When Gordon Brown stood outside number ten and promised change in our NHS there were probably many healthcare professionals whose hearts sank.They could only think that change is the last thing they want. Indeed the best sort of change would be a move to stability.

But politicians have to be seen to be doing something and changing things is a good way of getting visibility, even if the end result is not necessarily better, but just different. Unfortunately it appears that Brown has a fair amount of NHS baggage to cope with, which could tempt him into meddling.

The story so far

As Chancellor he has been responsible for the huge investment in the NHS.This appears to have resulted in a negative political payback, since most people do not believe that the NHS has got better.That really must annoy him and he must be itching to change that perception.

But what else do we know? That he is by temperament a micromanipulator – as anyone who has listened to his budget speeches must agree – but that he has supported the Blair reform agenda. Indeed, he is said to have told union chiefs he would refuse to reverse the reforms. He does have the advantage of a new Secretary of State, so there will have to be a period of relative quiet as Alan Johnson gets to know his new job.

So what exactly can he change?

He could give the NHS independence from political interference, with its own independent board.This would be seen as a bold strategic move, which could provide the NHS with more stability than it has had for years. However, it is thought that Patricia Hewitt intimated that the idea was a non-starter after reported consultation with Brown. The Tories and the BMA remain wedded to the idea but on balance such a move seems unlikely in the short-term.

He has the problem of cuts and hospital closures to deal with, without being able to spend any more money. He could pick a fight with doctors over what many think have been over-generous pay deals and focus on out-ofhours service provision in primary care.

He also knows, from everything he has heard round the country, that “we need to do better” and he has said that the NHS will be his immediate priority to “do better” at:

• ensuring access for patients at the hours that suit them
• getting the basics of food, hygiene and cleanliness right
• helping people to manage their own health
• ensuring patients are treated with dignity in the NHS
• providing the wider range of services now needed by our growing elderly population
• listening to and valuing staff.

An independent NHS?

He intends to make progress by putting more power locally in the hands of patients and staff. He will push for “a new settlement for a modern NHS free at the point of need – clear about where accountability lies – clear where government should set overall objectives, clear where it should not interfere, and clear how independently local people should have their voice heard and acted upon in shaping the future of the NHS.” One wonders what level of independence is being envisaged here.

In terms of structural change the most likely outcome are locally-driven moves to what are being called Health Economy Foundation Trusts, or HEFTS.

These could take whatever form the local health environment thinks is suitable and, when they achieve Foundation status, they will give a really viable level of independence.

Clinician engagement seems to be the missing link in all the reforms. Get this and the Gordon and Alan show could really achieve something big, but the negotiations will be tricky.