Too many suits in the NHS?: The Welsh Secretary's attack on health service reforms raises a Tory conundrum, says Paul Anand

THE ATTACK last week by the Secretary of State for Wales, John Redwood, on the managerial reforms in the National Health Service, the proliferation of administrators and the jargon of internal markets is a semiotic puzzle of the sort that might grace the pages of an Umberto Eco novel. What on earth does he think he's doing? Has he forgotten or, more to the point, does he think others do not remember, that this was all his party's idea?

It may well be true that there are too many managers and not enough nurses in the health service. But the only exercise in finding out - an interesting attempt to reconcile government figures on the numbers and salaries of managers by the Institute of Health Services Management, published last February - resulted in a spectacular own goal by the managers, because it suggested, incredibly, that each administrator was on average paid pounds 2m a year.

As with most important questions about the NHS, the problem is that no one really has a clue what is going on, least of all those in the Department of Health. One reason why it may be so difficult to establish the figures is that subversion of attempts to make the bureaucracy more responsive has become something of a speciality within Whitehall. While there is a very strong sense of internal accountability within the Civil Service, this often has the effect of turning what voters think and feel into some kind of residual error, to be brushed under the thick- pile carpet of so-called representative government.

The health service is no exception. Organisations that have been stacked on top of each other in a tidy hierarchical pile find it difficult to adjust to new rules of engagement. District health authorities are now supposed to buy health care on our behalf, but few have attempted to grasp the nettle of setting priorities. Unless they do, however, the purpose of their existence will be unclear. This is a legitimate role for managers, but apparently it is not being done.

Advances in medical technology and longer life expectancy are constantly forcing choices between who receives treatment and who does not. At present, however, these choices emerge not from a process of open decision-making, but as some sort of compromise between the primordial forces of inertia and murky professional interest.

If the NHS is supposed to be a market, then who is ensuring that competition is real, and not just a shadow play behind which hospitals develop and exploit cosy monopolies? Many industries consider some form of market regulation to be essential. The same sort of regulation should obviously be applied to regional health authorities under the new regime.

But there is no evidence that any part of the internal market is being regulated in this sense, either by the regions or by the department. It is therefore difficult to demur from Mr Redwood's questioning of the efficacy of district and regional bureaucracy.

It is also true, however, that the sham accountability typical of the service's management until Margaret Thatcher set her sights on it was hardly appropriate to running a school tuck shop, let alone a state service with a current annual expenditure of pounds 26bn. The promise of the internal market was based on the premise that 'consumer' choice would shake all this up as 'money followed patients'. Quite often, though, it still seems to be the patients who are doing the following.

Yet the situation is far from being the black-and-white picture it is often made out to be. It is easy to reel off the problems, from ward closures to waiting lists, but there have been some genuine achievements. Questions have at last begun to be asked about the illustrious but expensive medical teaching establishment in London. General practitioners in many areas are increasingly able to have their patients treated quickly. Many consultants are coming out of their ivory towers and holding clinics in surgeries closer to where patients live. And health care purchasers are beginning to consider the costs of treatment in a way that promotes the use of minimally invasive surgery, thus letting patients recuperate where they want to (usually at home). This may be an area where managers have actually had a positive effect.

In the minds of civil servants, these qualitative improvements have always seemed less significant than 'hard' numbers. But this is not necessarily how it seems to the public at large. And every time Brian Mawhinney, the Health Minister, says that the NHS has treated more patients than ever before, his words are received in silence. What matters to people is not that there were so many million consultant-patient 'episodes' in a particular year, but that when we have to go to hospital ourselves, we will not be kept waiting for hours to be seen; that staff will not be so demoralised and unhappy they cannot do their jobs properly; and that doctors tell us what the options and risks for particular treatments are, without presuming to make up our minds for us.

The conundrum presented by Mr Redwood's remarks reflects a deeper uncertainty in the Tory party about its relationship with the state. Early in the Thatcher years, reform was all the rage, even though this seemed to throw Conservative politicians into the business of strengthening government organisations. Mrs Thatcher's attention then switched from polishing the silver to selling it off, with the result that some Tories do not know which version of Conservatism they should be espousing.

At the moment the Secretary of State for Health, Virginia Bottomley, seems to be stuck with the wrong one: an outdated model of managerial reform which experience shows to be prone to hijackings. Mr Redwood claims that he intends to focus on only four indicators of performance: the success of treatment, waiting lists, costs and complaints. The irony is that such simplicity is quite typical of modern management practice, and it will be interesting to see how long it (and he) survives the Byzantine complexities of NHS politics.

William Waldegrave, another former All Souls fellow who tackled the NHS head on, called the service an administrative slum - and he was rewarded for his efforts by becoming minister for the 'little man', fronting the Citizen's Charter.

The author is a research fellow of Templeton College and a member of the sub-faculty of economics at the University of Oxford.

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