The buck stops here. The casualty nurse who can't find beds for the injured and dying, the brain surgeon whose microscope is ancient, the bone marrow consultant whose patients have to recuperate in airless cells, all have someone else to blame if things do not get better. The staff whose working lives have been detailed in Delivery Watch over the past month all do their best in difficult circumstances, but ultimately they will not get the sack if University Hospital Birmingham trust fails to improve. Mark Britnell will.
The 36-year-old chief executive is personally responsible to the Secretary of State for Health. Like others in similar posts, he knows it is up to him to make good the promise the Prime Minister made after the election. It is time, in other words, to deliver.
The Government has always been a useful bogeyman for NHS staff: there may have been patients dying on trolleys in the corridors, but what else could anyone expect while hospitals were starved of money? The Chancellor challenged that with his last Budget, by promising billions – enough for new wards, more beds, better equipment, and battalions of doctors and nurses (if they can be found).
So now the public expects. The patients will not accept excuses. The burden of potential blame has shifted on to hospital managers. "The chief executive is the pivotal position in maintaining and delivering services to stakeholders with a variety of expectations," says Mr Britnell, displaying a firm grasp of New Labour jargon. By stakeholders he means "the public, patients, profession, politicians and the press. This is the highly public external part of the job."
We are picking at sandwiches in his office, which is not big or impressive but far superior to the former store cupboard used by doctors treating leukaemia not far away. Mr Britnell is youthful, energetic, and confident of his ability to charm. Which is just as well: any hospital worker can ring a hotline 24 hours a day and rant at him, albeit via an answerphone.
"Internally, my main job is to direct and ensure the wellbeing of 6,000 staff and manage £270m of resources," he says. In addition, the trust's two hospitals, Selly Oak and Queen Elizabeth, are to share a new site. Private developers will put up the buildings, at a cost of £330m, then lease them to the NHS.
"Birmingham has been told it is going to have a new hospital for three decades," says Mr Britnell. "My first two years here have been spent trying to convince people it is actually going to happen."
The new hospital will open in about six years. Meantime there is a backlog of maintenance going back decades, estimated at £100m. Very sick patients can't be expected to wait for a new hospital, so expensive new facilities must be built. As we saw a fortnight ago, the brain surgeons are to get a new operating theatre costing £3m. It will be knocked down in six years. The trust would like to spend the money on opening existing theatres at nights and weekends, but can't: the system of NHS funding won't allow it, and neither will the employment rules.
"We need the flexibility to come to local agreements rather than be bound by terms and conditions laid down in 1948 and now out of date," says Mr Britnell.
A recent survey showed that most UHB patients and staff were pleased with their experiences of the NHS but frustrated at the state of the service as a whole.
"Health service staff have become deeply cynical about successive government promises over the last 30 years and it takes time and effort to persuade them to think differently," says Mr Britnell. "By their very nature professionals think they know best about services, and often they do. The problem arises when you move from a service led by professionals to one that is held to account by the consumer (the patient) or the customer (the taxpayer). What you are seeing at UHB is a transition which has started but will take years to mature."
Meantime patients are increasingly ready to challenge the way they are treated, not least because some doctors across the country have let them down in scandalous ways. "Until now we have always seen nurses as angels and doctors as gods," says Mr Britnell. "It is quite right for healthcare professionals to be brought down off those pedestals, but when people are forcibly knocked off them they can feel undermined and devalued."
His main challenge, however, is the gulf between our expectations and what can be delivered. The Chancellor's millions will take years to filter through, but if some results are not visible promptly the voters will become impatient and ministers nervous. Hospital chief executives tend to be in their jobs slightly longer than First World War fighter pilots, but only just. "We are watching a game played out in front of our eyes," says Mr Britnell, still smiling. "The politicians have started to see the NHS as a make-or-break issue. Now the money has been promised, the level of expectation is rising very fast, and there is a danger we will not be able to keep up with it."