National health, local dynamic: The Independent last week described the NHS as 'floundering'. Virginia Bottomley replies

IN THE PAST three years the NHS has undergone a transformation, the scale of which bears comparison with its original foundation.

All but a handful of NHS hospitals have been established as trusts. Health authorities have been given a new role: to establish priorities for their areas and commission the best services to meet them. GP fundholders have burst confidently on to the scene, showing the dynamism and innovation which result when doctors are given the means to back their own judgements with resources.

The purpose of this strategic change has been to replace the command and control structures of the NHS with a local dynamic. Responsibility for taking decisions has been devolved to those closest to the public and the patients whom the decisions affect.

This shift reflects the Government's approach to reform across the public sector: local diversity, competition and choice are replacing a monolithic service. It is very different from the Labour Party's view, where rigid centralisation is still in favour. Labour's opposition to GP fundholding betrays its deep and harmful instincts for levelling down rather than levelling up.

Critics who complain that no clear strategy has emerged from our reforms underestimate the energy and skill that have gone into achieving them. It is right, however, to look beyond the changes to the sort of health service we expect to create. With a consensus forming about the basic structural changes, we now have a secure platform from which to look ahead.

We start by recognising that we have, in effect, redefined what we mean by the National Health Service. The service should not be defined by who provides it, but by the fundamental principle which underpins their work: to provide care on the basis of clinical need and regardless of the ability to pay. Those who have difficulty with this idea should remember that general practitioners are, and always have been, independent, self- employed doctors under contract to the NHS.

The precise nature of the services provided should increasingly become a matter for local decision. We should be open-minded about this. I welcome, for example, a health authority in Hampshire inviting tenders for a new community hospital from the private sector as well as from NHS trusts. We should ask ourselves two questions only. Do patients benefit? Does the scheme offer value for money?

In the NHS of the future we can expect to see a much greater diversity of provision. The independent sector will supply some services, including direct patient care, under contract to health authorities and fundholders. New technology will cut hospital lengths of stay or remove entirely the need for hospital treatment. Medicine's capacity to switch care from hospital to community settings will mean an enhanced role for GPs and their teams. And we will see an increasing focus on improving health rather than just treating illness.

The NHS was founded to improve people's health and well-being. For 46 years an obsession with means rather than ends has seen that objective submerged in a welter of change and counter-change. No longer. We are better placed than ever to make public health the cornerstone of policy and to deliver on measurable objectives for raising the nation's health.

Again, the key lies in local action. Innovative health authorities will use the increasing sums spent on the NHS not just to respond to illness but to secure better all-round health. They will channel investment into interventions which are proven to be clinically effective. The NHS will be able to withdraw from those treatments, such as, some would argue, grommets, which are of dubious value.

It is our intention to encourage this trend at national level. Through clinical audit, clinical guidelines and monitoring outcomes we can improve and apply our knowledge of the most effective practice. Our national research and development strategy, the most advanced of its kind in the world, has at its heart the dissemination of information which is accessible to both clinicians and managers. The NHS is becoming a truly knowledge-based service. Reinforcing the research base of the NHS, working with the academic and scientific communities, will also be a key job in the new regional offices.

We must also reassess the implications of a healthier population which is living longer. Ever since Malthus's essay on population growth nearly 200 years ago, society has been troubled by the prospect of a growing mismatch between people and resources. In the NHS today the question is how we can best continue to provide a cradle-to- grave medical service to an ageing population whose longevity we are working hard to enhance.

Despite growing demands, we will not be forced to abandon the principle of universal NHS coverage. The Government's recent revised guidelines did not 'bury' the cradle-to-grave NHS. On the contrary, they reinforced a crucial principle of the Beveridge welfare state: individuals and families who can afford to do so must expect to make a contribution to their own long-term social care.

Social care - but not health care - has always been subject to a means assessment. No set of guidelines is likely to make less sensitive the dividing line between the two. William Reid, the Health Ombudsman whose comments triggered the review of the guidelines, has said that our revised guidance takes account of his concerns.

The health reforms, the Patient's Charter, the Health of the Nation White Paper and our work to improve the knowledge base of the NHS amount to potentially the most coherent set of health policies in the world, in which the needs of patients come first, health is stressed as much as health care, and the focus is on the quality of services and clinical outcomes.

A recent OECD report into the reform of the UK health service recognised the benefits our changes have brought patients, and the lead we have established with our public health strategy. We have an excellent opportunity to use our innovative policy framework to ensure that the founding goals of the National Health Service remain relevant and are delivered in practice in today's changing world.

The author is Secretary of State for Health.

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