One cannot work in or near the NHS for long without becoming aware of the public service ethos that permeates it like a spiced marinade around a particularly tough piece of meat. It has been such an integral part of the health service value system that questioning it risks excommunication. But what value will it have in the next century?
The public service ethos was born with the rest of the welfare state, out of the strong sense of community involvement and responsibility that was the Second World War's legacy. The NHS and its social welfare cousins were greeted by a great sense of relief: everyone was entitled to free and comprehensive health and social care, irrespective of age, income or social class.
But there was more - a sense of societal altruism, of all being in this together. Part of my warm glow lay in the knowledge that I was helping my fellow citizens in their times of need, just as I could count on them to come to my aid when I was down. This 'communitarianism' might be called the first dimension of the public service ethos.
Such societal altruism extended through geographical as well as social strata: witness the concept of the general hospital and uniform services in every district. This utilitarian approach still typifies British thinking on healthcare, and could be called the second dimension of the public service ethos. However little butter we have, we'll make damned sure we spread it all over the bread, even if it means none of us has enough.
The third dimension concerns how we use public money. Long after 1945, not only did the public purse have to pay for welfare services, but public sector workers had to provide them. Whether refuse collection, hospital catering, or district nursing, our egalitarian principles insisted that public employees provide them all. And any public money not spent directly on the recipient of care was deemed to have been wasted. No 'management' for us - we could (and did) do without, using administrative systems of high regulation and low scrutiny that worked well when services and finances were predictable.
No need for silly 'staff development' when dedication and long hours kept the welfare production lines going.
This was fine until the pace of change accelerated. First, technology increased exponentially: we were able to do more. Then society began to question the service it demanded and the price it paid. Suddenly, we had to find ways of squeezing more bangs out of our welfare buck while maintaining the original principles of 'communitarianism', utilitarianism, egalitarianism.
And we couldn't do it; public egalitarianism in delivering services was not sustainable, so the whole concept of the public sector was called into question. The private sector took over refuse collection and most hospital catering, by and large seeming to do it more efficiently than before; the privatisation of publicly funded service delivery had started.
Today, doubts remain about the private sector's capacity to provide care for those who need nursing home beds. Few have crossed the Rubicon of private medical services in a public setting - except fundholding GPs and health authorities with waiting-list money and no spare local NHS capacity. The ethos of a public service - though the service itself is increasingly delivered by private providers - seems set to continue. The move to a primary care focus, with its GP kernel of private sector providers, fits well with this zeitgeist. Having breached one of the dimensions of the ethos, how useful do the other two remain?
Utilitarian aspects of the ethos pose a conundrum to areas of public spending that appear marginal to patient benefit. On the one hand, our lack of recognition of the impact of management, and reluctance to acknowledge the value of training and development, seem short-sighted and narrow. On the other hand, a healthy dose of scepticism may be an excellent antidote to overbearing jargon and bureaucratic 'overkill'.
The challenge is to welcome management guidance to the service as we might welcome the input of town planners to co-ordinate haphazard attempts to build a new town. We don't want either set of bureaucrats to stifle invention and motivation, but we know that without them neither system would function.
We need to change the way we think about training and development - no longer can we exploit our welfare carers. Managers and clinicians without training in the increasingly technological NHS will become useless, if not dangerous, to their clients. Without development, they will be harder to recruit or retain. So much is already becoming apparent. As we accept the need to use good quality engine oil to keep our cars running, we should accept the need to spend public money to 'lubricate' our workforce and prevent expensive breakdowns.
Finally, the 'communitarian' aspects of the ethos seem surprisingly and refreshingly strong. The public and the service itself want an NHS which makes no distinction on the basis of wealth or social class and remains (more or less) comprehensive. The desire to preserve and improve 'our' NHS is still strong enough to bind individuals and organisations through enormous changes, and keep their commitment, often with no sense of their final destination.
The public service ethos seems ready for a comeback after the threat to its very existence in the early 1990s. We should rethink and reinvent the best aspects of our societal compassion. We should be prepared to give up some of the more inflexible aspects of our public sector values. What we need are strong services, publicly funded and with strong public probity, but with much more diversity in the manner in which care and its surrounding organisational 'trimmings' are delivered.