Reva Gudi: With the NHS and Whitehall, partnerships work best when there is trust

Dr Reva Gudi is GP and healthcare leader in Hayes, Middlesex, she is also a former Conservative parliamentary candidate, and serves as a local school governor and charity trustee. 

Working as a senior GP commissioner in Hillingdon, I quickly learned a truth: the best outcomes in negotiations and service redesign came not from clinical expertise alone, but from having skilled managers by my side.

Having led on various clinical service redesigns, I know that clinical arguments only gained traction because, as a team, we could translate them into financial reality and operational delivery. Thinking of one example, where we were met with strong resistance from my local hospital team, the robust case for change made by my manager and I, prompted them to get on board and work with us, to deliver, what was necessary.  Together we were stronger than either of us could ever be apart-a formidable partnership of frontline insight and strategic discipline, working in any setting across healthcare.

It is not unlike the relationship between MPs and civil servants in Westminster, in my view: different roles, but shared goals, and dependent on trust.

I have never worked in Whitehall, but as an outsider I have enough knowledge to understand some of the tensions that exist between politicians and the civil service and why. But crucially I understand people—because understanding people is what we as GPs do for a living. Whether in a consulting room or across a negotiating table, the same truth applies. Relationships thrive when roles are respected and trust is present, and they break down when suspicion and caricature take hold.

Yet both relationships, I would argue, are often clouded by mistrust and an unequal balance of power. In the NHS, managers are often seen to hold the upper hand over clinicians; in government, civil servants are thought to hold the upper hand over ministers. Perhaps this is because managers and civil servants see themselves as the only constants in turbulent systems, with long institutional memory. But this can turn natural tension into deep frustration.

Caricatures abound.

Clinicians complain of managers lost in spreadsheets and meetings, detached from patients; managers see clinicians as perhaps stubborn, demanding change, and blind to budgets. Ministers suspect civil servants of obstruction; civil servants see ministers as transient and ill-prepared. Each stereotype contains a grain of truth, but clinging to them is corrosive. Having worked closely with NHS managers, I know their reality: they are tasked with delivering near-impossible national targets on shrinking budgets. Equally, clinicians who bring the expertise to judge what will genuinely help patients and the health economy in the long run, feel overlooked. However it is clear that neither can succeed alone.

History offers perspective.

Margaret Thatcher, often remembered for her uncompromising style, nonetheless worked highly effectively with civil servants who shared her determination to deliver. She could be scathing about bureaucracy, but she valued competence, loyalty, and expertise. Reform, she knew, was impossible without the machinery of government operating at its best. The NHS is no different: clinical leadership cannot flourish without managerial competence, and managerial plans are meaningless without clinical credibility.

There is, of course, constant debate about the size of the civil service and NHS management. The call for leaner structures and improved efficiency is legitimate and necessary. No one would defend waste or poor performance. But blunt cuts made for political headlines can be self-defeating. Strip away too much management capacity and you damage the very partnerships that allow reform and delivery to happen. The real challenge is how to get the best from these partnerships.

The debate on reform, whether in the NHS or in Whitehall, is not about choosing one side over the other. It is about building trust, clarity of roles, and joint accountability. Cutting waste is right; cutting competence is ruinous. Reform must be purposeful, removing what is poor, keeping what is strong, and above all creating a culture where clinicians and managers, ministers and civil servants, see themselves as allies, not adversaries.

The lesson is simple. Each perspective is incomplete on its own, but powerful together, making the work itself far more rewarding and enjoyable too.

So, my call is this: invest in trust.

Surely that must be the starting default position in any partnership that wants to succeed. Respect professional roles, demand competence, and reward collaboration. Strip away suspicion, and the partnerships that carry both the NHS and government forward will flourish. Without trust, the system fragments. We must unlock the best of both worlds—clinical insight, managerial discipline, political ambition, and a civil service able to deliver.

The NHS, like government, is a partnership. Lady Thatcher knew it. And those of us who have lived it on the ground should never forget it.

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