Patricia Hewitt was right. This has been the best year the NHS has ever had. More patients have been treated than ever before—and treated both faster and more effectively. Survey after survey shows that those who have recently used the NHS think it is getting better.
Staff have not done too badly either. There are more nurses than ever before: 85,000 more since 1997. Entry-level nurses' pay has increased by 25 per cent in real terms. Doctor numbers have increased by over a third, and, as we all now know, their pay has also shot up. Even non-professional staff have seen substantial rises in pay.
So why all the fuss? Why was Hewitt shouted at by the nurses, told she was on another planet by the press and disbelieved by the general public? Partly it was because of the accumulating stories of hospital deficits and job losses. But even these don't really explain the manure that has been dumped over her and the government's heads in recent weeks.
The deficits—less than 1 per cent of total NHS spending—are trivial, the sort of sum that gets lost in the accounting noise of a large corporation. Moreover, if they are set against an underspend on capital last year, the NHS as a whole is in surplus.
The job "losses" are also tiny, relative to the NHS labour force of 1.3m. And most of them are not in fact real losses; they are decisions to freeze recruitment to unfilled posts and not to take on more agency staff.
One factor behind the hostility to Hewitt at the union conference she was addressing is inter-union politics. Unison and the Royal College of Nursing are both in the market for members. Running down the service you work in is a sure way to make yourself popular in the public sector. So it is not surprising that, as we have previously seen with teachers, public sector unions compete over who can best shout down the secretary of state.
But none of this fully explains the sense of malaise that infects the NHS—and other areas of the public sector. It reflects something more fundamental: an accumulated resentment by staff of being pushed around and having their autonomy threatened.
The resentment has several sources. Partly, it is the process of reform itself. Many feel, rightly or wrongly, that they have not been consulted, while those that have feel their views were not taken into account. It is also the sheer pace of change. The combination of patient choice, a new payment system for hospitals, foundation trusts, the use of the independent sector for treatment and diagnostics, the development of practice-based commissioning, the Connecting for Health IT programme, and a badly timed reorganisation of strategic health authorities and primary care trusts, all coming in at once, has placed an intolerable strain on many NHS staff.
But it also reflects an unease about the direction of reform. Medical professionals are brought up to believe that they are entitled to considerable autonomy, not only in clinical matters, but also in organisational ones. Consultants are used to running their own empires within hospitals. GPs are independent businesspeople, controlling their own small enterprises. Even nurses, though less powerful than doctors, have their own areas of power and control, especially where wards and patients are concerned.
But all this has been steadily eroded. Hospital managers have become more powerful (although they still have a long way to go before they can effectively manage consultants). The imposition of targets and performance management from the top have compelled both managers and professionals to confine their activities to what the government wants, and have severely limited their freedom of action in other areas. Even in clinical areas, doctors' prerogatives are being circumscribed by the development of government guidelines over what treatments they can carry out and what medicines they can prescribe.
Targets are now rightly dropping out of fashion. But the professionals are faced with what they perceive to be yet another major threat to their power and autonomy: the "quasi-market" in secondary, and increasingly primary, care that the government is setting up in large part as a substitute for performance management. The expansion of patient choice, increased competition from foundation trusts and the independent sector and the introduction of new providers of GP services all mean that if organisations are to thrive, there will have to be significant changes in both clinical and organisational behaviour. The discipline of the market is replacing the discipline of targets.
From the point of view of medical professionals, and indeed the NHS staff as a whole, this change from target to market should be an improvement. A command and control regime—where demanding targets are combined with heavy, top-down performance management—is demotivating and demoralising. It offers less freedom of action than operating as an autonomous agent in a market context: much less scope for initiative and much more being told what to do.
Of course, the downside is that with this greater freedom may come less security. However, this should not be overplayed. People lose their jobs in command and control systems, often with less opportunity for re-employment than markets offer. Also, in a world with a shortage of doctors and nurses, any medical professional who loses their job, in the unlikely event that their hospital or GP practice closes, would be unlucky to remain unemployed for long.
As a public sector professional myself, I would far prefer to work in the context of a quasi-market than under the dead hand of command and control. Maybe when NHS professionals have experienced the greater freedoms of the market—which most have yet to do—they will agree. The government, though, has to keep to its side of the bargain: to reduce the pressures of top-down performance management, and indeed eventually to eliminate it altogether.
