Liane Jones: Patronising Patricia, the cyborg matron for the brave new NHS

Ministers are largely insulated from pressures faced in hospitals

Before Patricia Hewitt entered the hall at the Royal College of Nursing conference, one of her advisers warned that there might be a spot of bother. There had been a few pointers - the coffin propped outside the conference hall door, the nurse grimly tolling a bell and proclaiming "NHS, rest in peace". Inside, Hewitt could see for herself the banners and placards, and read the same message on several hundred T-shirts - "Keep Nurses Working - Keep Patients Safe".

Nurses are no longer just angry with Hewitt and the Government. They are furious. Galled. Outraged. No one who heard their reaction to her speech could doubt that they were venting genuine emotion. At different points, they gasped in shock, murmured angrily, heckled, slow hand-clapped and booed.

The fuse for this explosion was lit last autumn with the announcement of job cuts as part of NHS reforms. Across the UK, hospitals are closing, departments are being merged and jobs are being cut. The RCN estimates that 13,000 NHS posts have gone since October. Some of these changes are due to financial crisis management, with hospital trusts under orders to balance the books. Others (as Hewitt was keen to point out) are part of a positive programme to provide more health care at the local level, via surgeries, clinics and mobile teams.

Hewitt went crisply in to face the nurses, on a mission to explain. She gave them facts (no winter bed crisis, waiting times at their lowest-ever levels). She gave them plenty of figures: 200,000 more staff working in the NHS than in 1997 and 87,000 of them nurses. She even gave the nurses encouraging advice. Having difficulties with workloads and staffing? Why not try reorganising rotas!

Soon after this, the heckling and booing reached such a pitch that Hewitt left the stage. The RCN's president, Sylvia Denton, said she had never seen such a display of fury in the quarter of a century she has been going to the conference.

But why are the nurses so angry just now? Much of what Hewitt said is undeniable - the Government is employing more nurses. Under Agenda for Change, which restructured pay scales within the NHS, most nurses have recently received decent pay rises. And comparisons with European nations suggest that reforming away from hospital-centred to local-level care would be good for the NHS.

Hewitt certainly seemed to think the nurses hadn't grasped the big picture. Before she made her escape, she complained that she was there to listen but what could she do if the audience wouldn't listen to her? And back she went to the Department of Health, where, one gets the impression, she will be shaking her head with her advisers over the impossibility of getting the nurses to take the long view.

And that's where Patricia Hewitt is wrong. Nurses do understand the point of changing the NHS. What's more, they are already implementing Hewitt's reforms. These "challenges", as the Prime Minister likes to call them, are not like the World Cup, trailed and promoted for years but not due to begin till next month. They have already started, and it is nurses who have been boxing and coxing to manage them. They are way ahead of the Government in adapting to new realities.

Every time a nursing post is cut or becomes part-time, or is downgraded to that of a health care assistant, the rest of the nursing team adapts to cope. When a ward cuts back on agency nurses, the permanent staff stretch their hours and change their rotas to fill the gap. They do extra hours on either end of their shift without pay. The RCN estimates it at 6.5 hours a week, per nurse, or to put it another way: nearly a full day for free.

This commitment is something that Hewitt doesn't understand. Nor does the Prime Minister, and nor - crucially - do the consultants who advise on our public services. Cabinet ministers are almost completely insulated from the pressures that nurses face. Consultants, who charge like wounded rhinos for every minute of thinking time, have failed to grasp the extent to which the NHS runs on goodwill.

That is why the new pay contracts for GPs and hospital consultants have cost much more than anticipated. Noticing that some GPs did an unexpected amount of preventative and liaison work, the policy consultants and DoH advisers offered handsome payments to all GPs to do likewise, calculating that it would be cost-effective by relieving other parts of the NHS.

But they hugely underestimated the number of GPs already doing the work without reward, so the salary bill rocketed, with little extra work being done. When new pay scales came in for hospital consultants, again the wonks found they had underestimated how many qualified for the higher rates.

Lucky GPs and consultants, then, finally to be rewarded for their labours. By comparison, the nurses' pay rise was far more modest - they still lag some way behind teachers, for instance. But I don't believe wages are at the heart of it. Fifteen years ago, I spent a year following a group of nurses at a time of reform in the NHS: care in the community was being introduced, and nurses were retraining and gaining more autonomy. There were some drastically differing experiences, but all had one thing in common - they wanted to provide the highest standard of care and they hated the fact that, despite all their flexibility and effort, the funding just wasn't there to let them do it.

Many of them have left nursing now. Fifteen years on, things have changed and in many instances have improved, but once again nurses are taking the strain and seeing patient care suffer. That is why, when Hewitt lectured them about staffing numbers, they heckled her with the slogan on their T-shirts. Hewitt must now be wondering if she'll be hearing "Keep Nurses Working - Keep Patients Safe" chanted on picket lines.

Could another minister with a less patronising style have connected with the audience? Perhaps. Hewitt's perfectly enunciated homilies certainly stoked their rage. There she stood with her unshakeable sense of rightness, her special firewall against destabilising human factors, a veritable cyborg matron for the brave new NHS. No wonder, having done so much of it themselves, the nurses wanted to make her sweat.

Liane Jones is author of 'Nurses: A Year in Their Lives'