Editor's Choice

Changing the “leadership” of the NHS

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7403.0-g (Published 19 June 2003) Cite this as: BMJ 2003;326:0-g
  1. Richard Smith, editor

    Britain's National Health Service, one of the world's largest public sector organisations, is highly unusual in not having a leader. Most organisations-and certainly all major corporations-have a leader. Tony Blair is the leader of Britain. Greg Dyke leads the BBC, and that huge organisation-comparable in some ways to the NHS-has changed dramatically since Dyke took over from John Birt. One of the best ways to change an organisation is to change its leader. This is not a cult of personality. But it does seem to be important-perhaps simply because people prefer people to abstractions-to have somebody who embodies power and accountability.

    So who is the leader of the NHS? One immediate problem is that there are four NHSs-in England, Scotland, Wales, and Northern Ireland. Who then is the leader in England? Is it Sir Nigel Crisp, the chief executive of the NHS in England and also permanent secretary in the Department of Health? If he is the leader, then he's exercising a uniquely anonymous form of leadership. I doubt if one doctor in 50 could identify him.

    If there is a leader of the NHS in England then it's the secretary of state for health. Unfortunately, however, secretaries of state feel like the leaders of an occupying power. The relationship between a doctor in the NHS and the secretary of state is like the relationship between an Indian villager and the viceroy of India in the 19th century: these are far away people with different sets of values. Few doctors, I suggest, would regard the secretary of state as the leader of the NHS.

    Nevertheless, the secretary of state is responsible to parliament for the NHS, and last week brought a change (p 1347). Alan Milburn resigned in order to “spend more time with his family.” This is a phrase that immediately starts political antennae twitching. Old lags like me remember that a previous secretary of state, Norman Fowler, resigned for the same reason. Perhaps, however, his family didn't want to spend more time with him-because within weeks he was popping up everywhere. Is it really possible that a forceful, ambitious, bruiser like Milburn wants to spend more time with his family? Good for him if it's true, but isn't there likely to be another reason? Rumours started immediately of financial or sexual scandal, but may he simply have jumped before he was pushed?

    The Department of Health is a mess-confused, demoralised, and overloaded-which is why the prime minister seemed to have great difficulty finding a replacement for Milburn. The ship is going down, and nobody wants to be captain. Press ganging was needed, and the NHS is now being led by John Reid, known as “the minister for today” because he's had five different seats in the cabinet. Might he supply the leadership the NHS desperately needs? Let's hope so-but I doubt it.

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