Labour's sweep to power in 1997 was followed by a groundswell of NHS optimism. Ten years on, an HSJ survey of 100 chief executives suggests the glory days are over. Helen Mooney asked a group of acute trust leaders why

For most acute trust chief executives the feeling is clear: they liked, agreed with and were happy to support 2000's NHS plan but they feel that since then, the government under Tony Blair has lost its way.

Other sentiments are also widely held, as became clear when HSJ asked a group of those at the top of acute trusts to share their experiences of a decade of the NHS under Labour: they believe they are not given enough support to do their jobs and implement change; they are easy scapegoats when things go wrong; and many hold acrimonious feelings towards primary care trust colleagues.

No love lost

Many acute trust chief executives believe the best days for the NHS under the current Labour government were earlier on, under the stewardship of then health secretary Alan Milburn (1999-2003).

There is certainly no love lost for current health secretary Patricia Hewitt.

'Hewitt is a disaster, she keeps tweaking things, she's got no idea of the bigger picture, she's indecisive. She's an utter disaster for the NHS,' argues one chief executive of an acute foundation trust in the North.

A Southern-based chief executive puts it even more bluntly: 'She doesn't know her arse from her elbow.'

The overriding opinion among acute trust chief executives is that the 'glory days' have all but disappeared from the NHS. Many are of the opinion that the NHS fared a lot better during Labour's first terms. Says one: 'The glory time was the Milburn time because he actually understood the NHS. The NHS plan was his baby.

'Where it all goes wrong is that the changing of the secretary of state and junior ministers means new people want to stamp their impression on the future direction of the service'.

There appears to be the common opinion that neither John Reid (2003-05) nor current incumbent Ms Hewitt have the same level of understanding of the NHS as had Mr Milburn.

'Milburn captured the mood, you may not have liked some of the things he was driving at but you felt there was a master plan.

'You got some sort of vision. It has gone downhill since then,' another foundation trust chief executive in the North declares.

A Midlands-based chief executive also hits out at what they see as Ms Hewitt's insincerity. 'She does not come across as sincere. She sounds condescending and won't admit to her mistakes.'

There is a palpable sense that the government has lost its way and backed down on the NHS reform agenda.

The chief executives HSJ spoke to felt the government was not prepared to wait out the original reforms to their conclusion to see the full effect of such change..

As one chief executive in the South East puts it: 'The government's attention to the NHS petered out and other things took their attention, then they started to look at what they had got for their money and there was a sense of too little too late, now there is a lot to do in a short time and I don't think there is real political backing for it.'

Cannon-fodder

Acute trusts chief executives - although they say they would love to see it - are deeply sceptical as to whether politics will ever be taken out of the NHS.

'Taking politics out of the NHS would be fantastic,' says one.

Another comments: 'It would give us less interference and more cover from politicians, unlike at the moment where NHS chief executives are seen as cannon-fodder.'.

But most chief executives do not think it is something that will happen in the near future, and many feel overburdened by the current regulatory regime.

'The fact that the NHS is so critical politically means that politicians can never let go of it,' says a chief executive in the North. 'Look what happens when they say: 'If there is a tough decision we are going to back you,' and then ministers come out in their constituencies and oppose hospital closures,' adds a Midlands chief executive.

One acute trust chief executive cites the health secretary's decision over cancer drug Herceptin as a case in point. 'In theory NICE [the National Institute for Health and Clinical Excellence] is an arm's-length agency, but as soon as Herceptin came out the health secretary bottled it. They can't walk away from the NHS, it's too political for them.

'Look at NICE, the National Patient Safety Agency and the Healthcare Commission - there are so many allegedly independent agencies already that just aren't.'

Many acute trust chief executives feel the government creates 'structures' within the NHS that do nothing yet are not demolished before more are created. 'There is such a degree of overlap and yet
new bodies are being created and nothing is ever taken away,' says one.

Regulation is a particular bugbear for acute managers, who view the Healthcare Commission with suspicion. One chief executive in the North even suggested that the commission will soon 'charge' acute trusts to provide solutions if they fail to meet the commission's targets.

As for the private sector, the message is again pretty clear. 'Absolutely fine as long as there is a level playing field.' Acute trust chief executives, especially those heading foundation trusts, want to be allowed to compete in an open market with the private sector to ensure their own survival and get the best value. 'Free choice, free competition, same price,' demands a Northern foundation trust chief executive.

That is not the reality now, according to the survey. Seventy-eight per cent said foundation trusts should be given the same freedoms on the private sector, while 94 per cent said acutes do not have a level playing field with private providers.

'Incompetent' PCTs

The strength of feeling about the 'incompetence' of primary care trusts is undeniable. Comments such as 'PCTs can't commission'; 'I could do the job better'; 'it's not fair that they seem to get rewarded for failure and incompetency' give a flavour of the opinion acute trust
chief executives hold towards their PCT colleagues.

As one chief executive in the South puts it: 'PCTs do not face the same level of blame when things go wrong. My PCT has had three chief executives in 18 months and the financial situation has just got worse and they still plod along and are then paid£300,000 to leave'.

That view is typical: among all acute trusts surveyed, 84 per cent said PCT chiefs do not face the same level of. blame when things go wrong.

And there is a real sense of frustration towards PCTs that acute trust chief executives believe 'cannot commission properly'.

'It's outrageous that as an organisation we pay people off and then they pop back into the system. I cannot really defend that,' says one.

Another suggests their strategic health authority backs the PCT at every turn.

'The PCTs toddle along and talk about partnership working, with the SHA sitting there, saying: 'That's it daddy, go and beat them up,'' adds another.

The reform agenda

Although the acute trust chief executives we spoke to voiced worries over a range of different targets from healthcare-acquired infection to the 18-week waiting-time target, these policies, they said, were not what kept them awake at night. As one chief executive puts it: 'We understand those sorts of things so we don't really get stressed over them, we know it's just about systems'.

What they are really concerned about is the government's 'inconsistency of decision-making'.

One chief executive in the South says what grates is the feeling that government does not apply its policies fairly across the system.

They are also noticeably tired of the lack of support from the government for implementing reforms.

A chief executive in the North warns: 'I'm not sure how attractive the NHS is going to be to managers over the next couple of years.

'It's the constant pillorying and being the scapegoat. If something goes wrong for the government, they always blame it on bad management'.

Personal belief in service keeps the jaded going

With an average working week of 50-60 hours, views on the personal cost of being acute trust chief executive were clear.

They were staunch in their devotion to what they believe the NHS stands for and stood by their choice to work in the health service and the public sector as a whole.

Most felt they were paid enough for the job they did, with one chief executive going so far as to describe his pay as 'obscene'.

But another, based in the South East, admitted it has 'started to grate' that GPs, consultants and PCT managers, following the reorganisation and other staff through Agenda for Change,
had been awarded pay rises while chief executives and board directors of acute trusts were 'left out in the cold'.

What acute trust chief executives were most jaded about when it came to their working lives was the perceived lack of support they get from the government to carry out reform.

'I think the government needs to be quite careful really because it needs managers to deliver its reforms over the last year or two [of the government's term in office],' warns one Midlands chief executive.

Another says that it is not about the money or the number of hours worked but about 'autonomy and respect'.

'What I really get upset about is the lack of value and support for the work we do.'

Another Midlands-based chief executive sums it up: 'I am weather-beaten, I do take all criticism personally, I do blow my top and get angry, but I deal with it because ultimately I am a passionate believer in the NHS'.