Who really has the power in the NHS?

I recently met a master’s student, Sara Haque, who is just finishing her dissertation on power dynamics between doctors and nurses in the UK. Her interim results are fascinating, but I won’t steal her thunder as this is still to be submitted and I shall publish the link as soon as it’s available. But our discussions got me thinking about the role that power has to play in the Health and Social Care Bill.

One of the key elements of the NHS reforms planned by Andrew Lansley, UK Secretary of State for Health is, in effect, a shift of power. Large tranches of budget (and he who holds the budget, wields the power) are to be moved from Strategic Health Authorities and Primary Care Trusts (PCTs) to the GP Consortia. He also plans to give greater empowerment to patients – ‘nothing about me without me’

The latter is, of course, a worthy aim. But how practical is this and how is power manifested day to day throughout an acute care trust or GP practice?

As an inpatient, however knowledgeable and stroppy I may be, I quickly learnt that the power in my ward depended on who I was interacting with at the time. Whatever the doctor may say, as soon as he or she left the ward, the nurses were back in charge. I also acknowledged that he who holds the needle, holds the power. I wrote recently how annoyed I was at the delay in my medication due to lack of cooperation and coordination between doctors and nurses, but that didn’t get me my IV antibiotic any sooner. The nurse held the power in that instance. And how powerful is a Chief Executive of a Hospital trust? Yes, they are in charge, but still have to bow to their paymasters.

Abraham Lincoln once said ‘Nearly all men can stand adversity, but if you want to test a man’s character, give him power’ How true.

I believe that one of the reasons that people associated with the NHS are feeling so uncomfortable right now is because it is very difficult to judge where the power lies. Human nature requires an understanding of the hierarchy at any particular instant. All good parenting manuals talk about boundaries. Management gurus impart the importance of clear goals, roles, responsibilities and accountabilities.

The general public hears the sound bites about empowerment, but find that they are reduced to thankful and/or fearful wrecks when faced with the mighty force of perceived superior qualifications, knowledge and status in unfamiliar surroundings. Are patients more unsettled now they feel they should be taking more responsibility for the decision about their care? Are GPs in danger of becoming power-crazed dictators or will they find the additional power an uncomfortable shift in the status quo? A bit of both I suspect. And the poor souls currently working in PCT’s? As a friend of mine used to say – they are ‘betwixt and between’.

The philosopher Foucault hypothesised that power is not a thing but a ‘relation’. Power ‘operates at the most micro levels of social relations’. So perhaps anyone who works in, or is treated by the NHS is only as powerful as their most recent interaction. Despite the transient nature of power, I feel we would all benefit from further clarity on the powerbases of the ‘new NHS’

And doctors and nurses? In the context of much mutual respect, they’ll still bitch about each other behind their backs.

Plus ca change.