What values drive the NHS? What glue keeps over a million people working in a service which costs less than almost all others in the developed world but which is at least their equal?
Talking to senior members of the NHS Executive, one might conclude that the NHS's four values are patients, people, passion and participation. Yet that isn't quite how it seems on the ground, where those values feel inaccurate and appear disingenuous on close inspection.
Without doubt, patient care drives all who work in the service. From consultant to clerk, from porter to pathologist, almost all who choose to work in the NHS do so with a strong public service ethos and a desire to do something worthwhile with their careers.
But buried in this positive motivation lies the Achilles heel of the whole of the welfare state: there are no limits. Once we have signed up to doing the right thing, it becomes impossible to do enough of it.
Morally, and sometimes literally, the system blackmails us into doing more and more in the name of the public service.
'No weekend locum, doctor? Well, you can't leave the patients without medical cover, can you?'
'Understaffed on the ward, sister? Patients still need their bedpans. So we'll all have to work that bit harder.'
'Too many letters to write, Ms Dogsbody? Our freeze on staff recruitment to allow us to spend more on patient care means you'll have to stay a little longer each day.'
And if you refuse, your public service credentials are besmirched in your own eyes and the rest of the NHS.
Once you are in the public service system, it becomes virtually impossible to deal effectively with the burden thrust on you. The only way of coping is by not joining in the first place.
So a conflict arises between the first two stated values: if we have to make a choice between patients and people, we choose patients every time.
In the rush for ever more activity for each pound, those working in the system are flattened.
Long-term training, personal and managerial development, even clinical updating, are luxuries taking second place to delivering care.
Nurses are sometimes asked to pay for their own continuing professional development, while managers plead for time to allow their organisations to take stock, grow and evolve. To no avail.
The NHS is probably the most exploitative organisation in this country in the way it uses and abuses its employees.
No ethical private sector company would deal with its workforce in this way, and the reasons are not altruism or moral fibre.
Open the most basic management textbook and you will see that any mature organisation recognises that its success and profitability depends upon motivated, trained staff who feel valued, work harder, innovate, lose less time to sickness or absenteeism, stay with the organisation longer, and keep the company's clients happy and satisfied.
The 19th century Quaker industrialists housed and educated their workforces and their families because, at least as much as for any sense of moral value, it ensured they were more productive and made more profit for the company.
That truism seems to have been lost in the NHS of the 1990s, despite it being the UK's largest employer and supposedly in the business of caring for people.
In the chase for short-term gain (more efficiency) the service's longer- term development has been forgotten, and we are beginning to reap the harvest. There are shortages of doctors, though medical school production lines churn them out; the total of nurses qualifying each year is a fraction compared to 20 years ago; and senior managers contemplate with apprehension a service in which the turnover of chief executives can be as high as 30 per cent in a year.
It is as if a major car manufacturer concentrated so completely on this year's production that it ignored the need for new models and strategic improvements a few years down the line, and neglected to give any thought to making the company attractive to new engineers or designers.
Saddest of all, this approach to human resource management does not originate in the Department of Health or even in the minds of politicians, but in the values underlying the welfare state.
As long as the public perceive the need for training or time for reflection as self-indulgent frippery, their political leaders will drive the NHS in the same way. And as long as the NHS continues to deliver the goods, there will be even less incentive to change the way we do things now for the sake of some potential recruitment crisis in the dim and distant future.
Maybe the time has come for the NHS to shape its own destiny more positively. That would fit in nicely with the participation value espoused by the NHS Executive, and would be welcomed by those in the service, despite the rhetoric of the past few years.
Participation implies openness and receptiveness to new ideas, which have not lain comfortably with the traditional risk-averse blame frame of the NHS. If the language of participation is to be believed, there will need to be room for more risk-taking and, with it, more constructive mistake-making.
As for passion, there is still quite a lot of that in the service, although some of it is focused on resentment and job insecurity.
Perhaps the NHS should become more passionate about its own future and learn to use its people better, so that in the longer term patient care can be sustained, or even (dare one say it?) improved.
Maybe we should learn to be better at saying 'no' now, to allow us to say 'yes' more often tomorrow.
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