Funds alone cannot save cash-swallowing NHS

Tony Blair has a nightmare about the NHS. It is that the £2bn extra for the health service announced in Tuesday's Budget will disappear into a black hole.

Spectacular as the sum undoubtedly is, the health service has an unrivalled capacity to swallow cash without making progress against the rising tide of demand. With the next election possibly just over a year away, there is little time to spend the extra in a way that will be noticed by voters.

In the longer term, with an average 6.1 per cent real annual increase to 2004, the Government's aim is nothing less than transformation of the health service to meet rising expectations, heading off demands for privatisation, and winning itself a third term as saviours of the most popular public service.

Will it be enough? Much will depend on the response from the professionals who run the service. On Tuesday evening the Prime Minister, who is taking a huge personal gamble by assuming the leadership of the NHS reform programme, told a hastily assembled group of NHS leaders that in return for the extra cash they must agree to draw up and drive through radical plans to modernise the health service. One observer commented: "He made them an offer they couldn't refuse. It was collaboration Don Corleone-style."

Tensions are most likely to arise where what professionals believe is best for the NHS clashes with what politicians see as most visible to patients.

Big, centrally planned and funded projects such as NHS Direct, the telephone helpline, and the announcement of cancer and heart tzars to lead "crusades" look impressive. But what matters to the professionals is whether there are enough beds, enough nurses to staff them and enough drugs for those who need them.

If damaging headlines are to be avoided next winter, there must be enough in the general allocation to local services - outside any modernisation fund - to prevent cases like that of Mavis Skeet, the throat-cancer patient whose operation was repeatedly cancelled until her condition was terminal.

The first call on next year's Budget increase of £4.9bn (the planned £2.9bn plus the extra £2bn announced in the Budget) will be cutting waiting lists. After this winter's flu outbreak, the Government is still 60,000 short of its pledge to reduce the in-patient lists by 100,000 by the next election. Last year it added to its burden by promising to cut out-patient waiting lists, which have risen sharply.

Although the pledge has been criticised heavily by doctors for distorting clinical priorities - less urgent patients get quicker treatment to achieve the targets - it is a promise that cannot be shirked. This will almost certainly mean sending more patients to private hospitals to be operated on at NHS expense. Mr Blair signalled his approval of this strategy earlier this month when he said if money was available but there was no capacity in the NHS "I have absolutely nothing against using the independent sector."

Extra beds will be needed before next winter to head off a repeat of this year's flu crisis. These will be less difficult to find than the staff to run them. Many hospitals have beds or wards that are mothballed and there are community hospitals that could be reopened as convalescent homes to help clear the beds blocked by elderly patients awaiting discharge of which Mr Blair complained yesterday.

Gordon Brown promised an extra 10,000 nurses in his Budget speech, to be recruited over two years, but that will still not cover the Royal College of Nursing estimate of 17,000 UK vacancies. A recruitment drive by the Government last year brought in 4,500 and is being repeated this year.

Extra doctors will be harder to find. Medical schools are taking on 1,000 extra students over the next five years but it will be 15 years until they are consultants. NHS trusts are recruiting overseas but this will help only a few.

The best hope lies in making better use of doctors' time by passing some of their duties to specially trained nurses or a new kind of health care worker who would bridge the divide between nurse and doctor.

Ministers believe the flexibility of the health care workforce, highlighted by Mr Blair yesterday, is the key to improving responsiveness and efficiency. Two working parties are examining the matter and are due to report on it in the next few weeks.

In addition to the front end needs of more operations and more patients treated, a sizeable slice of the money is likely to be required for the care of old people. The Government is due to respond to the Royal Commission on Long term Care in the summer and some reports have suggested it will agree to make nursing care of residents of old people's homes free (it is currently means tested). The cost will depend on how tightly nursing care is defined but is unlikely to be less than £600m.

In the longer term, by 2004, the health service will be able to boast a string of new hospitals, now being built with money raised under the Private Finance Initiative, and much improved accident and emergency units which are now being modernised. But experts remain doubtful as to whether Labour will have done enough to save the service.

Jennifer Dixon, the health policy analyst at the Kings Fund think tank, said: "I can't see this staving off the debate about the need for radical change in the future. We may be better off than we are now but we won't be able to do all we want to. We won't be able to avoid rationing."

Nigel Edwards, policy director of the NHS Confederation, said: "The key question is how the professionals behave and what they do with the money. If we can change the culture to get the laggards up to the standard of the best, we may have done enough to show the NHS is worth sticking with."