The shock of the new

Admitting that the great majority of staff and the public had felt excluded last time round, NHS chief executive Alan Langlands said: 'It is going to be enormously important to ensure we don't fall into that trap a second time.'

He told a conference that the NHS Executive had stayed deliberately silent after the publication of the white paper to allow time for its messages 'to sink in', but that he was now ready to start talking about its implementation.

Mr Langlands warned: 'We need to tackle the implementation process without breaking step. If we allow some of the basics to go by the board while we are tackling this, we lose the confidence of staff and patients.'

Speaking largely without notes, he conceded: 'We will have to make quite a bit of effort over the next few years not to lose our way in a process which becomes the property of those who are managing the health service.'

It was a theme to which he returned later in his speech, when he admitted that 'a small group of us - a couple of thousand people across the health service - took off and left everyone else in their wake' during the earlier reforms.

'It left a whole lot of people feeling disenfranchised. We can't do that again. We have to take people along with us in this process,' said Mr Langlands.

He told the conference, organised by Harrogate Public Sector Management Centre, that while he had been impressed by the energy being put into the reforms by many doctors and managers locally, partnership was essential.

'I see far too many people as I go round who, in the classic health service way, are playing for position,' he said.

'In one case recently we came across an acute trust huddled with a group of about 40 GPs saying, 'we haven't invited the community unit because we don't think they are going to exist very much longer'.

'That doesn't strike me as the right definition of partnership.'

He said the Executive was acutely conscious of the strain winter pressures currently put on the NHS. He had seen some examples where its response with social services was a model of partnership. But that was not always so.

'There was even one place where I had to introduce the director of social services to the chief executive of the health authority. I knew both of them, but they didn't know each other - which was slightly worrying,' said Mr Langlands.

There had also been delay in issuing guidance on implementing The New NHS while work on the public health green paper, Our Healthier Nation, was completed. 'I don't think they are separate projects or separate entities.'

He went on: 'We expect to break this silence soon.' The Executive would set out an 'integrated programme of action' to implement the white paper and those aspects of the green paper 'where early progress needs to be made'.

There were, said Mr Langlands, six key objectives which would 'become the touchstone for what I genuinely hope is a 10-year programme in the making'.

They were:

to improve health and reduce inequalities in health;

to continue to provide more integrated services;

to improve quality and raise standards;

to continue to drive up performance and efficiency;

to enable staff to make the maximum contribution to policy development and implementation;

to improve public confidence and commitment to the NHS and to social services.

'One bit of the jigsaw that you have not seen and probably won't see in much detail is the comprehensive spending review,' said Mr Langlands.

That was currently taking up 'a great deal of time' within the Department of Health.

There was, he told the conference, a need for a 'consistent set of principles' on implementing the white paper. 'This is the point at which politicians hand on the baton to the people who have to make change happen on the ground.'

That process would have to involve staff as far as possible and be based on partnership. 'There is no point having an HA implementation plan, a trust plan and a local authority plan. Somehow these are going to have to be integrated.'

'Ideological diktats' would not replace common sense in trying to reconcile the need for primary care groups based simultaneously on natural boundaries, with populations of around 100,000 and coterminous with local authorities.

But he had a warning: 'Where there is a firm line is on natural communities. We mean natural geographical communities, not natural communities of like- minded people.'

Nationally, said Mr Langlands, he and his colleagues faced a 'fairly onerous' programme to ensure that legislation was in place by 1999-2000.

He continued: 'Later this month we will be producing the chief medical officer's work on strengthening the public health agenda...

'In March we will have to have in place guidance on primary care group formation. And we are going to try from the end of March onwards to pilot the NHS Direct system.

'Some of the rather difficult problems around extra-contractual referrals and the commissioning of specialist services we will have a position on in the spring.'

Mr Langlands said: 'We hope to have health action zones up and running in some places by April. There will also have to be some attempt to give life to this idea of longer-term agreements between health authorities and trusts.

'Sometime in June or July we will have to prepare the traditional Priorities and Planning Guidance in a way which supports the government's objectives and which supports all of you developing health action programmes locally.

'And at the end of 1998 we will be at the beginning of the process of having the first national survey of patient and user experiences.

'Just think of that as one element in the process of change and you will have some impression of the work that needs to be done.'