Command and control retains much attraction for politicians of all hues

Published: 03/10/2002 Volume II2, No.5825 Page 17

Many of those responsible for the day-to-day running of the service yearn for greater freedom from central control to allow them to manage organisations according to local circumstances. And the government has promised just that.

But the history of the NHS tells us that such pledges should be treated with caution, for the command and control model has been a feature of the service since its inception (feature, pages 22-24). The reasons for this are not hard to find. Proposals for moderate change do not win elections and politicians of both major parties have looked to fundamental reform to deliver improvements. When this is not forthcoming as quickly as hoped - and when is it ever? - there is a tendency to rein in the promised freedoms.

Supporters of the internal market believed that care could be improved by devolving budgets to health authorities. But the purchasing function never fully developed and the centre could not leave local markets to themselves. Whether primary care trusts can instil greater confidence is open to some doubt.

Despite Labour's pledges to replace competition with collaboration, it has still felt it necessary to develop a powerful performance management and regulation regime to deliver the desired improvements. Even foundation trusts would be foolish to expect total freedom from central surveillance. The speed with which local difficulties can become national news makes that an impossibility.

However successful this government is at 'letting go', the savvy manager will know that any achievement will always be realised with the hot breath of politicians on their necks.