five - Power and politics in the NHS

Summary

Introduction

Before examining the role of NHS managers and professionals in child protection networks, it is important to gain an understanding of the evolving politics of the NHS. As a near monopoly provider of health care in the UK, the NHS is the principal, though not the sole, ‘field of action’ for the health policy network. In this network, according to Wistow (1992), the medical profession has played a significant and enduring role. However, the stability of the policy community has been subject to challenge in recent years as Conservative and then Labour governments have attempted to gain greater control over the direction of NHS policies and in doing so have redefined relationships between the state and the professions. As the Benson model indicates (1975, 1983), this shift in external power relations has affected the balance of power within the policy community as well as relationships between elements within the medical profession.

In addition, the devolution of service planning to the local level increases the potential for a more plural process and raises the prospect of local issue networks. In Benson's terms, these may involve the participation of both ‘demand’ or ‘support’ groups. The greater number of constituencies to be served may encourage more overt forms of political activity, including between professional interests, as they ‘jostle’ for position. This chapter will explore these changes in so far as they may impact ultimately on the operationalisation of child protection policies. It will also examine the governability of the NHS and, in association with this, the changing relationship between the state and the professions. The ability of governments to implement health policy will be discussed in relation to changing centre–local relations and, in particular, the compliance of key professional groups. The role of the health professions will be explored, as will the place of the ‘silent citizen’ in NHS politics. While concluding that the medical profession, and increasingly general practice, still exerts considerable influence within the health policy community, it appears that the state has succeeded in exerting greater control over the profession as a whole. The state–medical profession dynamic is, however, only one consideration in local provider networks. The interagency and interprofessional politics within networks are contextualised by the firm regulatory steer of the centre.