The NHS regional offices are increasingly arms of central government

Peter Garland is an able and experienced civil servant. His understanding of the way the NHS Executive works and his knowledge of the health service financial regime in particular will be great assets to Northern and Yorkshire region when he takes over as director (see news focus, pages 12-13).

But does anyone now recall what was said when regional health authorities were replaced by civil service outposts just three years ago?

The idea then was to take the NHS 'closer to the centre' by giving it a real voice in decision making. Former NHS managers dominated the first wave of regional director and national NHS Executive appointments, and the idea voiced by some that a civil service culture of service to ministers rather than the field would permeate the regions was dismissed out of hand.

Can anyone now square the role played by regional offices with the authority and strategic oversight enjoyed by the old RHAs and their much-valued independence from central government?

Are they still able to create a buffer between the 'keep the minister happy' civil servants and NHS managers focused on strategic commissioning and service delivery? Of course not.

It is not just that key jobs since 1996 have gone to civil servants rather than health service managers. No one begrudges Mr Garland or human resources director Hugh Taylor their posts.

And it is still possible for a health service manager to break through to the top echelon, as London regional director Nigel Crisp has demonstrated. But the gap between the job of health authority or trust chief executive and regional director now seems far wider, and the leap required from one to the other more difficult, than it was before.

It is clear that the fears of those such as former West Midlands regional general manager Professor Brian Edwards, who left for academe rather than continue to run his region as a civil servant under the direct instruction of Whitehall, have been largely borne out.

The direct-line relationship which now exists between the health secretary and

every manager in the health service was laid bare, if anyone still doubted its existence, in the report of the inquiry into Ashworth Hospital last month, which commented: 'The polite fiction that regional chairs and officials are merely advisers and agents of the secretary of state is just that - a fiction. The reality is that no sensible chief executive would treat their regional director as anything other than a line manager in all but name.'

Few would want to return to the old RHAs. Despite considerable downsizing in their final years, the regional baronies had managed to remain largely immune from reform for almost 50 years. They were frustratingly prone to second-guessing the decisions of lower tiers of management.

And let us not forget who gave us the great scandals of NHS mismanagement. But the question must be asked: is the experience of those who have spent their careers managing the health service properly valued by those who now make decisions at national level or has it become a handicap to advancement? And is civil service bureaucracy really an appropriate tool for the management of the NHS?

A final word, for now, should go to a politician musing on the best way of ending the internal market after nearly two decades of Conservative rule: 'If we are properly to bring together the commissioning and providing of healthcare within a single system, we have to revisit the question of the role of the regional office. The regions, shorn of their responsibility and subject to civil service regulation, are no longer in a position to pull the NHS together.'

The venue for these comments? The then NHS Trust Federation's final annual conference in September 1996. And their perceptive author? The then shadow health minister, Tessa Jowell.