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It is easy to blame the government for all the NHS's problems.But could managers improve things by being less supine, asks Andrew Wall

Naming and blaming has become a habit in the NHS. But who are the culprits? In HSJ the government gets a lot of stick, but then so do the managers. It is less acceptable to criticise clinicians and beyond the pale to suggest that patients themselves might bear some of the blame for things going wrong.

That things are not right scarcely needs saying.An impossible agenda for change, numerous targets and deadlines, unhappy staff of all kinds, disconsolate patients. . . an air of crisis pervades the NHS.

Let's start with patients, whose expectations fuel some of the unrest. The much-vaunted satisfaction rating has shown a steady decrease as we feed avidly off the bad news stories the media offer us daily.We want the best and it is a scandal if we do not get it.

The latest in advanced surgery, the most expensive if unproven drugs, four-star hotel care, choice and yet more choice. These, we say, are our rights and if we do not get them we may sue.

There is no doubt that the expectations of the population are now unrealistic and, to the extent that people are not prepared to pay more into the public purse, their demands are hypocritical.

One of the saddest developments is the erosion of trust between patients and clinicians. But clinicians are partly responsible for the deteriorating relationship. Even if they have learnt how to be sensitive to what patients are telling them, as a group they are still too willing to use the threat of walking away from the NHS as a negotiating tool.

GPs are at it again. No one says the new order in general practice is without problems, but sulking and threatening to go home is not the best way of sorting them out.

How many times have consultants said that they are not able to engage in clinical governance without more time - more money, in other words?

Should a profession really have to be paid to demonstrate its professionalism?

By now, you might be showing sympathy for the managers who have to preside over these warring parties. But they also create some of their own problems. Reorganisations are now endemic, but they are usually about management structures rather than patient needs. And despite the pressures many managers feel, they like it that way.

It keeps them busy with the process and justifies their existence.

HSJ's academic columnists are constantly pointing out the weaknesses in some of the proposed changes, but never a word from the most influential managers, except the usual suspects who praise every government initiative as 'an exciting challenge'.

Why have managers become so supine? Surely as a body they could stand together and make the point that the present agenda is impossible and, a great deal of the time, counter-productive?

It is convenient to blame the government, but let's be fair. It has a mandate to put right the steady decay of the NHS presided over by its predecessors, and that was never going to be done quickly.

It is the way that it approaches the problems that is so questionable.On the one hand, it is blatantly populist; see all that rubbish about modern matrons and TVs at the bedside.On the other, it completely fails to harness the very real concerns (to use one of its favourite phrases) about its policies for change. It reacts to stimuli from others - such as the 'bodies on the chapel floor' case - and yet is impervious to the more reasoned critiques of its major policies.

Can the NHS survive when so much is wrong - not only about its performance but about the attitudes of everyone concerned? The first thing is to have an unequivocal re-statement of the value of public services which, as the recent terrorist attacks in New York and Washington have demonstrated, are the only way of dealing with major national crises.

Endless debates about the merits or de-merits of private sector involvement wear away the spirit of staff and managers alike, while patients, not really understanding much of the argument, just see it as yet one more manifestation that something is rotten at the heart of the NHS.A moratorium on clinicians attitudinising in return for a renewed declaration of trust in them from the government and the media would help.

Finally, patients and the public generally need to leave their expectations of heroics to the television soaps.They have to accept that, despite everything, most staff in the NHS still want to do a good job but face grave difficulties which only the electorate can force the government to overcome. If only some of these changes of attitude could be achieved, naming and blaming could be dumped, recognising that its crude and destructive impact doesn't do anyone any good at all.

Andrew Wall, a former general manager, is visiting senior fellow, health services management centre, Birmingham University.