Amid the muffled shrieks of a few early casualties and victims, and in a fog of confusion, the Tories' detested NHS reforms' set sail on April 1.
The changes in the NHS & Community Care Act abandon any attempt at planning of services, resorting instead to an untried Thatcherite notion of an internal market' in which authorities will be reduced to seeking to buy treatment for patients in their area.
The health authorities will be able to go shopping to local directly-managed hospitals, and further afield, to the new 'opted-out' hospitals, politely termed Self Governing Trusts, or even to the private sector. However the NHS as a whole will have no extra money, amounts available for patient care will be reduced by the huge increase in administrative costs.
The preparation for the new Act has already caused havoc, with dozens of health authorities cutting back services to eliminate deficits. However some health authorities have fallen far short of balancing their books, and have been permitted to start the new financial year with substantial cash deficits.
Indeed, ministers remain in two minds about whether the NHS Act is the most radical (and unpopular!) reform ever imposed on the health service, or whether it represents a barely percep tible change.
As the launch date has neared, most of the more far-reaching changes have been toned down, or delayed:
• The community care proposals have been shelved for two years -until after the next election.
• The changes in funding to health authorities have been phased over several years.
• The competition between hospitals for shares of the internal market has been restrained by pleas from ministers and top Gambling: Health secretary Waldegrave NHS chiefs for a year in which districts and regions make no substantial changes.
The potentially chaotic launch of GP practices free to spend their own budgets has been restricted by lack of interest: only 306 GP practices out of the 950, covering 3% of the population, have been given the go-ahead.
• And the list of opting out hospitals has been whittled down to the minimum required to save political face - from a first list of 200 applicants to just 56 Trusts on April 1 (a top secret report from City consultants warned Waldegrave that only 14 of the 65 eventual applicants were financially viable).
Despite these soothing measures, many managers admit that it will be difficult to preserve a 'steady state' and avoid new damaging cuts in service.
The problems will be severe in London, where hospitals face high overhead costs that must now be reflected in the prices charged for patients from outside health authorities: already Bloomsbury health authority, is complaining that health authorities are breaking the rules, and diverting patients away from Bloomsbury to lowerpriced treatment. The pressure to do this kind of thing will increase as the year goes on.
Outside London, health authorities and Trusts face a host of problems. In Oxford region huge cash shortfalls continue to force new cutbacks, with Oxford itself cutting f2.2m and Kettering f1.7m. The Kettering cuts include a ban on any sterilisation operations for women, while health chiefs are refusing to pay for any patients to be referred to other districts.
The effects of these and other cutbacks on hospitals and trusts have not yet been calculated: nor have the effects of increased administrative costs.
Meanwhile the replacement of planning with unenforcible mock 'businessstyle' contracts for care leaves a strong possibility that gaps will be left in services, and that hospitals will focus resources on profitable' acute services, to the detriment of less lucrative but essential care of the elderly, people with mental illness and the longterm sick.
John Lister HANDS OFF OUR NHS The campaign fighting hospital opt-outs.
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