The struggle for control of the NHS continues

'Who is really in charge?' asked Sir Gerry Robinson on returning to Rotherham Hospital for the BBC. He was hoping staff would say the 'chief executive', but many shyly admitted that they thought it was still the consultants.

Who should run the NHS - doctors, managers or politicians? Unfortunately, each group has its own emphases, at odds with the others. Doctors are concerned about the welfare of their patients (and also, let us be honest, about their own status).

Managers have a vested interest in looking competent, proving that their area is meeting targets and coming in under budget. Politicians want the NHS to appear cool in the eyes of the public: when modifications are proposed, their first reaction is to look in the mirror and ask 'Does this NHS change look good on me?'

Good, practical ideas can often be squashed at the highest levels by politicians who don't want bad short-term publicity, however beneficial for the NHS the proposed changes might be in the long term.

How do we balance these competing interests? It's the public's NHS, so the politicians need to be involved. We can't remove their more baleful effects by making it a quango: the DoH would forever be exerting pressure on its chief executive to conform to their political agenda, pressure which would be transmitted down the NHS hierarchy.

Nor do I believe that managers should run the NHS alone: they are too concerned with the inanimate bottom line and less in tune with the ultimate raison d'etre of the NHS which is about patients, not profit.

Nor should doctors or nurses be solely in charge: clinicians who are truly good managers are a rare breed. Doctors and nurses might have the best interests of patients at heart, but seldom do they have the necessary highly tuned management skills.

In truth, all three groups have an important part to play, but each needs to be aware of its own limitations and to defer to other groups where these have greater expertise or responsibility.

No, Sir Gerry, managers should not be in charge of the NHS. We need a truly symbiotic relationship, not a master-servant one, and it is not yet clear where the boundaries between the three groups should lie.

Dr Lancelot is a GP from Lancashire. Email him at

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