The will is there, the cash is there, but where are the doctors?

Comment: Julian Le Grand

I must confess to an initial cynicism about the Government's national plan for the NHS. Those of us who have been in the welfare state business for a long time, and have seen so many "most fundamental reforms since Beveridge" come and go, find it difficult to summon up much enthusiasm for another one.

I must confess to an initial cynicism about the Government's national plan for the NHS. Those of us who have been in the welfare state business for a long time, and have seen so many "most fundamental reforms since Beveridge" come and go, find it difficult to summon up much enthusiasm for another one.

The process by which the plan was constructed seemed hasty and populist. And there was the dreadful association of the name; the failure of George Brown's national plan for the economy was what did for the 1960s Labour government.

Yet I have to say that the plan that has emerged is quite radical. This is particularly so where performance management is concerned - especially for doctors. The days of unmonitored professional autonomy are over. Consultants will have job plans specified by the employer and linked to an annual appraisal. In fact, all doctors will have to participate in annual appraisal and audit - data from which will feed into the General Medical Council's five-yearly revalidations.

The GMC itself is put on probation: it will have to deliver reforms that will "restore public and professional confidence". At the same time, the payment structure for GPs and consultants is being revamped, with rewards being explicitly tied to NHS performance. More carrots are on offer for the good; but the bad will be beaten with sticks - and heavy ones at that.

Trusts rated "red" under the new traffic-light system will be reviewed every two years by the independent inspectorate, the Commission for Health Improvement, whose size is to be doubled. On the other hand, "green" organisations will get rewarded financially, will be reviewed less frequently and will have greater freedoms.

Radical changes indeed. But will they work? This depends crucially on the attitude of the medical profession. Although doctors' leaders were involved in the drafting of the plan, it is difficult to see GPs and consultants at the coal-face placidly accepting the degree of micro-management to which they are to be subjected. But the series of scandals involving incompetent doctors may have sapped confidence so that they cannot mount an effective resistance. In that case, we may see some significant short-term improvements in quality - with much fury from those getting sticks, not carrots.

But will these improvements be enough to deliver the electoral benefits on which the pollsters and others in No 10 are doubtless pinning their hopes? Here I am less hopeful, for there remains a problem of resources. Not money - with Gordon Brown's largesse there is going to be plenty of that - but whether the resources are there for the money to buy.

The number of doctors for every 1,000 people in the United Kingdom is 1.8, the lowest in the European Union. Indeed, it is the lowest for all countries in Eastern and Western Europe except for Albania and Turkey. Italy has more than three times as many doctors per head; Germany more than twice as many; France slightly less than twice.

The number of doctors is crucial because they determine a health system's capacity. Other factors that are important include the number of nurses (Britain is ninth in the EU); the way doctors and nurses are used (rather efficiently in the NHS); and buildings and equipment (not so good). But ultimately it is impossible to increase significantly the services provided without more doctors.

And extra doctors are not easy to come by. They take seven years to train, and it is much longer to create an experienced consultant. Unsurprisingly, recent research has shown the more experienced a consultant in general the better are his or her results.

The plan's authors propose increasing the number of places for medical student, and recruiting from abroad. But graduates will not appear until much too late to get the kind of results needed if the plan is to be a political success.

Nor will the new concordat with the private sector solve the problem. The consultants are the same as the ones who work in the NHS. It may be possible to divert them to NHS work by payment schemes - an idea that may have the interesting consequence that waiting lists rise in the private sector. But if they did, those being treated privately would rejoin the NHS waiting list with little overall gain overall.

So there is little alternative but to wait until we train new doctors, which will take time. We shall not really know if the plan has worked until after the next election, and probably not until after the election after that. Ironically, the chief beneficiary of Tony Blair's national plan may be William Hague.

Julian Le Grand is the Richard Titmuss Professor of Social Policy at the London School of Economics