Your Humble Servant rides with the new Four Horsemen of the Apocalypse

To: Don Wise, chief executive

From: Paul Servant, assistant chief executive

Re: The new Four Horsemen of the Apocalypse

Dear Don

New financial year, new tariff, new market forces factors and same old problems. More money going from primary care to acutes, huge swings in projected surpluses and deficits, contracts unsigned and the wheels of arbitration turning arbitrarily. Luckily we also have the four principles of co-production, subsidiarity, clinical ownership and leadership and system alignment. I like to think of them as the new Four Horsemen of the Apocalypse.

But what do they mean?

Co-production means decision making with partners who are also stakeholders and might even be patients about how to implement decisions the DH has already co-produced for you.

Subsidiarity means ensuring decisions are taken at the right level in the system. The DH has said that where necessary it will enable things to happen locally, where possible. This is all about assuring blame can be apportioned as close to the patient or as far from the DH as possible, and of course what is necessary and possible is defined from the top - where you are not allowed to look because, to misquote Bismarck, DH policies are like sausages and it is best not to see how they are made.

Clinical ownership and leadership is about doctors and nurses running things. Well it’s about a few doctors and nurses running things, lots of GPs owning things and the reintroduction of an old principle that doctor knows best, which surely the Bristol inquiry, the creation of NICE and the emergence of regulatory empires suggest otherwise.

System alignment is everyone agreeing with the DH that these are four bloody good principles.

So what does this all mean for managers? You’re not a doctor, a patient, Lord Darzi, a stakeholder, a regulator or a policy maker. You do what you’re told and get chopped when it goes wrong.