The NHS at 60
Authors: John Squire Kirkham
Journal: Journal of the Royal Society of Medicine (2008)

Your editorial, based largely on benign misunderstandings and wishful thinking in the style of one Rowan Atkinson, urges clinicians [especially those over 40 and fed up] to engage in the debate – presumably with management and politicians (JRSM 2008;101:327). This is dangerous. During the first 20 years of the NHS most clinicians did engage and co-operate with a tiny number of mostly very able administrators and agents of the Ministry of Health, resulting in a very happy NHS indeed becoming the ‘Envy of the World’.

The ‘COGWHEEL’ reorganization in 1974 heralded the imposition of an ever increasing management structure, the poor managers more and more burdened by often hasty and reactive schemes, plans, structures, initiatives, targets and the rest, running to millions of words, introduced by a succession of Health ministers, few of whom were long in post and many of whom seemed to have little understanding of health generally or the NHS, and little ability to formulate and think through workable plans.

A sensible strengthening of management clearly was needed – first to organize the increasingly complex and expensive technology available; second to try to contain the huge increases in costs by real increases in efficiency; and third to introduce rationing. It all went wrong, for many reasons, most caused by poorly worked out and poorly drafted plans and dictats from the politicians. The abject fear of feeble politicians of association with the idea of rationing of health care in the public mind has led to blundering cuts and devolvement of responsibility to the often powerless managers, rather than to the rational economies and sensible rationing that could have followed an open debate.

It is quite wrong, and most regrettable, to suggest that clinicians have so far failed to engage. A large proportion have at times done so, but most of these have found it a bruising and unsatisfactory experience, while many of those who have persisted seem to have adopted management values, making them unfit to represent patients, doctors and other health professionals.

Before engaging, therefore, doctors should be well aware of the natural aims and aspirations of those on the other side of the table. Politicians, both local and national, always aware of their need of popularity for re-election, will rarely be concerned beyond the short term. To a Minister, health is a portfolio to be held for just long enough to impress sufficiently for promotion in the next reshuffle. It is much easier to make cuts in services, often deviously disguised, than to achieve economies by real efficiency. A good manager is ambitious and aware that advancement will require loyalty to the organization as his overriding priority. This may be strengthened by bonus payments, sometimes for questionable successes. Altruism is unlikely to appear until the manager or official is very senior, and even then is likely to fail in competition with the Honours system. Whilst recognizing that the managers have a tough and sometimes thankless task running the service as the politicians direct, we must never forget that the patients' ultimate safeguard lies in the independence of the medical profession – and, almost as importantly, that our integrity depends on us fighting against any erosion of that responsibility. We should be involved but we must not be assimilated.