Published: 21/11/2002, Volume II2, No. 5832 Page 15

While explanations for the rejection of the consultant contract in England and Wales abound, none has struck at the heart of the matter.

If the government wants to change the relationship between doctors and the NHS, the issue is not primarily a technical one involving a renegotiation of their contract. Nor is it about money.

The real issue has more to do with politics and power.

What is at stake is a fundamental reshaping of the management of healthcare in which clinicians (including nurses) become pivotal. They are currently seen (and see themselves) as being done to rather than as the doers.

The present senior management of the NHS, populated in the main by non-clinical lay managers, makes it too easy for doctors to wield power without responsibility.

But why should they do otherwise when they see their managerial colleagues being ground down by the unrelenting and unreasonable demands and pressures placed upon them by ministers and, worse still, by the prime minister personally.

In such a highly charged and political climate, there is little prospect of doctors being encouraged to take on the mantle of management.Most may have little understanding of management and even less interest in it, but they can see that their management colleagues are not managing. They are not even agents of government granted a degree of autonomy and respect.

Rather they have become little more than political flunkeys.

Such self-righteousness and control freakery on the part of ministers and their advisers are anathema to the professional mindset in medicine or elsewhere.

It is not so much management that doctors are railing against in rejecting the new contract as the form of political management that is corroding the NHS and destroying trust between doctors, managers and government.

This is not to hanker after some golden age. Indeed, some of what passed for 'trust' in the past could all too readily become unhealthy collusion between managers and doctors. But nothing compares with the present dysfunctional intermingling of management and politics. This is why a fundamental rethink about managing healthcare, and the place of clinicians within it, is now unavoidable.Non-clinical lay managers cannot manage clinical work.A few will succeed because of their charisma or whatever, but they will remain the exception.

Moreover, such a structure breeds an infantilism about management among clinicians, for whom it becomes too easy to stand on the sidelines and criticise while opting out of assuming any responsibility for what happens to their organisation, beyond immediate self-interest.

Until doctors are truly put in charge, the divide between medicine and management is likely to become increasingly acrimonious. Of course, doctors can opt out and sell their services back to the NHS, thereby retaining their clinical freedom and ability to wield power without responsibility.

Moreover, given the market-style public sector the government seems hell-bent on creating, who can blame them for exercising their entrepreneurial talents?

It would be a tragedy if the debacle over the contract results in a further dismantling of the NHS, not as a monolithic entity but as a managed health system in which primary and secondary care work in partnership and in which doctors play their full part in managing their work in clinical production teams and through clinical pathways which they control with support (and not meddling) from managers or politicians.

Is such a scenario possible? Yes, because the alternative is an unmanaged US-style system of healthcare which will not serve the public interest.No, if the government's present macho management style persists. It is worth noting that such a climate of fear and political interference in management is not so evident in Scotland, which may go some way to explaining the support for the contract among doctors there.

South of the border, anyone seduced by the reassurances ` over devolution is not living in the real world.

The government, having staked its electoral fortunes on rescuing and modernising the NHS, is not likely to let go. But the conundrum is this: unless it does, then those recalcitrant, 'greedy', pig-headed doctors will continue to live up to their stereotype.

David Hunter is professor of health policy and management at Durham University.