An unhealthy dictatorship

The revolution in the National Health Service is creating a dangerous authoritarianism. Introduction of markets, rightly heralded as a way of breaking up a monolithic bureaucracy, is also leading to dictatorship within the service. Yesterday, two developments illustrated the tensions produced by change in the NHS. In Scotland hospitals released their death-rate statistics for the first time. These welcome figures, though primitive, should help doctors to discover how they can match the best trea tment offered in other hospitals. Those who put patient welfare first can only regard such data as a boon, provided it is used responsibly.

Meanwhile, the British Medical Journal yesterday published a series of articles detailing the rise of "Stalinism" in the NHS and alleging that staff are terrified to speak out openly. The BMJ spoke of a climate of fear within the NHS. The language was certainly hyperbolic. But the sentiments chimed with the experience that many people in the service have had of a macho management culture. Loyal, public-spirited staff no longer feel safe to criticise the inadequacies of a system that is still much in need of improvement.

Thus on the same day were laid bare two apparently contradictory images of the new NHS: the first open and accountable, the second closed, secretive and defensive. Strangely, both pictures are accurate. Their juxtaposition highlights how the reforms, while making considerable strides, are also threatening important values. As yet there is no sign that Virginia Bottomley, the Secretary of State for Health, even appreciates the problem.

The heart of the matter is the introduction of market disciplines into a public service. Much can be gained in terms of efficiency and quality of service. But the ethos of a public service such as health is impoverished if it becomes indistinguishable from that of the commercial world.

The new commercial NHS has generated much-needed information about prices and the outcomes of treatment: hence the Scottish death-rate leagues. Managers have also sought to gain administrative control of their units. They have encountered a resistant workforce, most notably among the doctors. A bitter conflict between the new elite, managers, and the old elite, doctors, has dramatised the collision between health economics and medicine that is now several decades old. The administrators seem intent on silencing doctors and other staff with restrictive contracts.

In any normal company, it would be right that managers should win this battle outright. Doctors have for too long been able to dictate the future of the service. Ever since they labelled Aneurin Bevan, the founder of the NHS, a "medical Fuhrer", many have thought themselves a law unto themselves. It is right that they should have to account for their time like any other employee and it is, after all, the manager's job to manage.

But this argument can be applied only so far to the NHS. Healthcare is not like food nor even education. Consumers are, and probably always will be, poorly equipped to question the service they receive. Sick people make poor advocates and even healthy ones are ignorant. It is therefore the job of doctors and other professionals to speak out on behalf of patients and to protect their interests, particularly in times of financial strictures. To claim that commercial confidentiality demands the public silence of healthcare workers is to forget that the internal market is in the public interest not for private profit. This is not the brutal world of fizzy drinks sales.

So it is not acceptable merely to dismiss the complaints of doctors as the whining of a conservative group intent only on preserving their own privileges and pay. There may be some truth in the accusation, but it is not the whole story. The public needs to have its say about a service that costs the taxpayer £38bn a year. The NHS requires many voices. One of its great strengths has been a certain openness, the fact that it is the site of a range of interests each of which enjoys a public voice. The corporate values of confidentiality and hierarchy should not replace those of pluralism and public accountability.