The hospital without patients; a triumph of her majesty's civil service.

THE HOSPITAL WITHOUT PATIENTS

In 1985, WETA, Washington's public television station, imported another one of those BBC series. It was called "Yes, Minister' and portrayed the relationship between the elected officials of Britain and its permanent civil service. The program was not wildly popular in Washington, possibly because both the bureaucracy and the politicians found it too true to be funny. Later, it played on 46 of the nation's 280 public TV stations. It wasn't too popular out there either: nobody outside Washington believed that government could possibly be run that zanily.

The book that the show inspired consists of the fictional diaries of James Hacker, an aptly named member of parliament whose party has just won the elections and who finds himself a cabinet minister in charge (or so he thinks) of the Department of Administrative Affairs, which was created to control the civil service. Hacker's diaries are supplemented by those of his aide, Sir Humphrey Appleby, the senior civil servant in the department (who has no doubt about who's in charge), and by the recollections of Bernard Woolley, Hacker's private secretary. Appleby's and Woolley's notes are important because, as Lynn and Jay observe, Hacker was once a journalist, and has no particular talent for reporting facts.

Make a few allowances for the differences between parliamentary and presidential government, and Yes, Minister tells you a great deal about how America is governed. In Sir Humphrey's parlance, "permanence is power'; it is the civil servant, not the political appointee, who has tenure. The average minister lasts only 11 months; the term expectancy of a U.S. assistant secretary is slightly more than 18 months. These people, who are just passing through, cannot be permitted to interfere with the smooth running of government. The object--nay, the duty--of the civil servant is to "housetrain' the politicians or political appointees who have wandered into their midst. A new man is considered housetrained when he sees things through the eyes of the senior civil servants.

For instance, Hacker's party has come to power having pledged, among other things, to slim down the civil service; as head of the Department of Administrative Affairs, Hacker feels obliged to set a proper example and instructs Sir Humphrey to study how many people could be trimmed. Humphrey accepts the job with his usual, "Yes, Minister.' Soon a story appears in the Daily Telegraph, noting with glee that Hacker has recruited 400 new civil servants in his "economy drive.' Humphrey is astonished that Hacker is upset: "You demanded a complete survey. . . . If you create more work, more people have to be employed.' Humphrey then points out the advantages to his boss. Hacker can put out a press release announcing that, because of the successful conclusion of the economy drive, the staff is now being trimmed by 400 people.

On the pleasure-pain principle of behavior modification, Hacker finds himself paying increasing heed to Humphrey's guidance. Or, as Hacker puts it, a certain warmth has developed in their relationship--as between a terrorist and his hostage. The day will come when an apprehensive Hacker will be called to No. 10 Downing Street. There the Prime Minister's political advisor will tell him the civil service is now saying he's a pleasure to deal with. "That's what Barbara Wodehouse says about her prize-winning spaniels,' the advisor will add.

The following excerpt from Hacker's diaries comes from an earlier point in his training, when the minister is still tugging at his leash. We pick up the story as Hacker is telling of his embarrassing performance that day before Parliament.

--Leonard Reed, contributing editor 

March 15th

I can hardly believe it. Parliamentary questions today were a disaster! A totally unforeseen catastrophe. Although I did manage to snatch a sort of Pyrrhic victory from the Jaws of defeat. The first question was from Jim Lawford of Birmingham South-West who asked me about the government's pledge to reduce the number of administrators in the Health Service. I gave the prepared reply, which was a little self-congratulatory --to the civil servants who wrote it, of course, not to me!

Somebody had leaked this wretched paper to Lawford. He was waving it about with a kind of wild glee, his fat face shining with excitement. Everyone was shouting for an answer. Humphrey--or somebody--had been up to his old tricks again, disguising an increase in the numbers of administrative and secretarial staff simply by calling them by some other name. This looked like it was going to be a real political stink. Had it stayed secret, it would have been seen as a brilliant maneuver to pass off an increase of staff by 7 percent as a decrease of 11.3 percent-- but when leaked, it suddenly comes into the category of a shabby deception. What's more, an unsuccessful shabby deception--quite the worst kind!

Thank God one of my own backbenchers came to my rescue. Gerry Chandler asked me if I could reassure my friends that the inquiries would not be carried out by my own department but by an independent investigator who would command the respect of the House. I was forced to say I was happy to give that assurance.

March 16th

This morning started none too well, either. Roy picked me up as usual, at about 8:30. I asked him to drive me to the Ministry, as I was to spend all morning on Health Service administration. He started needling me right away. "Chap just been talking about that on the radio,' he said causually. "Saying the trouble with the health and education and transport services is that all the top people in government go to private hospitals and send their kids to private schools.'

This egalitarian stuff, though daft, is always a little dangerous if it's not watched very carefully.

"And they go to work in chauffeur-driven cars,' added my chauffeur. I didn't deign to reply. So he persisted.

"Don't you think there's something in it? I mean, if you and Sir Humphrey Appleby went to work on a number 27 . . .'

I interrupted him. "Quite impracticable,' I explained firmly. "We work long enough hours as it is, without spending an extra hour a day waiting at the bus stop.'

"Yes,' said Roy. "You'd have to make the bus service much more efficient, wouldn't you?'

Roy chuckled. "You were lucky they didn't ask you about that new St. Edward's hospital,' he said jovially.

"Why?'

"Well . . .' he smacked his lips. "They finished building it 15 months ago--and it's still got no patients.'

"I suppose,' I said, "the Department of Health and Social Security (DHSS) haven't got enough money to staff it.'

"Oh, it's got staff,' said Roy. "Five hundred administrators. Just no patients.' Could this be true? It hardly seemed possible.

"Who told you this?' I asked cautiously.

"My mate Charlie,' he explained. "He knows all right. He's the driver for the Secretary of State for Health.'

When I got to the office I summoned Humphrey at once. I told him straight out that I was appalled by yesterday's debate.

"So am I, Minister,' Humphrey said. I was slightly surprised to find him agreeing so vehemently.

"The stupidity of it . . . the incompetence,' I continued.

"I agree,' said Humphrey. "I can't think what came over you.'

I blinked at him. "I beg your pardon?'

"To concede a full independent inquiry . . .'

"Your stupidity, Humphrey!' I roared. "Yours!'

"Mine, Minister?'

"Yes. Yours. How could you drop me in it like that?' To be fair, he personally hadn't dropped me in it. But his precious department had. Humphrey, however, seemed disinclined to apologize.

"A small omission from the brief. We can't foresee everything.' Then his face resumed an expression of pure horror. "But to concede a full independent inquiry . . .'

I'd had enough of this. "I didn't particularly want an inquiry either,' I pointed out. "But if you're drowning and somebody throws you a rope, you grab it.'

"It was not a rope,' replied Sir Humphrey. "It was a noose. You should have stood up for the department--that is what you are here for.'

"Nowhere in my brief was there the slightest indication that you'd been juggling the figures so that I would be giving misleading replies to the House,' I said.

"Minister,' said Humphrey in his most injured tones, "you said you wanted the administration figures reduced, didn't you?'

"Yes,' I agreed.

"So we reduced them.'

Dimly I began to perceive what he was saying. "But . . . you only reduced the figures, not the actual number of administrators!'

Sir Humphrey was pained. "You said reduce the figures, so we reduced the figures.'

"How did it get out?' I demanded. "Another leak. This isn't a department, it's a colander.' I was rather pleased with that little crack. There was another silence. "Anyway,' I concluded, "at least an inquiry gives us a little time.'

"So does a time bomb,' observed my permanent secretary.

"If only you'd said we'd have a departmental inquiry,' he complained, "then we could have made it last 18 months, and finally said that it revealed a certain number of anomalies which have now been rectified but that there was no evidence of any intention to mislead. Something like that.'

"But there was an intention to mislead,' I pointed out.

"I never said there wasn't,' Sir Humphrey replied impatiently. "I merely said there was no evidence of it.' I think I was looking blank. He explained.

"The job of a professionally conducted internal inquiry is to unearth a great mass of no evidence. If you say there was no intention, you can be proved wrong. But if you say the inquiry found no evidence of intention, you can't be proved wrong.'

I had to deal with the matter in hand, namely that I had agreed to an independent inquiry. "Couldn't we,' I suggested thoughtfully, "get an independent inquiry to find no evidence?'

"You mean, rig it?' enquired Sir Humphrey coldly. This man's double standards continue to amaze me.

"Well . . . yes!'

"Minister!' he said. Bloody hypocrite.

"What's wrong with rigging an independent inquiry if you can rig an internal one, I should like to know? Though I already know the answer-- you might get caught rigging an independent inquiry.'

"No, Minister, in an independent inquiry everything depends on who the chairman is. He absolutely has to be sound.'

"If he's sound,' I remarked, "surely there's a danger he'll bring it all out into the open?'

Sir Humphrey was puzzled again. "No, not if he's sound,' he explained. "A sound man will understand what is required. He will perceive the implications. He will have a sensitive and sympathetic insight into the overall problem.' He was suggesting that we rig it, in fact.

"Ah,' I said. "So "sound' actually means "bent?'

"I mean,' he tried again, "a man of broad understanding.' I decided to short-circuit the process by making some suggestions.

"Then what about a retired politician?'

". . . and unimpeachable integrity,' added Humphrey.

"Oh I see.' I paused to think. "What about an academic or a businessman?'

Sir Humphrey shook his head.

"Okay,' I said, knowing that he had someone in mind already. "Out with it. Who?'

"Well, Minister, I thought perhaps . . . a retired civil servant.'

I saw his point. "Good thinking, Humphrey.'

"Sir Maurice Williams could be the man,' he went on.

I wasn't too sure about this. "You don't think he might be too independent?'

"He's hoping for a peerage,' said Humphrey quietly, with a smile. He appeared to think he was producing an ace from up his sleeve. I was surprised. "This won't give him one, will it?'

"No, but the right finding will give him a few more Brownie points.'

"Right,' I said decisively. "Sir Maurice it is.'

March 17th

A long meeting with Bernard Woolley today.

"You asked me to find out about that alleged empty hospital in North London,' began Bernard. I nodded.

"Well, as I warned you, the driver's network is not wholly reliable. Roy has got it wrong.'

I was very relieved. "How did you find out this good news?' I asked.

"Through the Private Secretaries' network.'

Although the Private Secretaries' network is sometimes a little slower than the drivers' network, it is a great deal more reliable--in fact almost 100 percent accurate. Bernard explained that at this hospital there are only 342 administrative staff. The other 170 are porters, cleaners, laundry workers, gardners, cooks, and so forth. This seemed a perfectly reasonable figure. So I asked how many medical staff.

"Oh, none of them,' replied Bernard casually, as if that were perfectly obvious in any case. "We are talking about St. Edward's Hospital, aren't, we, Bernard?'

"Oh yes,' he answered cheerfully. "It's brandnew, you see,' he added as if that explained everything.

"How new?'

"Well,' he said, "it was completed eight months ago, and fully staffed, but unfortunately there were government cutbacks at that time and there was, consequently, no money left for the medical services.'

"A brand-new hospital,' I repeated quietly, to make sure I had not misheard, "with 500 administrative staff and no patients?' I began to recover myself. "My God,' I said. "What if I'd been asked about this in the House?' Bernard looked sheepish. "Why didn't I know? Why didn't you tell me?'

Bernard explained that apparently one or two people at the DHSS knew. And they have told him that this is not unusual--in fact, there are several such hospitals dotted around the country. It seems there is a standard method of preventing this kind of thing leaking out. "Apparently it has been contrived to keep it looking like a building-site, and so far no one has realized that the hospital is operational. You know, scaffolding and skips and things still there. The normal thing.'

March 22nd

Today I had a showdown with Humphrey over Health Service Administration. I had a lot of research done for me at Central House because I was unable to get clear statistics out of my own department. They continually change the basis of comparative figures from year to year, thus making it impossible to check what kind of bureaucratic growth is going on.

I learned this morning that in ten years the number of Health Service administrators has gone up by 40,000 and the number of hospital beds has gone down by 60,000. Furthermore the annual cost of the Health Service has gone up by one and a half billion pounds. In real terms! But Sir Humphrey seemed pleased when I gave him these figures. "Ah,' he said smugly, "if only British industry could match this growth record.'

"Growth?' I said. "Growth?' He nodded. I was staggered. "Are you suggesting that treating fewer and fewer patients so that we can employ more and more administrators is a proper use of the funds voted by Parliament and supplied by the taxpayer?'

"Certainly.' He nodded again.

I tried to explain to him that the money is only voted to make sick people better. To my intense surprise, he flatly disagreed with this proposition.

"On the contrary, Minister, it makes everyone better--better for having shown the extent of their care and compassion. When money is allocated to Health and Social Services, Parliament and the country feel cleansed. Absolved. Purified. It is a sacrifice.'

This, of course, was pure sophism. "The money should be spent on patient care, surely?'

"With respect, Minister,' began Humphrey, one of his favorite insults in his varied repertoire, "people merely care that the money is not seen to be misspent.'

I reminded him of the uproar over the mental hospital scandals. Cynical as ever, he claimed that such an uproar proved his point. "Those abuses had been going on quite happily for decades,' he said. "No one was remotely concerned to find out what was being done with their money--it was their sacrifice, in fact. What outraged them was being told about it.'

"Are we or aren't we agreed that there is no point in keeping a hospital running for the benefit of the staff?'

"Minister,' he admonished, "that is not how I would have expressed the question.'

Then he fell silent. I pointed out that that was how I had expressed it. Clearly, he had no intention of answering any straight question unless it was expressed in terms he found wholly acceptable. I gave in. "All right,' I snapped, "how would you express it?'

"At the end of the day,' he began, "one of a hospital's prime functions is patient care.'

"One?' I said. "One? What else?'

He continued as if I had not said a word. "But, until we have the money for the nursing and medical staff, that is a function that we are not able to pursue. Perhaps in 18 months or so . . .'

"Eighteen months?' I was appalled.

"Yes, perhaps by then we may be able to open a couple of wards,' he said.

I instructed him to open some wards at once-- and more than a couple. He countered by offering to form an interdepartmental committee to examine the feasibility of monitoring a proposal for admitting patients at an earlier date. I asked him how long that would take to report.

"Not long, Minister.'

"How long?'

I knew the answer before he gave it, "18 months,' we said in unison.

"Terrific!' I added sarcastically.

"Thank you,' he replied, charmingly unaware,

"I suggest that we get rid of everyone currently employed at the hospital and use the money to open closed wards in other hospitals. And when we can afford it,' I added sarcastically, "we'll open St. Edward's with medical staff! If you would be so kind.'

Humphrey then argued that if we closed the hospital now we would delay the opening of it with patients for years. "You talk,' he said accusingly, "as if the staff have nothing to do, simply because there are no patients there.'

"What do they do?' I asked.

Humphrey was obviously expecting this question. He promptly handed me a list comprising all the administrative departments: Contingency Planning Department, Data and Research Department, Finance, Purchasing Department, Technical Department, Building Department, Maintenance, Catering, Personnel, Administration.

I couldn't tell, as I read, if Humphrey was playing a practical joke. Department 10 contains administrators to administrate administrators. I studied his face. He appeared to be serious. "Humphrey,' I said, very slowly and carefully. "There-are-no-patients! That-is-what-a-hospital-is-for! Patients! Ill-people! Healing-the-sick!'

Sir Humphrey was unmoved. "I agree, Minister,' he said, "but nonetheless all of these vital tasks listed here must be carried on with or without patients.'

"Why?' I asked.

He looked blank. "Why?'

"Yes. Why?' I repeated.

"Minister,' he said, "would you get rid of the Army just because there's no war?'

I replied firmly. "Enough is enough. Sack them all.'

He refused point-blank. He said it was impossible. He repeated that if we lost our administrators the hospital would never open. So I told him just to sack the ancillary workers. He said the unions wouldn't wear it. I compromised. I instructed him to sack half the administrators and half the ancillary workers. I told him to replace them with medical staff and open a couple of wards. I also told him that it was my last word on the subject.

March 25th

Today I paid an official visit to St. Edward's Hospital. It was a real eye-opener. The Welcoming Committee--I use the term in the very broadest sense--was lined up on the steps. I met Mrs. Rogers, the chief administrator, and an appalling Glaswegian called Billy Fraser who rejoices in the title of Chairman of the Joint Shop Stewards Negotiating Committee.

"How very nice to meet you,' I said to Fraser, offering to shake his hand.

"I wouldn't count on it,' he snarled.

I was shown several empty wards, several administrative offices that were veritable hives of activity, and finally a huge deserted dustry operating theater suite. I inquired about the cost of it. Mrs. Rogers informed me that, together with Radiotherapy and Intensive Care, it cost two and a quarter million pounds. I asked her if she was not horrified that the place was not in use.

"No,' she said cheerfully. "Very good thing in some ways. Prolongs its life. Cuts down running costs.'

"But there are no patients,' I reminded her.

She agreed. "Nonetheless,' she added, "the essential work of the hospital has to go on.'

"I thought the patients were the essential work of the hospital.'

"Running an organization of 500 people is a big job, Minister,' said Mrs. Rogers, beginning to sound impatient with me.

I told her that this situation could not continue. Either she got patients into the hospital, or I closed it.

She started twittering. "Yes, well, Minister, in the course of time I'm sure . . .'

Billy Fraser then started. "Look here,' he began, "without those 200 people this hospital just wouldn't function.'

"Do you think it's functioning now?' I inquired.

Mrs. Rogers was unshakeable in her self-righteousness. "It is one of the best-run hospitals in the country,' she said. "It's up for the Florence Nightingale award.' I asked what that was, pray.

"It's won,' she told me proudly, "by the most hygienic hospital in the Region.'

I told her that I'd said my last word and that 300 staff must go, doctors and nurses hired, and patients admitted.

"You mean, 300 jobs lost?' Billy Fraser's razorsharp brain had finally got the point.

I spelt it out to him. "A hospital is not a source of employment, it is a place to heal the sick.'

He was livid. "It's a source of employment for my members,' he yelled. "You want to put them out of work, do you, you bastard?' he screamed. "Is that what you call a compassionate society?'

"Yes,' I answered coolly, "I'd rather be compassionate to the patients than to your members.'

"We'll come out on strike,' he yelled.

I couldn't believe my eyes or ears. I was utterly delighted with that threat. I laughed in his face.

"Fine,' I said happily. "Please, do go on strike, the sooner the better. And take all those administrators with you,' I added, waving in the direction of the good Mrs. Rogers. "Then we won't have to pay you.'

March 26th

It seems I didn't quite wipe the floor after all.

Bernard and I turned on the television news. First there was an item saying that the British government is again being pressured by the U.S. to take some more Cuban refugees. And then-- the bombshell!--Billy Fraser came on, and threatened that the whole of the NHS in London would be going on strike tonight at midnight if we laid off workers at St. Edward's.

Humphrey came in at that moment. "Oh,' he said, "you're watching it.'

"Yes,' I said through clenched teeth. "Humphrey, you told me you were going to have a word with the unions.'

"I did,' he replied. "But well, what can I do?' He shrugged helplessly. I asked him what we were supposed to do now. But Humphrey had come, apparently, on a different matter--of equal urgency. "It looks as if Sir Maurice Williams's independent inquiry is going to be unfavorable to us,' he began. I was appalled. Humphrey had promised me that Williams was sound.

"Unfortunately,' murmured Sir Humphrey, embarrassed, looking at his shoes, "he's also trying to work his peerage in his capacity as Chairman of the Joint Committee for the Resettlement of Refugees.'

I inquired if there were more Brownie points in refugees than in government inquiries. He nodded. I pointed out that we simply haven't got the money to house any more refugees. The phone rang. I was told rather sharply by a senior policy adviser that Number Ten had seen Billy Fraser on the six o'clock news. By "Number Ten' he meant the PM. Number Ten hoped a peace formula could be found very soon. A most beautiful solution occurred to me. A thousand refugees with nowhere to go. A thousand-bed hospital, fully staffed.

Humphrey saw what I was thinking, of course, and seemed all set to resist. "Minister,' he began, "that hospital has millions of pounds' worth of high-technology equipment. It was built for sick British, not healthy foreigners. There is a huge Health Service waiting list. It would be an act of the most appalling financial irresponsibility to waste all that investment on . . .'

"But . . . "I said carefully, "what about the independent inquiry? Into our department? Didn't you say that Sir Maurice's inquiry was going to come down against us? Is that what you want?'

"I see your point, Minister,' he replied thoughtfully.

I told Bernard to reinstate, immediately, all the staff at St. Edward's, to tell Sir Maurice we are making a brand-new hospital available to accommodate 1,000 refugees, and to tell the press it was my decision. Bernard asked me for a quote for the press release. "Tell them,' I said, "that Mr. Hacker said that this was a tough decision but a necessary one, if we in Britain aim to be worthy of the name of . . . the compassionate society.' I asked Humphrey if he was agreeable to all this.

"Yes Minister,' he said. And I thought I detected a touch of admiration in his tone.