Quiet eye at centre of a permanent storm

Some of the fundamental changes I don't think should be reversed by anyone. No one is going to say we shouldn't manage the health service. No one is going to say we should just go back to handing out the money in the way we used to and not think about population needs and effectiveness. No one is going to say we should put up the insulating walls again between GPs and hospitals. These are the important things that have happened."

The words are those of Alan Langlands, chief executive of the NHS, fencing his way round the question of whether Labour is right to want to abolish GP fundholding.

His predecessor got boiled in oil ahead of the 1992 general election for pronouncing Labour's then plans a disaster. Mr Langlands is determined to make no such mistake.

Fundholding has been "a mechanism for increasing the influence that GPs have on the way health services develop" he said last week before Labour's plans were leaked. It has stimulated primary care and produced "a much more profitable" relationship between GPs and clinicians. "I don't think you can take these things away."

It is, however, "important to separate means and ends," he adds. And one of the "dreadful terms that has crept in over the past few years has been `non-fundholder'. There are many, many capable GPs doing innovative things and providing very good services who are not fundholders. There are several ways to a skin a cat". Nonetheless, he says, carefully balancing his answer, the evidence on fundholding is "pretty persuasive" and needs to be taken into account.

Mr Langlands, 43, is the quiet eye at the centre of the permanent storm that is the NHS, a man who is fortunate to have the reputation of getting calmer as the water gets rougher.

He is clear that the NHS reforms have brought real gains. He quietly declines with a smile to rehearse the battery of statistics with which ministers normally defend what they have done. But waiting times are much shorter, throughput is up and patient access to services has improved, he says.

"But I don't deny there are problems. I recognise the health service is working damn hard to deliver and against the background of all sorts of changes that are nothing to do with organisational reform - medical technology, developments in practice, social expectation. Against that people are having to slug it out in some places.

"And gradually we are going to have get ourselves off the efficiency index hook. That is not going unacknowledged. The NHS executive understands that, ministers understand, the Treasury understands the importance of balancing measures of efficiency with measures of service quality. When I go round the country I am not just interested to know what the length of stay is - I am interested in infection rates, readmission rates, and just what life is actually like out there."

It has, he acknowledges, been a period of the most turbulent change, with no one back in 1989 really appreciating the scale of what was being undertaken. "I don't think we really understood what was being let loose ... we have had to learn as we have gone along." And while the NHS was undergoing its biggest upheaval in nearly 50 years, "all the other planets with which we interact were changing as well" - social services and community care, social security funding, new incentive systems in universities and a new market-driven system of research.

"The result was a long period of pre-occupation with the nuts and bolts of the system. I certainly think managers became so involved that other things, such as the traditional interest in the development of services, slipped away.

"I hope we have lived through that and I do see signs of people getting back to the task in hand." At a recent meeting in Wandsworth of GPs, managers, nurses and consultants "they weren't talking prices and contracts and the language of the market". They were talking about how to make urology and other services better - the sorts of things Mr Langlands delighted in 15 years ago when he was a hospital manager.

He sees signs of hope too in NHS waiting lists for elective surgery having stabilised in the regions that have done the best job in cutting waiting times. "This does suggest that if you get over the hump, you can actually get waiting times down and keep them down - that the demand for elective surgery might be finite."

And he sees benefit in the wide range of experiments in different ways of purchasing and commissioning care now under way in the NHS. "That is a very different way of doing things from a few years ago when certain people were saying" - he refers to when Kenneth Clarke was Secretary of State, but is too politically acute to say so - "that `if you let people have pilots they will never do anything'. There's a natural experiment going on out there and we ought to benefit from it."

With the fundamentals in place, he says: "I think it is possible to proceed at a more considered pace" and accept that some of the changes need "adjustment". He is bullish too, about the NHS now having a clearer strategy than his critics would give him credit for six months ago. And he is clear that there are limits to ideas such as the private finance initiative which could see whole hospitals, doctors and all, run by the private sector.

"It is difficult to judge," he says, "but I don't think so. It is not at all clear that will be achieved. I do believe the vast majority of health services will remain in public ownership." Given the links between service, education and research "that feels pretty important to me".

Before he knew our poll result, we asked Mr Langlands if he thought the NHS would still be there in five years, ten years, and at the end of his lifetime. "Yes, yes and don't know," he said - "because the end of my lifetime is too far away. But I believe the NHS is so deep-rooted in the British psyche that it would be difficult ever to get away from it -I certainly hope so."

NICHOLAS TIMMINS

Public Policy Editor