Deborah Orr: The NHS is suffering from reform fatigue

No Health Secretary, in the 59 years of the NHS, has had a weirder brief than Alan Johnson. For, by his own admission, his job is to keep his nose out.

"There will be," he promised at the dawn of his elevation, "no further centrally dictated, top-down restructuring to primary care trusts and strategic health authorities for the foreseeable future."

The logic behind this undertaking is that the service is reeling, not primarily because of structural difficulties, but under the strain of a couple of decades of endless reorganisation. Money has been poured in at an unprecedented rate and battalions of new staff have been recruited from all over the world. But still morale is so low that pushing around a nice clean mop appears to be more than the public can expect for its money. "Deep cleaning" is an aspiration, and anti-MRSA pyjamas are on sale at Marks and Spencer. This latter, one notes, is a sterling example of responsive private sector provision.

Johnson, in a not unfamiliar governmental initiative, therefore made "consultation" his first priority as Health Secretary. A year is to be spent listening to the people who work in the service, and a report will be published on how things can be improved. The nation waits with bated breath.

In the meantime, though, Johnson is making do with listening to all those national clinical directors Labour has been busy appointing since 1999, all of them specialists in their medical fields, and all of them briefed since almost the start of the present government's tenure with crafting an NHS that is clinically rather than bureaucratically led, plugged into the thinking on the ground, rather than answerable to the agenda of Whitehall. In theory, anyway.

Professor Mike Richards, the national clinical director for cancer, was the very first of these "tsars" to be appointed, and has therefore been slogging away at formulating NHS policy on cancer for eight years now. This week's Cancer Reform Strategy is his little baby, delivered with all the calm and efficiency one has come to expect from NHS births since Patricia Hewitt told us back in April that by 2009 birth in Britain would be of a utopian order, by way of some magical formula as yet unrevealed.

There is little to take issue with in what the professor suggests, accepting of course that the strategys's lack of ambition is an indication that Richards is dealing in reality, not "aspiration". As promises go, I have to confess, I find the prospect of waiting five years for the happy day when, if diagnosed with cancer, I need wait only a month for radiotherapy, to be less than overwhelming. I can guarantee that in five years time my preference will be not different to the preference I nurture now, which is for radiotherapy absolutely the minute I get diagnosed, if not before.

Still, Rome wasn't built in a day, and Richards has at least secured funding that seems directly linked to the achievement of this goal. 200m will be invested in extra radiotherapy equipment and staff over the next three years. Nevertheless, the words of Norman Lamb, the Liberal Democrat health spokesman, still tend to ring in the ears. "The strategy is at risk due to government inability to secure value for money in the NHS," he reckons. He is not the only one who harbours such fears.

As it happens, I wholeheartedly agree with the idea that the NHS is suffering from reform fatigue, and that whatever the imperfections of the present structure, we are better off, for the time being, soldiering on with it. Anyway, a lot of what's wrong with the NHS is distressing not because it is so difficult to fix, but because it ought to be really simple to fix. NHS workers hate to be told it, but a lot of the trouble really is with attitudes on the ground. Johnson's consultation is an opportunity to address this. But workers must take the chance to make changes themselves, instead of endlessly complaining about the changes that have been imposed upon them.

Take the long-running specialist appointments nightmare, which has been the focus of government worry for so long. There has been improvement in this area, in so much as the patient now has some say, sometimes, in the labyrinthine process of setting one up, always through the agency of a gate-keeping GP (unlike in, say, France). Yet still the service complains that missed appointments cost a fortune (in 2005 it was about 575m), as if this is something that is quite beyond its control.

Will missed appointments cost a fortune when all the preventative cancer screening to be rolled out by the Government in the next five years comes into existence? You bet it will, because unlike the rest of the world, including the world of private medicine, the NHS bizarrely believes it is not cost-effective to employ a little diary management, and call appointees a couple of days before to check that they are still in a position to turn up.

The problem has further implications, as far as the Cancer Reform Strategy is concerned, as one of the recommendations is that there should be more treatment at home or in the community. Again, this is one of those ideas that sounds simple and good, but isn't because of the passivity of the NHS in diary management, and the passivity it projects in turn on to patients. This results is the astonishing practice whereby the various operatives who have home-based patients under their care quite often tip up unannounced, expressing tremendous surprise when the patient is, say, off getting a blood transfusion after an emergency admission to hospital, or has been in a hospice for a few weeks.

Maybe phone-call budgets are a great deal more tight than petrol budgets or time budgets among NHS workers. But one concludes, after one has been exposed to this piecemeal way of working for a length of time, that sheer stubborn lack of personal initiative must be part of the formula that stops individuals working within the service from communicating directly to the patient themselves in the most efficient manner available.

It is probably the right thing for me to declare an interest at this point, and confess that I have just spent an abject summer looking on as my own precious, magnificent father died of cancer, amid a whirlwind of well-meaning NHS workers whose kindness and concern, palpable as it may have been, was easily outmatched by their lack of co-ordination or leadership, and their reluctance to manage their day or their week in an efficient fashion. My family and I did not have much to marvel about during those miserable months, but we did marvel at the profligacy with which time and energy, two things my dad had been robbed of so suddenly and cruelly, was frittered so pointlessly away before our very eyes.

d.orr@independent.co.uk