The NHS needs a major operation, and one of Gordon Brown's first acts as prime minister was to call upon a leading surgeon to undertake the task. Just before being appointed as a health minister in June, the respected oncologist Professor Ara Darzi had been drawing up plans to reshape services in London. His blueprint was radical - new "polyclinics" would be established so that more care could be delivered outside hospitals; the more controversial flip side, however, was fewer local maternity, paediatric and A&E wards. The first stage of his nationwide ministerial review, published yesterday, put less stress on closures - perhaps partly because fewer tough choices will be needed in most of the country than in London. But the possibility of an early election doubtless affected the balance of the report.
Be that as it may, Lord Darzi's immediate conclusions were welcome, focusing on making doctors more accessible. Labour has banished the longest waiting times and driven up the quality of care, but patchy provision of family doctors outside of office hours remains a real weakness. When GP pay was increased by a quarter in 2004, the chance was missed to extract more flexible hours in return: the number of NHS hours worked by family doctors actually declined. It would, of course, have been better if the problem had been tackled at a time when a large prospective pay rise was still strengthening the ministerial negotiating hand. But Lord Darzi believes he has found ingenious ways to make working weekends pay. There were also other measures to make the service more accessible. Lord Darzi's boss, Alan Johnson, announced plans for 150 new walk-in centres - hosting GPs along with other services, such as dentistry and physiotherapy - as well as 100 extra practices in the run-down areas, where they are needed most.
Most of the tough decisions, to merge or scale back hospitals, will not need to be taken for months. Some painful change will be needed - not just to secure efficiency, but also to build up centres of expertise. David Cameron must know that his promise to preserve every district hospital in formaldehyde is just not serious. Until now, however, technocratic talk of "reconfiguration" has lacked credibility. Financial deficits made it look like a shabby cover for cuts, and medics had little reason to endorse plans that ignored their concerns. But now, at last, there is at least a chance of a rational discussion about rationalisation, both because the service is back in the black and also because doctors are back in the driving seat. Lord Darzi yesterday appointed a team of clinicians in every region to map out the pattern of services that they believe are required. If, after discussion with colleagues, they conclude that things have to change then that should carry real weight - with both the public and their fellow professionals.
The engagement of health professionals is one welcome change from the Blair years. Another is a subtle shift in the role that choice is intended to play. Lord Darzi yesterday emphasised its importance in primary care. If the likes of Boots were running GP surgeries there would be tricky issues about big business controlling NHS purse strings through practice-based commissioning. But when it comes to selecting a family doctor, patients are well placed to shop around. That is less true, however, in the hospital sector, where the Blairite drive to expand competition became frenzied: yesterday's Health Service Journal revealed the huge number of operations that private firms are being paid for but not carrying out. Lord Darzi's suggestion that services must be shaped by clinicians is one of several signs that the new government understands that choice in healthcare should be balanced by a measure of planning. The next challenge is to refine the rules on competition so that such planning does not end up unravelling in the marketplace.
