The Captain shouts his orders and the crew carries on as before

This may once have been the most succinct description of how the NHS worked, but no more. ‘Modernisation’ has introduced a second crew, to check that the first obey orders. And there is no shortage of orders, from NICE guidelines to National Service Frameworks, so there is much to do.

The first crew – the old administration of the NHS, reshuffled into PCTs and Strategic Health Authorities, plus all the clinical and support staff – have to conform to growing lists of new instructions. The second crew – the Modernisation Agency, the Health Development Agency, NICE, the National Patient Safety Agency and the Commission for Health Improvement – beaver away to make the ‘hands on’ crew obey the guidelines.

There is a logic to this world of parallel administrations, which flows from the problems inherent in centralised bureaucracies. Administrative machines become trapped in unchanging power relationships with professionals, and in deferential decision-making rituals, which impede change. An example of the former is the enormous difficulty the NHS has in changing the way in which specialists work, perpetuating inefficiencies and stifling innovation. An example of the latter is ‘waiting for guidance’, an everyday experience in the NHS which prevents decision-making because permission is lacking.

There are also formidable problems in this parallel world, mainly created by the catalytic role of the second crew. At best, the two streams of activity become confused about their relationships, especially when individuals move from one to the other, or even occupy both. Who is in charge, who has authority over whom, and for what? This is complicated by the vagueness of instructions emanating from both the Department of Health at the head of the first crew, and the Agencies of the second crew.

At worst, monitoring the first crew undermines their commitment to the NHS, by over-burdening small groups with excessive work tasks. The value-based rationality that sustains many of those who work in the public sector is damaged if their activity is checked too often, particularly when the guidelines seem simplistic and contrary to professional experience. An example is the economically-motivated claim that the newer, Prozac-type, antidepressants are no better and no more tolerable than the older tricyclic group of antidepressants. Clinicians know this isn’t so.

The consequence, in this parallel world, may be that falling NHS morale is not offset by increasing resources, that recruitment problems continue and that staff commitment declines. If all that happens, innovation will falter again and the political argument will change in the direction indicated by the recent petition of eminent specialists to The Times. If the old system cannot be reformed, should it be replaced?