'I follow neither rhyme nor reason, only the health secretary. I am a member of an elite, a new breed of NHS chief executive, ruthless and efficient - not like the old softies, few of whom now remain'
I am an NHS chief executive, accountable to the health secretary. I rely on her patronage and carry out her orders, no matter how absurd. If today she tells me to do something, I do it unquestioningly and explain why it is right. When, next month, she asks me to do the exact opposite, I will justify that too.
I follow neither rhyme nor reason, only the health secretary. I am a member of an elite, a new breed of NHS chief executive, ruthless and efficient - not like the old softies, few of whom now remain. Our mission is to maintain the facade of a universal and comprehensive NHS, win elections for the government and privatise the health service. We face an ungrateful general public, as well as unruly and selfish clinicians. So we employ tactics that help us get our own way.
First, if the evidence or logic is shaky, we reach for mantras. Take the ubiquitous 'delivering the right care, in the right place, at the right time'. Bereft of meaning or any objective means of verification, it can cover just about anything. Exactly like 'modernisation and improvement'. What is modern and improving? What we propose. What do we propose? What is modern and improving
So before the general election, we praised community hospitals as modern and the future of local care. Post election, and ordered to cut services to save money (without admitting this), we seek to close them. So, in May the community hospital is modern and improving; by June it is obsolete.
Second, we do not lose sleep over evidence-based practice - otherwise we would never get anything done. We are realists. Take Evercare - where specialist nurses ('community matrons') manage people with long-term conditions at home to reduce unplanned hospital admissions (thus enabling us to close inpatient beds). We know Patricia Hewitt's talk of a 30 per cent reduction is nonsense.
After all, research shows Evercare does not work. But our job is to follow our political mistress, not the evidence. So we close beds anyway, with or without community matrons, never mind the impact. Of course one failsafe way to cut unplanned admissions is to bar entry to those in need by closing emergency medicine departments. And this is what we are doing.
No strangers to paradox, we find realism does not preclude wishful thinking. Empirical doubts are for losers and wimps. We close NHS beds today but promise paradise tomorrow in the form of armies of peripatetic health professionals. But we have no idea of their effectiveness or of how to pay for them. Likewise, we support community hospitals in principle, but are currently closing or cutting back 106 out of 320 in England. And we don't advertise that many 'new' community hospitals will be downgraded district general hospitals!
Third, if we make drastic cuts, we resort to the classic claim that 'patient care will not suffer'. I confess to astonishment at the gullibility of the national press in reporting such statements at face value. We also retreat regularly into the NHS phantom zone: instead of talking about real patients and their needs, we resort to indistinct visions, 'models of care' and 'care pathways'. These have a suitably stultifying effect.
Fourth, we refer only to carefully chosen performance targets, omitting to mention that, behind these, other care is going up in smoke, in particular for older people and people with mental health problems or learning disabilities. There are simply too many of them and they do not get better. Basically, we don't want them in the NHS.
Fifth, we use red herrings, particularly health and safety, to achieve our ends by stealth. So we close elderly care beds 'temporarily' because we lack the staff to keep them open safely. We fail to explain that the situation has arisen only because we demoralised staff, encouraged them to leave, then imposed a recruitment freeze. Under the rules, we must consult about changes to services but 'temporary closure' is not change, so we keep quiet. How long is temporary? As long as a piece of string. A year on and the beds remain firmly shut; they will never reopen.
Sixth faced with overwhelming opposition (sometimes tens of thousands of people) to local closures, we announce that we asked the 'wrong' questions in consultation, and so got the wrong answers - so we can ignore it.
If the going gets tough we pass the buck, explaining we are under orders from strategic health authorities, who in turn maintain that they are merely regional post boxes between local trusts and central government. Meanwhile the health secretary denies knowledge of all things local. We are all in it together. There is no accountability or responsibility; we form the perfect complicit circle resistant to reason and discordant voices.
Finally, we rely on the health professionals who sit on boards to be ambitious, weak or misguided enough to go along with it all. They and hapless non-executive directors - who (thankfully) don't know the half of it - guarantee that even our most controversial proposals are approved unanimously.
I am an NHS chief executive. I have immense power, responsibility and salary, and know I am right. After all, I do what Patricia Hewitt says, which, by definition, must be right. Some think I am aware of the destructive things I do - otherwise I couldn't do them - yet manage simultaneously to shut them out mentally. George Orwell, I remember from university (I was a bit of a leftie then), called it doublethink. I disagree. I have a conscience, I have integrity, and I act in good faith. I sleep soundly at night. In short, I am a true public servant.
Michael Mandelstam is author ofBetraying the NHS: health abandoned , published by Jessica Kingsley Publishers (www.jkp.com)