Published: 21/03/2002, Volume II2, No. 5797 Page 24 25
The crooks, comedians and eccentrics loom out of the past first. There was the dapper, uppercrust payroll manager who combined National Front membership with defrauding his health authority. The gay macho health board secretary jailed for violent and random attacks on strangers.
The bumptious colonel, appointed to head an HA, who declared he had 'an empty mind to see the wood for the trees', and whose leaving speech - mere months into his three-year contract - was delivered to the strains of My Way. And the insouciant non-executive who shouted 'boring' before walking out of the secretary of state's speech.
All these were curious, colourful departures from the solemn and weighty issues which have preoccupied the health service during my 18 years on HSJ, the last eight as editor. Because they were so odd and untypical, they glow in the memory.
So, too, do those moments of privileged access which journalists enjoy, and which may bring sudden unlooked-for insights - or just reveal the vulnerable, human side of the high and mighty.
Touring a hospital with NHS chief executive Sir Len Peach, he disclosed that he had never come across the concept of the consultant's 'firm'. Or chasing a determinedly elusive Duncan Nichol, on his appointment as NHS chief executive, in the days before media savvy and presentation were all: a reluctant 10-minute telephone interview was his sole concession to press exposure.
And the sound of Edwina Currie's stilettos echo still, crossing the deck of a Thames barge to attend a meeting of the HSJ editorial advisory panel (we liked novel venues).Mrs Currie, then a backbench MP and fond of making an entrance, arrived late.A hush fell as two elegant black-stockinged legs cautiously descended the ladder into the hold. Because she had to leave early, the whole performance was repeated in reverse an hour later.
I joined HSJ in the era of crown immunity and Körner, of value for money and compulsory competitive tendering. Performance indicators were in their infancy, and income generation was about to become a faddish distraction, prompted by the HA which commissioned management consultants to devise an array of money-making wheezes, then sold their report to other NHS organisations for£100 a copy. Above all, it was the era of Griffiths and the 'general manager'.
The Sainsbury chief 's report on modernising NHS management set the scene for years to come; arguably, without it, most of what has happened since would not have been possible.
And much of HSJ's reportage would have taken a very different shape. Or would it? For a whole sheaf of identical issues make our pages today as in 1984.
The week I joined, the government was exhorting the NHS to improve relations with the private sector, and the Confederation of British Industry was expressing doubts about increased health spending.My first piece was about patients who fail to turn up for appointments; today the service is still searching for the holy grail of a booking system.
Waiting lists cast their pall over everything then as now, and the Cinderella services have yet to enjoy an outing to the ball, let alone marriage to the prince.
Nurses are still underpaid and overworked, doctors are forever on the verge of resigning en masse. The army of ancillary workers continues to be scarcely regarded, though their contribution to the 'patient experience' is crucial.
Much of the dilapidated pre-First World War building stock is still in use. The 'rationing debate' has made its way out of policy journals and into the tabloids, accompanied by the perennial chants to stop using the NHS as a 'political football', while the rhetoric of devolution is, as always, paired with creeping centralisation.
Now, as then, and throughout the years between, ministers are in the grip of an obsessive compulsive disorder to restructure the service. But the past 25 years show that none of the NHS's assorted structures have alleviated its major underlying problems one jot.
Continuity spans even the change of government, and in the most unexpected areas.When Labour replaced the Conservatives in 1997, some managers believed they could stop feeling cowed by their political masters and speak out freely without fear of the call from regional office. But Stalinism merely gave way to spin, applied with equal ruthlessness.
None of which is to pretend that everything remains the same.Where once the NHS's most neglected patients trod wanly in the grounds of Victorian asylums, now dwell the prosperous occupants of luxury flats. In 1984, the first long-stay institution was still two years from closure.
The periodic scandals uncovered in long-stay hospitals have metamorphosed into periodic scandals about the failures of community care - usually when a patient kills someone, though perhaps a greater disgrace is the number who kill themselves.
Orwell chronicled the decline of the English murder; I have watched, if not the decline, then at least the shifting nature of the NHS scandal.
Instances of psychiatric abuse or filthy kitchens gave way 10 years ago to transgressions involving money. Bedazzled by the great ideological adventure to privatise support services and get rich quick, managers were at the heart of these scandals.
The colossal waste of public funds at Wessex, West Midlands and Yorkshire regional health authorities epitomised this phase. They contributed to the poor image of NHS managers in the 1990s, and made them sitting targets for the 'grey suits bad, white coats good' propaganda shamelessly peddled by politicians - Labour and Conservative - who should have known better.
The public have long since forgotten these cases.
But now the white coats are bad too, and people will not so easily forget more recent scandals: Bristol and Alder Hey, Shipman, Ledward, Neale and a clutch of other medical miscreants whose travesties of clinical care have led to the long walk down Great Portland Street before the cameras to the steps of the General Medical Council. These have contributed to the most fundamental change of the past 18 years - indeed of the past five: the erosion of public confidence in the NHS. In the 1980s, contemplating alternatives to the NHS was a pursuit confined to young Turks in right-wing think-tanks; today it fills prime-time slots on evening television.
Perhaps the surprise is that it has taken so long, given all the folly and whim of policy-making in the past two decades. Take, for example, the slavish adherence to mechanistic formulae which dictated ever diminishing resources for inner city healthcare. Take the reckless abandon with which hundreds of thousands of beds have been lost, well beyond what changing care patterns made desirable.Witness round after round of 'efficiency savings'which chipped away unheedingly at staff morale and service quality.Witness the flat refusal to ban tobacco advertising and the doltish denials - dissent from which was career-limiting - that the service was underfunded, or that poverty was linked to ill health.Consider consultants' contracts.
And remember the internal market.
Like the public, HSJ was deeply sceptical about the internal market. Surveys showed it to be unpopular with a majority of managers, and our robust coverage brought a 20 per cent circulation rise in the year after Working for Patients was published.
But if the concept had any supporters outside the Cabinet, it was among the managers leading its implementation, and a group of zealots objected to our stance, signing a Department of Healthinspired letter demanding we desist from 'pouring scorn' on 'changes which will drag the NHS into the real world'.Our criticisms centred on the practical and political impossibility of closing 'uncompetitive' hospitals as if they were failing high-street shops.We pointed out that many trusts would have financial problems, some would not survive, they were too secretive and insufficiently accountable and many of the promised freedoms would prove illusory.
'The reforms will give rise not to a management utopia but to unforeseen ramifications which will lead to conflicts as yet unpredicted.Managers will be forearmed only if forewarned, 'was our response.
History began to vindicate us within weeks of the market's launch. By 1993, we predicted: 'Eventually, the value to the NHS of collaboration and co-operation will be reasserted.The importance of harmonious working relationships will once again be stressed as essential for the patient's benefit.'
All that has come to pass, accompanied by levels of funding the NHS could only dream about in the 1990s.Yet its future looks more uncertain than at any time in its 54 years.
Many managers who preached the wonders of the market went on to praise with equal vigour the New NHS reforms designed to obliterate it.Unprincipled, hypocritical, opportunistic? In a few cases maybe, but most were simply doing their job as public servants - carrying out the wishes of the government of the day, which can unfairly give the impression of merely following fashion.
Having observed NHS managers closely for nearly two decades, what strikes me most forcibly are the modesty and idealism with which they shoulder a massive weight of responsibility, their appetite for learning and qualifications, ability to cope with complexity and high level of professional accomplishment. I have also been moved by their enthusiasm and loyalty for HSJ - the most rewarding part of the job. Long may that affinity continue.
Peter Davies joined HSJ as a reporter and feature writer in 1984, becoming deputy editor in 1987 and editor in 1993.He is leaving to become a freelance writer, editor and editorial consultant.