The NHS: An institution on life support?

Britain’s public institutions were once the self-confident instruments of a globally respected nation that successfully faced down every challenge, from world wars to internal strife, while other European nations collapsed around them. But today they seem to be in permanent crisis.

The BBC is still trying to recover from the fallout of the Savile affair, while its competitors in the press are doing no better, facing the prospect of state regulation after the Leveson inquiry. British politicians, who were once said to inhabit “the mother of parliaments”, are even less trusted, even before the expenses scandal. The police have also faced inquiries into their behaviour at the Hillsborough disaster and their use of spies against protestors, while the Church of England has been divided over gay bishops and the Occupy protests.

‘The avalanche of targets and form filling that many see as smothering compassion and initiative might even be more a symptom of institutional drift rather than a cause of it’

But this sense of crisis isn’t just seen in the traditional arms of the state. The touchier-feelier public services are feeling the heat too, whether the social services, with a continual revelations of failures in child protection, or the university sector’s travails over fees.

Finally, the NHS, perhaps the most venerable of Britain’s institutions, has been turned upside down by reforms and beset by scandal, with the Mid Staffordshire scandal being only the most visible of many. So what is behind the seemingly continual wobbles afflicting the great institutions of state?

Losing sight

Many people, particularly those on the frontline of the public services, feel left adrift by leaders who they see as having lost sight of their key role − serving the public. With back covering and buck passing the order of the day, have the self-serving interests of institutions squeezed out the day to day service of patients and clients?

The avalanche of targets and form filling that many see as smothering compassion and initiative might even be more a symptom of institutional drift rather than a cause of it. Others, particularly in the NHS and BBC, see a deliberate policy of denigration of the public service ethos to pave the way for marketisation and privatisation.

‘The rise of the expert patient is seen as another way to rebalance power’

Others would argue that this is a case of chickens coming home to roost. The era of the internet whistleblower and the demise of deference have bumped up against archaic and arrogant institutions, bringing years of scandal to light.

The enforced openness of the freedom of information act and public enquiries are gradually shining light on the dark underside of entrenched privilege. In the health service, the rise of the patient expert, now gaining friends in high places such as NHS England, is seen as another way to rebalance the power between arrogant professionals and their patients.

Growing pains

Or is this too bleak a picture? Institutions have always faced crises and periods of transition; this may just be the latest set of growing pains of changing to meet an era of better informed and confident consumers, or the tightened belts of austerity. Either way, there is much discussion on how to move forward.

“Leadership” is a key buzzword in public sector circles, but does the focus on developing it suggest we are suffering a shortage of it? The same goes for openness − while everyone is keen to be as “transparent” as possible these days, what does that mean for the day to day functions of the service, with every decision perhaps being second guessed? Might the continual calls for greater transparency in public institutions simply undermine the public’s trust further?

Managing change

But deeper political questions may be at play as well. With the end of any big ideological divides in society, a trend towards managerialism has come to the fore in the way public services are delivered, with “evidence based” policies replacing openly political ones.

‘Confusion at the top seeps down, through continual reorganisations, enquiries and targets, leaving those on the frontline struggling to hold things together’

The end of the Cold War era “enemy within” (the trades unions) and “without” (the Soviet Union) seems to have left the British political class bereft of a clear objective or sense of what their purpose is. Confusion at the top seeps down, through continual reorganisations, enquiries and targets, leaving those on the frontline struggling to hold things together.

The Battle of Ideas festival’s strand of debates on “Institutions in crisis?” aims to unpack all these issues and more. We have a multidisciplinary set of panellists, from medicine, the police, law, teaching and elsewhere to share their experience and perspectives on the problems facing the public services and the institutions of government. Are criticisms of institutions fair comment or hostile carping? Have the public services lost their way?

Do we need stronger leadership to hold the line, or rethink the entire way that public services are delivered for the 21st century? Expect these questions to be asked more and more as our institutions continue to weather the storm of the transparency age.

Robin Walsh is a graduate medical student and writer on medical issues. He is speaking at the Battle of Ideas festival on 19-20 October at London’s Barbican. HSJ is acting as media partner.