Not long ago I was asked conduct an inquiry into a spate of fatal events among the patients of an NHS Trust, and to determine whether there was a single factor that explained them. There was not; but when I reported to the Medical Director of the trust that while there was no such factor, it was clear to me that his staff were incompetent, unmotivated and completely unaware of what the purpose of their work was other than the filling in of forms (thousands of them, often with contradictory answers to the same questions in them), he replied with an almost Buddhist calm, ‘But that is the standard expected these days.' He reminded me of a collaborator in an occupied country explaining that there was nothing he could do in the face of overwhelming military force.

 

Just as the Mid-Staffordshire NHS Trust was not unique in the NHS, so the NHS is not unique in British public administration, but rather one example, and perhaps not even the most important example, of the way in which it now works. It is true that scandals in the NHS cause more commotion when they are uncovered than scandals elsewhere in the public sector, because we are (wrongly, in my view) more worried about our health than anything else. But for the long-term future of the country, education is more important. There is a deal of ruin in a nation, said Adam Smith; but the use of procedural outcomes in practically all the educational institutions of the country, from kindergartens to universities, is one way to produce that deal of ruination.

 

Who is responsible for this ruination? I think Mrs Thatcher, with her crude sub-Marxist view of the professions as mere exploitative monopolists, set the process going, putting the bacteria in the milk as it were. She thought that the methods and disciplines of the marketplace, imposed by ‘scientific' management, but in the absence of anything resembling a real market, would eliminate chronic inefficiency in the public service. This was naïve, not to say stupid; only too predictably it called into being a managerial class, cunning and unscrupulous, that quickly developed its own vested interests and that was easily able to outwit any little politician who lined up against it. After all, a minister is only for a few months; a bureaucrat is for life.

 

Moreover, Mr Blair seized his chance very cleverly, transforming his party from that of the working to that of the nomenklatura class. The chief executive of one of the NHS trusts in which I worked stated quite openly that he job was to get the government re-elected. The problem is that defeating this class is like trying to get the sourness out of sour milk.

 

So we have seen the future, and it is Mid-Staffordshire NHS Trust. The  best we can hope for (though it is a rather forlorn hope) that any reforms suggested by the Francis Report will not make things worse. Unfortunately, for every disaster produced by the adoption of procedural outcomes there are six procedural outcomes waiting to be adopted.