OPINION

Published: 14/07/2005, Volume II5, No. 115 Page 17

I never made it to the NHS Confederation conference this year.

Nor the human resources in the NHS one, come to that. So I fear I have no celeb gossip for you from late nights in the Broad Street style bars. * Nevertheless it has been fun working through the coverage, trying to piece together the new health secretary's views on such weighty issues as the future of payment by results, the role of the market in healthcare and the fate of organisations that get into financial difficulties. And perhaps also trying to tease out her personal views from the no doubt substantial briefings from her senior civil servants and policy advisers.

Sometimes, though, it is possible to miss the obvious. Jane Keep, writing to Feedback (2 June), remarked how struck she had been by the 'femaleness' of Patricia Hewitt's presence, contrasting it with an NHS that still feels 'very male'. Could her appointment, Ms Keep asks, help the NHS regain its balance through an 'injection of some more female energy'?

It is an intriguing question. This most basic difference between Ms Hewitt and her immediate predecessors is self-evident, yet some of its implications may not be. The very fact that not only the health secretary, but also most of her ministerial team, is female has thrown into sharp relief the thickness of the glass ceiling in NHS management.

Ms Hewitt could not, for instance, have failed to notice at her first 'top team' meeting how few women were in the room.

Incidentally, the forthcoming programme of strategic health authority mergers - sorry, organic growth - may well reinforce male dominance. Most of the seven current female SHA chief executives hold office in London and the South East, where change is expected to be felt more sharply than in the North and West.

But it is also the perceived 'maleness' of the NHS managerial culture that is being called into question. After years of posturing machismo, confrontational commissioning rounds, aggressive performance management, so-called 'P45 targets' and downright bullying, could we be about to see a change of management attitude led from the very top?

And, in truth, some curious messages about style are starting to creep out of the meeting rooms and along the corridors of Richmond House - about a genuine interest in engaging disaffected and initiativeweary staff. About a wish for stability as well as delivery. And especially about the need to treat people who are doing their best for the NHS with courtesy and respect at all times.

If a change is already afoot, it was not apparent to many in Birmingham last month. Then again, we often hear what we expect to hear. Most of the reporting of Ms Hewitt's recent speeches, perhaps understandably, highlights the 'press on with reform ... foot flat down on the accelerator' strand of rhetoric rather than any of the more subtle messages about engagement.

This is a boy racer metaphor for a male scale of priorities. The suits are naturally curious how the new ministerial team will handle thorny political issues such as privatisation and market management. When it comes to the softer stuff, frankly we have heard it all before. Improving working lives? Later, perhaps.

And the 'male' values seem to be reinforced from all quarters. Look back over June. Bill Moyes, chair of foundation regulator Monitor, urges the Department of Health to create a single strong healthcare regulator to enforce control and eliminate 'muddle', and to introduce DoH direct rule of primary care trusts and SHAs. NHS Confederation policy manager Martin Hensher calls for a 'rapid and brutal shake-out' of poor hospital performance. A 'bloody shake-out - at the first possible opportunity - of those who are not going to cut it'. (The intention, naturally, was to 'encourage debate').

The National Audit Office and Audit Commission tell NHS bodies to improve their financial management skills or face the consequences.

Authority, empire building, discipline and the devil take the hindmost: the NHS we all know and love.

So what would a more 'female' NHS look like? How would we recognise it? And why would a health secretary dare to try something different, especially in a health system where the reintroduction of a market model has already brought such momentous improvements in performance?

One good reason is that the NHS workforce remains mainly female.

Not only has it been alienated by the content and speed of recent reforms; little effort has been made to 'engage' it. Helping clinicians understand payment by results, for instance, has received scant DoH investment. With the principal building blocks of the new system in place, now might be a good time to start.

A quiet revolution has been taking place in the medical profession.

Medical school intake in England is now predominantly female. The rugby club and the college bar are withering. The long-term social effects will be enormous, and already the men one often finds speaking for the profession are less and less representative.

NHS managerialism has its origins in the 1980s as a counterweight to 'consensus' - otherwise known as doctor dominance. Managers adopted the imagined bravado of the business world, and the language of the armed forces, to compete with the physicians and the surgeons.

Hence all those military metaphors - the 'front line', the 'muck and bullets'.

Will it be possible to appeal to these groups who after all constitute most of the NHS - through a less confrontational management style, and yet maintain the improvements in access, responsiveness and quality that patients expect? Can we have delivery without machismo? There are signs that Ms Hewitt intends to try.

* But why, I hear you all ask? Oh, putting the finishing touches to the new book, if you must know - It is out at the end of July. Not quite everything you ever wanted to know about the financing of long-term conditions.

End of shameless plug.