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Many readers of this journal will work for some of their time in the public sector, either in the National Health Service itself, as I do, or, as the editor of this book, in other public institutions such as universities. This book explores both the changes in political philosophy which have led a new culture of management of the public health services, and the consequent experiences of those who have to engage with this, and the demands this makes.
When I left an earlier career in educational administration I undertook to myself that, in my new career, I would keep away from managing and management and concentrate on the clinical. I am not sure whether I believed it at the time, but I have not kept to it.
I meet regularly with a number of colleagues who, like me, work as counsellors in GP practices in South London, and one continuing strand within our group is anxiety at whether the local Health Commission will continue to fund us and the work we do. For those of us who work within fund holding practices there is a further anxiety about whether the practice will decide to retain us. One person has recently lost her job because, it seems, the practice ceased to appreciate her work within their framework of values where effectiveness is measured within a narrow notion of cost, which is confined to the cost of treatment, and which excludes the wider costs, financial and otherwise, of not treating the patient.
One of our continuing tasks is to find a way, or ways, of demonstrating what we believe is our effectiveness, when it is hard to establish criteria of this which are valid for us, and which will be convincing to those whom we need to convince, whose value systems are quite different.
It is tempting not to continue this struggle, to close the consulting-room door and concentrate on the clinical. It is difficult that we feel that the boundary of our work is not sufficiently held by others so that we have to struggle to hold it ourselves, when a vital part of our clinic