'I do not follow rhyme or reason, only the secretary of state'
I am a typical NHS chief executive and accountable to the secretary of state for health. I rely on her patronage and carry out her orders. If today she tells me to do something, I do it unquestioningly and explain why it is right. When, next month, she asks me to do the exact opposite, I do it and explain why it is right. If she asks me to stand on my head I comply but try to convince everybody that my feet are on the ground. If I succeed, as I usually do, they are the ones who turn upside down.
I do not follow rhyme or reason, only the secretary of state. I am a member of an elite, a new breed of NHS chief executives, ruthless and efficient - not like the old softies, few of whom now remain. Our mission is to maintain the facade of a universal and comprehensive health service, win elections for the government and if possible privatise the health service - all at the same time. In a hostile and thankless universe we deliver health care to an ungrateful general public, and in the name of unruly, selfish and benighted health professionals. We have many means of getting our own way.
First, if the evidence or logic is shaky, we reach for mantras. For example, the ubiquitous &Quot;delivering the right care, in the right place, at the right time by the right people&Quot; is bereft of meaning and of any objective means of verification. Heaven sent, it can cover just about anything at all. Likewise we put everything down to &Quot;modernisation and improvement&Quot;. This term, too, is invaluable; it is self-fulfilling. What is modern and improving? It is what I propose. What do I propose? Why, what is modern and improving of course.
Not a u-turn...
Let me offer an example. Before the general election, we praise a particular community hospital as modern and the future of local health care. After the general election, when ordered to make cuts to services to save money, we seek to close it. So in May the hospital is modern and improving; by June it is old fashioned and obsolete. The term &Quot;modern&Quot; is indeed a delightful, movable feast.
Second, we don't lose too much sleep over evidence-based practice; we would never get anything done. We are realists. Take, for instance, Patricia Hewitt talking about managing people with long term conditions at home, and thereby reducing unplanned hospital admissions of such people by 30 per cent. True, a study funded by the Department of Health suggests only a few per cent reduction in admissions - and only then if we employ lots of specialist nurses or &Quot;community matrons&Quot; at considerable cost. But our job is to follow our political mistress, not worry about the evidence. So we close down beds by the score anyway, with or without the specialist nurses, and with little idea of the impact.
Paradoxically then, we find realism does not preclude illusionism and wishful thinking. We espouse faith in the new health creed of &Quot;care closer to home&Quot;; empirical doubts are for losers. We close NHS beds today but promise paradise tomorrow. We conjure up armies of peripatetic health professionals roaming around local communities - even though we do not no how many will be required or how effective they will be, and in any case lack the money to pay for them.
Third, if we implement particularly drastic cuts, we resort to the chief executive's classic counter: &Quot;Patient care will not suffer.&Quot; I must confess to astonishment at the gullibility of the national press in reporting such statements at face value. If pushed, we also escape into the NHS phantom zone; instead of talking about real patients and their needs, we resort to indistinct visions, &Quot;models of care&Quot; and &Quot;care pathways&Quot;. These generally have a suitably stultifying effect.
Quite honestly, we are sometimes given to such outrageous statements that in any context other than the NHS they would be taken for parody.
Selecting a target
Fourth, we are highly selective, referring only to carefully chosen performance targets, not to others. We omit to point out that, behind these targets, other health care is going up in a conflagration, in particular for older people, and for people with mental health problems or learning disabilities. There are simply too many of them and they don't get better.
For example, we strangle inpatient rehabilitation, both acute and non-acute, and instead claim to meet nearly everybody's rehabilitation and recuperation needs in their own home, and all within six weeks. This is our customised, economy version of &Quot;intermediate care&Quot;. We don't mention that for some people it is impractical. Indeed we operate rules that exclude certain patients from rehabilitation in their own homes - for instance, if their needs are too complex, they lack the potential for six-week rehabilitation, or the home environment is inappropriate. The sheer irrationality of pushing a policy that we know cannot work is no obstacle.
Fifth, we love floating red herrings, particularly health and safety, to achieve our ends by stealth. So we close elderly care beds &Quot;temporarily&Quot; because we lack the staff to keep them open safely. We claim to have no choice, and that it is beyond our control. But we do not explain that the situation has arisen only because we encouraged staff to leave (by intimating they had no future), and then imposed a recruitment freeze. The word &Quot;temporary&Quot; is also important here. Under the rules, we have to consult about changes to services. However, we argue that &Quot;temporary closure&Quot; does not equate to change, so we stay quiet. How long then is temporary? As long as a piece of string. A year on and the beds remain firmly shut; they will never reopen.
Sixth, we exploit ambiguity. We profess to support community hospitals. The public supports them too. Good, we all agree. Except they think community hospitals have beds and consultants whereas we know there will be no beds or consultants, just glorified GP practices. However, we are meant to be following a national policy of community hospital development. And the Community Hospitals Association is making life difficult. It is putting it about - correctly, it seems - that out of 320 such hospitals, some 110 are threatened with cutback or closure. Old or new build, it makes no difference. In fact, it gets worse. It turns out that half the &Quot;new&Quot; community hospitals promised by the government will in fact be no more than downgraded and rebadged district general hospitals. Thank goodness the public have not cottoned on to this yet.
Seventh, when in a corner, we improvise. For instance, faced with overwhelming opposition (often tens of thousands of opposed views) to proposed local changes, we may have to think fast. We calmly explain that we were too straightforward in asking whether local people wanted services closed (even though this is what the consultation was all about). So, having committed the heresy of transparency - by asking the wrong questions as it were - we obviously ended up with the wrong answers. Therefore we can ignore all the opposition. Even I have to admire the brilliant sophistry of the modern NHS chief executive.
Eighth, when the going really gets tough we play the great game of non-accountability - most competently, it has to be said. In league with the strategic health authorities and the secretary of state, we form the perfect complicit circle resistant to reason and discordant voices. We chief executives combat criticism by explaining we have no choice and are under orders from above. SHAs, when approached, plead ignorance and call themselves a mere post box, an honest broker between local NHS trust and central government (although I must confess even I get annoyed by the sheer limpness of the SHAs). And the secretary of state herself? She denies knowledge of all things local.
We're all in it together, of course. No one owns up, there is no accountability and no responsibility. And all this Department of Health policy about patient choice and the involvement of local communities? A joke. In fact, when a whole lot of us got together at a conference recently, we had a good chuckle about it.
We have two final weapons in the locker. Crucially we rely on clinicians and health professionals who are ambitious, weak or misguided enough to go along with it all. They sit on the board as executive directors and support proposals which horrify them professionally. But, miraculously, they always come through when it counts. As do the hapless non-executive directors. They do not know, do not want to know, and anyway are not up to knowing, the half of it. In any case, we don't want them to know. Thus no matter how controversial our proposals the board always approves them, unanimously.
Last, but not least, myself. I am entrusted with immense power, responsibility and salary. Patricia Hewitt smiles upon me and says I am a &Quot;good chap&Quot;. I do what she says and, by definition, what she says must be right. So I am right as well. Some think I am guilty of mental cheating. That is, although aware of the destructive things I am doing - otherwise I couldn't do them - I manage simultaneously to shut them out mentally in order to maintain my intellectual integrity. George Orwell, I remember from university (I was a bit of a leftie then), called this doublethink. I have thought about this very hard, in fact doubly, both sober and intoxicated - I believe the ancient Greeks did this before reaching an important decision. My conclusion? I have a conscience, I have integrity, and I act in good faith. Above all, I am a true public servant.
Michael Mandelstam is author ofBetraying the NHS: health abandoned , published by Jessica Kingsley Publishers ( www.jkp.com).