Bring on the clowns

Then came the great guru Griffiths, who decreed that administration was dead and from its ashes would rise the phoenix of management. Managers had discretion, which gave them power. Managers were still bound to the rulebook, but moves to cash-limit NHS resources allowed them power of discretion over allocating money according to local or national priorities. Thus, the choice between a new MRI scanner or a refurbished operating theatre began to need managerial input.

The power of discretion was key to the rise of management, and it is easy to see how discretion came to be seen as influence, and how influence itself might become identified with leadership. There is no value judgement to be made about this; senior managers have sensible views, and their ideas should clearly be incorporated into developing new policies and strategies for the NHS.

There is a debate to be had elsewhere about the implications of moving from a professionally led system to a managerially led one, in which professionals are held more to account, but in which financial and external constraints are more likely to interfere. I want to concentrate on leadership in the public sector and its impact over the past few years.

Once management had become established, it was inevitable the transition towards leadership would begin, and the political environment of the early 1990s accelerated that move. Conservative governments are traditionally more 'hands off 'than their Labour equivalents; the post-Griffiths phase implied the NHS was safe in managers' hands. The spirit of decentralisation accompanying the creation of trusts and fundholding practices brought a perception of self-determination never seen before in the NHS.

The most senior managers became chief executives, while chairs and self-driven boards were often drawn from industrial backgrounds, so the parallel with entrepreneurial private sector companies was always present. In that environment, it was inevitable that leadership would emerge as the key task of those heading the system. But such a view of the public sector was simplistic: it took little account of the external political environment.

The metaphor of a regulated market was used, with politicians as the regulators, imposing a framework within which the new leaders' entrepreneurial skills could flourish.

But the NHS is too driven by a public service ethos, by egalitarianism and external probity, to run as a genuinely free system. And if the political constraints were felt under a Conservative regime, how much more might they chafe under a Labour government, with its natural inclination to control and regulate?

So initially it came as a surprise that Tony Blair's new Labour government continued to use the rhetoric of decentralisation and local autonomy. Leadership as a concept seemed to be growing and gaining credence. More leadership development courses began to appear, as more senior managers were groomed for the starlight of leadership.

But how much room is there for leadership in the 'New NHS', with its prescribed national service frameworks, its National Institute for Clinical Excellence, its health improvement programmes reflecting national policies, and now its national plan to ensure equity (for which read equality, not the same thing), and mark everyone's progress with red and green traffic lights?

What are required now are not leaders, but implementers - those who do not need their own vision but are highly skilled at persuading others to follow them along paths prescribed by the politicians. The difference is crucial. Leaders are driven most by their vision, the farsightedness that allows them to leap over little local difficulties in search of their Utopia.

Implementers need only to be started up and launched into their allotted tasks for them to deliver whatever is required.

So we are recruiting square pegs to fit into round holes. Worse, the rhetoric disingenuously continues to celebrate diversity, locality, leadership and initiative, while the reality is increasingly about conformity.

Worst of all, there seems to be little way of changing this. The government is at that stage of development when only opinions matching its own are tolerated. Criticism has become more difficult to verbalise. Critics are marginalised and ridiculed, and a sense of stifled resentment is emerging.

But there may be a way to express dissatisfactions and misgivings without being reported to the thought police - through the court jester, that benign innocent who had permission to state the obvious, make tasteless remarks, put into words the feelings of others not safe enough to do so. The wise monarch heard these remarks, and made good political capital from them; the foolish ignored them at their risk.

For the jester's innocence works in both directions: allowing criticism, but also allowing the monarch to change direction and heed the populace without losing face. The veneer is preserved, but sensibility is restored.

So come back, all you potential jesters; give up your aspirations to be leaders in a system without room for true visionaries, and beat your paths to those providing development courses for court jesters. You'll make a fortune, and influence the service a lot more effectively than you have so far.