Power is sometimes the most fascinating thing in the world, and yet it so easily becomes the dullest.

Power in and of itself isn’t interesting. It’s just heft, a monolithic kind of stupid freedom.

Power becomes fascinating in relation to purpose, and in observing its affect on relationships. Used properly, power is always a means; never an end.

The NHS is an interesting venue to observe the dynamics of power. It combines the closed behaviour of elite tribes – medical and managerial, each with their codes, special language, routines and traditions – with a much-mouthed and often-meant commitment to making healthcare equitably available.

Sometimes, when we are all fighting and pointing fingers, we should try to remember that.

Power and games
Among the most stupid ways to regard power is to see it as dominance in a zero-sum game.

Game theory is a fascinating hybrid of philosophy and applied economics. Wikipedia suggests that game theory “attempts to mathematically capture behaviour in strategic situations, in which an individual's success in making choices depends on the choices of others”.

The three Cs: choice, competition and commissioning
We are moving into an era of healthcare choice and competition. Alongside commissioning, these three Cs will determine the fate of the NHS over the next few years.

Mathematical models to decide future actions and behaviours are probably discredited for a generation by the global recession. Nonetheless, mathematics and economics, alongside behavioural psychology, have a huge part to play in this next bit of the journey. This next bit needs to be data-rich, or it will leave the NHS not just poor but broken

There is a massive blind alley open to us, which we will enter en masse and at speed if we treat choice and competition as dogmatic principles. All three Cs are tools – they are means to ends.

The evidence is starting to swing in the direction of choice and competition, though as yet, the benefits are modest and the transaction costs have been high.

This is not to say that choice, competition and commissioning should mean that nothing anywhere ever closes (I’m not in the BMA, you know).

Rather it is to refocus attention on using the three Cs as tools to improve access, move care upstream, drive out unacceptable variation, centralise where necessary, localise where possible and be cost-effective.

Budgets should be the zero-sum games in the NHS. The past decade has increased management costs (which must now be cut to 1/3 of their 2008-9 levels), but the NHS can now have meaningful discussion about where its costs arise.

Paternity – sweet for the old-school hierarchs
One problem that the traditional NHS power hierarchs will face is that the new system is not going to be about thrones, dominations and fiefdoms – where power is always a zero-sum game.

The old school power hierarchs had one question to ask the rest of the system: ’Who’s your daddy?’

The old school is closing, due to the arrival of evolution on the curriculum. Intelligent design from the top down has been tested to destruction. It might have worked for the NHS system. It certainly worked for the old-school hierarchs. It doesn’t produce a 21st century healthcare system.

Stalinism was an effective management strategy in the NHS’s maternity suite of post-war, deferential austerity. But from that maternity suite, paternalism was entrenched.

Stalinism, like wooden clogs, worked after a fashion: it got bedpans’ resonance all the way from Tredegar to Westminster. It also created a system that didn’t exist, and gave everybody access. However, top-down intelligent design of that new system believed that usage of the NHS would tail off after a few years. We are still waiting.

The new system is going to be about relationships, interdependencies, motivation, and shared risks and rewards. It is also going to be about empowering patients and the public. Oh yes, and GPs too.

Maslow – altogether a better hierarch
One of the best explainers of motivation was Abraham Maslow. His hierarchy of needs remains an excellent framework, splitting the deficiency needs (physiological and safety) function from the love / belonging, esteem and self-actualising needs which create purpose.

The birth of a new system won’t be easy: birth never is. Fear, pressure and shouting about ‘who’s your daddy?’ will make it worse. The midwifery must be technically safe, but dysfunctional relationships and upbringing are likely to scupper any chances of success.