creation of foundation trusts and new watchdogs to work alongside rapidly evolving primary care trusts.

The effects of these are probably not yet being felt by patients on the ground, but they will have major implications in the way hospitals and family doctor services are run in the future.

No more "one size fits all"

The government's been under pressure to deliver on it's promise to reduce waits for treatment.

The total number of people waiting for treatment has fallen by 12% in a year if you take the figures at face value.

But ministers have admitted that this doesn't reflect patients' experience and more needs to be done to attack the "hidden waits".

These include the wait to get diagnostic tests done, and then the wait for the consultant to make a diagnosis.

Waiting times have been reduced through tough targets and help from the private sector.

We can expect to see more private companies carrying out diagnostic tests such as endoscopies and scans in future.

Indeed, as ministers regularly tell us, we, no longer do we have a "once size fits all" health service.

Instead, we have a partnership of public, private and voluntary providers.

It all sounded rather promising - but do these superior institutions do what they say on the box?

Some call this privatisation by stealth - others prefer to see it as "nationalisation" of the private sector.

The point is, the boundaries between public and private are increasingly being blurred.

This year a record number of patients had their hip replacements or cataract operations carried out in private facilites.

By the end of 2005 patients will have a choice of where they are seen for treatment.

What's on offer must include a private facility.

It is part of a programme to deliver more "patient choice".

In reality that is unlikely to mean a mass migration of patient across the country to get their care.

Rather, it is a philosophy that will seek to introduce business principles into the NHS - a sense that if the services aren't up to scratch the customers will walk.

An internal market by any other name.

Foundations for the future

In April we witnessed the birth of the first wave of foundation hospitals.

Elite hospital trusts with the freedom to spend and borrow as they wish.

This "earned autonomy" freed them from the "shackles" of Whitehall control.

It all sounded rather promising - but do these superior institutions do what they say on the box?

It is early days yet and many foundation trust managers privately are frustrated by the reluctance of Whitehall to let go of the apron strings.

There are battles with a new NHS tariff system which the foundation trusts are the first to implement, and those that are heading for major financial deficits have been swiftly dealt with by the regulator.

The big question in the coming year will be just how much freedom will foundation trusts be able to exercise and will the growing role of the private sector threaten their ability to survive financially?

Public health

2004 has been the year when public health seemed to come of age.

Smoking is a top target for ministers

There have been more reports on obesity; smoking and sexual health collectively than there have been for many decades.

The driver is partly medical and partly economic.

For the government to deliver on it's promise of reducing heart disease it has to be seen to be addressing the issue of passive smoking and the health threats posed by a trebling in obesity rates over two decades.

Derek Wanless, who was commissioned by the treasury to make an assessment of health spending, told Gordon Brown, that unless more attention was paid to public health, NHS spending would have to be doubled by 2022 just to keep still.

So the government has set out it's policy proposals in a Public Health White paper - much of which is likely to find it's way onto the Labour party's manifesto.

They include:

• A ban on smoking in all enclosed public places that serve food
• A traffic light system of labelling for food which have a high fat, sugar or salt content
• The promise that serious thought will be given to the introduction of a watershed for tv adverts promoting so called "junk food".

The government is terrified of being accused of running a "nanny state" - telling the public what to do.

However, there is a view though amongst some of the most libertarian libertarians that on issues of public health, a bit more nannying wouldn't go amiss.