The gathering storm

Since the summer, when the ailing state of the NHS in Oxfordshire was laid out for all to see (it even became a regular subject at Prime Minister's Questions) things have been ominously quiet.

But six months on, the two biggest health trusts have been reviewing progress as we head into winter, traditionally the time of most intense pressure whether we are talking about the accident and emergency department or your GP's surgery. For it is now clear that both the Oxford Radcliffe Hospitals NHS Trust and health primary care are entering new eras, with massive structural change and reorganisation being delivered alongside drastic savings plans.

Tomorrow, hundreds of people are expected to take to the street, marching from Hinksey Park to Broad Street, to attend 'A Defend The NHS' rally. It follows an impressive demonstration last month in Banbury, showing the continued level of public alarm about proposals to curb services at the town's Horton Hospital.

David Cameron placed job losses at Oxfordshire health trusts at the heart of his first major campaign as Conservative leader to "stop Brown's NHS cuts".

He told The Oxford Times: "In Oxfordshire we have got that terrible combination of big deficits and real service reduction. What I've seen in Oxfordshire has helped inspire me to make this into a big national campaign. People are not just disappointed but perplexed after all that money has gone into the health service."

At almost exactly the same time the two chief executives charged with getting Oxfordshire NHS on its feet had shocking messages of their own to deliver to their annual general meetings outlining the latest positions - shockingly optimistic, that is.

Trevor Campbell Davis, chief executive of the ORH trust, said that the cost cutting in Oxfordshire's main hospitals was actually improving the quality and speed of services for patients.

He said: "The challenge has been to find ways of doing things that increase efficiency and improve services for the patients, giving them a better experience in hospital. What I find interesting is you can do both of these things to a large measure."

The key, he says, has been to ensure patient hospital stays continue to be reduced to the shortest period of time.

Patients' desire to be back home within two days is understandable, not least when the top man remarks with disarming frankness: "Compared with 20 years ago hospitals are dangerous places. People in hospital tend to be older, more frail, susceptible to infection and at the same time many infections are becoming resistant to antibiotics."

Better use of operating theatres and outpatient clinics has also helped, with much store attached to the locally-devised Key Performance Indicators, to reduce cancellations and increase the numbers of day cases. Rather than closing 130 beds, the trust has in fact been able to close 160.

But all this talk of ensuring "smooth journeys through the system" could be blown away by the arrival of General Winter at Headington. Mr Campbell Davis admits there is a real risk of patients again having to wait for beds once winter sets in, particularly in accident and emergency.

The biggest challenge to the hospital's ability to cope through the winter will inevitably come from hospitalised pensioners. The chief executive said: "We still typically have between 60 and 80 patients in hospital, ready to be discharged, who should not be in hospital. But we are not able to discharge them because there is nowhere for them to go."

The number of compulsory redundancies is now likely to be in the region of 60, about ten per cent of the 600 jobs to go. High levels of redeployment and the massive turn-over of staff at the trust is the principal reason redundancies have turned out to be far lower than anticipated.

But this will be of small comfort to those campaigning against the trust's plan to downgrade services at the Horton, which would see the closure of the special care baby unit, and a reduction in children's and maternity care.

With the consultation period for the trust's proposals ending today, the chief executive recognises the Horton represents a highly vulnerable flank. "I know our proposals are causing concern," he said. But the main reasons for the proposals are to do with modern clinical practices and patient safety rather than to do with finance."

A new book, Betraying the NHS, by Michael Mandelstam, published later this month, holds up the Horton as an example of a trust's lack of frankness with the public. Mandelstam, a legal specialist in health matters, writes: "The Oxford Radcliffe Hospitals NHS Trust would deny it had any intention of closing Horton Hospital - even though it had just been included in a local district council plan for residential development."

Across Headington, sits Andrea Young, the new head of Oxfordshire Primary Care Trust, a trust with a smaller profile than the Radcliffe's, but one with a budget of £692m, and altogether greater spending power.

The woman responsible for providing or buying the bulk of the county's healthcare, was even keener to proclaim the dawning of a brave new morning of financial stability, slim-lined services and greater public involvement in the county's new-look NHS.

But then the trust she heads is newly formed, bringing together the five short-lived PCTs, of Cherwell, Vale, North East, South West and South East and Oxford.

It has come into being as one of the UK's biggest primary care trusts with the promise of reducing duplication and bureaucracy, although some will take this as the clearest admission that the previous complex reorganisation was a costly mistake.

From day one, however, it will find itself grappling with its unhappy inheritance of overspending and insufficient Government funding. For the new PCT must deliver £18m of savings by the end of 2007 with heavy job cuts. There will be a 13 per cent reduction in managerial staff and a 6.5 per cent reduction in clinical jobs, to help bring down staff costs by £4.2m. The new PCT, however, is still unable to say what this will mean in terms of jobs to go.

Few, if any, patients will have been able to detect any discernible change in their NHS this month, despite the emergence of this NHS leviathan.

Yet make no mistake, Ms Young and her soon-to-be-appointed board, will be making key decisions about Oxfordshire's community hospitals and the role of the independent sector in delivering services.

A package of reforms also has major implications for Oxfordshire GPs, who will be increasingly urged to take greater responsibility for the spending on prescriptions and referrals to consultants.

The new system, known as practice-based commissioning, will seek to make GPs and community nursing staff far more budget conscious.

It is hoped that instead of wasting hundreds of thousands of pounds by prescribing branded top-of-the-range drugs from leading companies, the more financially-savvy GPs will go for cheaper options whenever possible.

The threat that practices which refer high numbers of patients to consultants or specialists will be targeted might suggest the new regime is rather more about stick than carrot.

But south Oxfordshire GP Stephen Richards, who has taken up an interim appointment as chairman of the clinical executive in the new PCT, certainly does not see it that way. "In the current years the trust will spend the equivalent of £1,170 per head of population. That is an awful lot of money. The key thing is there will be one voice for primary care. The new PCT means that GPs in 86 practices in Oxfordshire are drawn back into the same organisation for the first time in six or seven years."

He said GP practices for the first time were given "indicative budgets" as an early step in involving GPs in how taxpayers' money is spent. Local GPs are already grouping themselves into consortia - one covering Oxford, five in south east Oxfordshire, nine around Witney and so on - who will be encouraged to share specialisms.

As an example Dr Richards described how even within his own practice, other doctors did not realise that he was qualified to inject joints and therefore had not benefited from a specialism available literally in the next surgery. For patients, he says, it holds out the promise of 'one-stop' clinics, allowing more people to be seen locally for a whole series of treatments in areas such as dermatology and physiotherapy.

The steady drop in GP referrals to hospitals has not been totally self-imposed. The Clinical Advisory Liaison Services was created with the task of sifting through GP referrals. Banbury MP Tony Baldry described the system as a "Stalinist process" which involved second guessing and vetting referral letters from GPs, causing delays and leaving outpatient clinics half empty.

Dr Richards believes CALS is merely a short-term measure to help balance the books. "I cannot see CALs working in its current form for much longer." Like others his eyes are fixed on a horizon when the millions have been made and the budget balanced.

But with no plans to change the crucial national NHS funding formula, which leaves Oxfordshire's trusts receiving proportionally less than other regions, it could yet be a false dawn of more reorganisations and 'More NHS for your money' sloganing.