Chapters 2, 3 and 4 of Prof Stephen Harrison's book, published by Avebury 1994, reproduced by permission. (Not all the tables are reproduced)
This chapter has three main purposes. The first is to provide a general background against which the rest of the study may be read. The second is to establish that notions of more individually accountable management, in particular a chief executive or general manager, have on several occasions in the history of the NHS been considered and rejected. The third is to show that such notions, if implemented, would represent a radical departure from earlier NHS practice.
The chapter is divided into five sections. The first provides an overview of developments in the organisation and management of the NHS from its foundation until immediately before the commissioning of the Griffiths Report in 1982. This overview shows a consistent and growing interest in the topics of management and organisation. The second section looks beyond these formalities to the actual practice of management in the service, finding an official and institutionalised unwillingness to challenge the medical profession in the way implied by conventional notions of management. The third section gives an overview of the analysis and prescription offered by the Griffiths Report of 1983. The fourth section summarises the central argument of the chapter; the proposal to introduce general management was radical but not new. The chapter concludes with a postscript which describes the further and subsequent set of radical organisational arrangements associated with the white paper Working for Patients (DoH et al 1989).
In 1948, the newly-created NHS took the form of a 'tripartite' structure, a political compromise between the Labour government and various provider groups (Willcocks, 1967, p. 105), in which control of primary care was separated from that of community services, which in turn was separated from that of hospital services. The initial management arrangements for these three parts of the service very much reflected what had gone before. In the case of primary care, General Medical Practitioners (GPs), General Dental Practitioners, Pharmacists, and Opticians were self-employed practitioners whose contracts were administered by Executive Councils upon which the four professions were themselves heavily represented. This arrangement differed little from that made following Lloyd George's National Insurance Act of 1911 (Willcocks, 1967, p.75). The staff of the Executive Council, whose role was to maintain GPs' lists of patients and to receive practitioners' claims for payment, was headed by an Administrator with managerial control only over the staff, not the practitioners.
The second arm of the tripartite arrangements was provided by local government: County Councils and County Borough Councils. These bodies lost their former duties and rights to provide hospital services, remaining responsible for preventive services, maternal and child welfare, health visiting, home nursing, ambulances, and the school medical service (Levitt, 1979, p. 19). Such local authorities appointed a health committee of councillors, to whom the Medical Officer of Health (MOH) was responsible for the above services. Although it was widely perceived by MOsH that they had lost a great deal of executive authority as a result of the loss of local authority hospital services (and District MOsH lost a great deal more to County MosH), they nevertheless remained, in effect, chief executive officers with formal authority over all their staff, including other doctors (Lewis, 1986, pp. 46-9).
Hospital authorities constituted the third part of the structure. Great Britain was divided into nineteen (later twenty) Regions, each containing a medical school and each controlled by a Regional Hospital Board (RHB) responsible to the Minister of Health. Groups of hospitals (occasionally single large hospitals) within each Region were presided over by Hospital Management Committees (HMCs) or Boards of Governors in Scotland. Groups of English hospitals with medical undergraduate teaching functions were run by Boards of Governors, who, unlike HMCs, were responsible noi to the RHB but directly to the Minister of Health. The membership ol Boards and Committees was part-time, honorary, and appointed rather thar elected (see Watkin, 1978, pp. 24-26): doctors were heavily represented (Allsop, 1984, p. 17). Boards and Committees employed a chie administrative officer (often known as the Group Secretary), and individual hospitals were normally managed on a day to day basis by a triumvirate consisting of Hospital Secretary, Matron, and Medical Superintendent or medical administrator (Central Health Services Council, 1954, pp. 12-14) The 'tripartite' arrangements are outlined in Figure 2.1.
It was not long, however, before these management arrangements, and management more generally, were to come under a scrutiny to which they have been subject, and with increasing intensity, ever since. Even before the advent of a Conservative Government in 1951, concern had been growing about the costs of the NHS, which had consistently exceeded estimates (Klein, 1983, pp. 33-40). The Guillebaud Committee, established in 1953 to investigate the cost of the NHS, made it clear in its report that there was no financial crisis; rather, estimates had failed to allow for demographic change or the occurrence of inflation. Nevertheless, it went on to call, in very general terms, for more emphasis on 'oversight and supervision of the service' (Committee of Enquiry, 1956, para 211). At roughly the same time, the Bradbeer Committee was responding to the uncertainties about management relationships expressed by NHS managers from widely differing pre-NHS backgrounds. The Committee legitimised the existing trend for HMCs to have one chief administrator at Group level but a triumvirate arrangement at hospital level (see above); it opposed the appointment of matrons or medical officers at group level, and (like Patients First twenty-five years later: see below) argued that lay departmental heads within a hospital should be responsible to the Hospital Secretary (Central Health Services Council, 1954, paras. 20, 28, 196).
Bradbeer had reported before Guillebaud, so that the latter had been able to
endorse the former's conclusions about the virtues of the triumvirate model
of hospital management. This conclusion was vigorously criticised by the National
Association of Hospital Management Committee Group Secretaries in their commentary
on Guillebaud; though they stopped short of proposing a general manager for
the hospital, they sought a more substantial role for the hospital secretary
than implied by either Bradbeer or Guillebaud:
The suggestion that ... administration ... undertaken by a doctor "can
have an important bearing upon hospital efficiency and costs" is all too
true, but not, it is feared, in the sense intended ... It is little short of
ludicrous that great economy ... shall be claimed as a merit of "medical
administration" ... The Guillebaud Committee has clearly and rightly regarded
the "comprehensive" administrator as essential ... but it should be
clearly understood that this ... cannot exist side by side with any theory of
"medical administration" (National Association of Hospital Management
Committee Group Secretaries, 1957, para 17).
Guillebaud had called for more attention to be given to the recruitment training
and promotion prospects of NHS administrative staff and these were the subjects
of the subsequent Noel Hall (1957) and Lycett Green (1963) Reports (Watkin,
1975, pp. 159, 175).
The first decade of operation of the NHS had provided the occasion for the medical
profession to call for a review of it; the Porritt Committee produced a wide-ranging
Report on behalf of the British Medical Association (BMA) and the Royal Colleges.
Notable amongst its recommendations was its call for the integration of the
three parts of the tripartite structure, though without changing the employment
status of doctors. In each locality the three parts of the service would be
separately managed by a medically qualified administrator, though at the level
of the individual hospital the Bradbeer recommendations (see above) were endorsed
(Medical Services Review Committee, 1962, paras. 77, 85, 425). Simultaneous
with Porritt's deliberations, the Hospital Plan for England and Wales was being
produced (Ministry of Health, 1962); this was to result in the concept of the
'district general hospital', offering a comprehensive service from 600 to 800
beds, together with appropriate outpatient and diagnostic services (Allen, 1979,
p. 72). It also provided the occasion for an enhanced management role in planning
and commissioning capital developments.
The period of Labour Government from 1964 to 1970 was also to provide a sustained,
if diverse, emphasis on questions of management. A 1966 paper on the management
functions of hospital doctors noted that 'the industrial manager works in a...unified
and clear environment; his responsibilities are...readily definable and his
work is...easily evaluated... In British hospital management, these supportive
and critical elements are lacking' (Advisory Committee, 1966, pp. 8-9). The
paper went on to urge Consultants to improve management by improving the scientific
scrutiny of their work (p. 9). In Scotland, however, the Farquharson-Lang Report
was recommending that RHBs and local Boards should employ a 'chief executive'
and moreover felt 'reluctantly obliged to disagree with the conclusion [of the
BMA] that the chief executive...must, inevitably, be a medically qualified person'
(Scottish Health Services Council, 1966, pp. 62-63). Although the Report was
publicised in England, this particular conclusion was not (Watkin, 1975, p.
195).
Although Farquharson-Lang had implied that the desirability of a chief executive
was widely recognised, in England this was not unanimous. In the same year as
Farquhar son-Lang, the Salmon Committee (covering Scotland as well as England)
reported on the subject of a management structure for senior nursing staff.
It concluded that, notwithstanding Bradbeer (see above), senior nurses had insufficient
status, and went on to propose a hierarchical structure for the profession,
to include a chief nursing officer at Group level (Ministry of Health, 1966,
pp. 4, 60-61). The Salmon Report was accepted in principle by the Minister and
introduced, initially on a pilot basis, between 1967 and 1972 (Watkin, 1975,
p. 318). The Mayston Report soon afterwards applied similar principles to local
authority nurses (Watkin, 1978, p. 113).
Nevertheless, Farquharson-Lang found some support from south of the border. In what may well have been a reaction against Salmon, a joint working party of the Institute of Hospital Administrators (IHA) and the King's Fund criticised Bradbeer on different grounds, accusing it of having 'failed to grasp the nettle that someone had to be in command of the [hospital] with authority over all the rest of the staff (Joint Working Party, 1967a, p. 24). The report went on to choose the term 'general manager' (pp. 32-34) for such a person, responsible to whom would be, amongst others, a medically qualified Director of Medical and Paramedical Services (p. 38 ff). In what transpired to be a prophetic statement, the Working Party noted that its recommendations might not be immediately acceptable to doctors, and might take more than ten years to come about (p. 42).
During the same period, the medical profession itself had begun to look at the relationship between NHS management and hospital medicine; a joint committee of the Ministry of Health and the profession produced in 1967 the first of three 'Cogwheel Reports' (so named after the logo on their cover), which urged doctors to recognise their essential interdependence with each other and to set up specialty based 'divisions' within hospitals, each sending a representative to a 'Medical Executive Committee'. The Chairman of this latter body would act as the chief medical spokesman (sic) for the hospital or group of hospitals (Joint Working Party, 1967b, pp. 2-4). The Ministry quickly commended the Report to HMCs and Boards of Governors and medical staff in many districts began to organise themselves either along the lines recommended or some variation of them, though progress was uneven across the country (Watkin, 1975, p. 244). Parallel developments occurred in Scotland as a result of the Brotherston Report (Watkin, 1975, pp. 245-7).
Other health service professions were also interested in management, albeit in a more direct way than the doctors; following Salmon (see above), the Zuckerman (1968) and Noel Hall (1970) Reports recommended management career structures for scientists and technicians, and pharmacists respectively, employed in the NHS (Watkin, 1975, pp. 341-349).
The late 1960s also saw the first applications to the NHS of quantitative management techniques, such as organisation and methods study. Originally used as an aid to planning, such techniques became widespread after 1967 as a means of introducing payment-by-results schemes for hospital manual workers, since current government pay policy required productivity increases in return for pay increases (National Board for Prices and Incomes, 1967).
It will be recalled that the Porritt Report (see above) had suggested a degree of administrative unification of the tripartite structure of the NHS; also, by the mid-1960s consideration was being given to the reorganisation of local government (Alexander, 1982, p. 6). It was not surprising therefore that in 1968 the then Labour Minister of Health, Mr Kenneth Robinson, published a Green Paper (consultative document) on the administrative tructure of medical services (Watkin, 1975, p. 166). As Klein (1983, p. 90) notes, there was a widespread consensus that greater integration of services was required, together with widespread recognition that medical opposition made the transfer of health services to local government a political impossibility. By later in the same year the Ministry had been amalgamated (also in pursuit of greater integration of social policy) into the new Department of Health and Social Security (DHSS) under Mr Richard Grossman, and in 1970 the latter published a second Green Paper in which it was announced that a reorganisation would take place, with health services (defined in terms of the roles of the health professions) to be administered by (in England) some 90 area health authorities, each sharing boundaries with the local government authority responsible for social services (DHSS, 1970, pp. v-vi). Each authority would be advised by a Chief Administrative Medical Officer, a Chief Nursing Officer, a Chief Administrative Officer, and a Chief Financial Officer (DHSS, 1970, p. 20). (Owens and Glennerster [1990, p. 11] are mistaken in their assertion that a chief executive was proposed.)
After the election of a Conservative Government in 1970, the new Secretary of State for Social Services, Sir Keith Joseph, published a White Paper (DHSS, 1972a) setting out the government's reorganisation intentions; although there were some differences, including the retention of a regional tier of organisation and some explicit references to effective management, the 'successive proposals ... show a remarkable degree of continuity' (Klein, 1983, p. 91). Consideration of possible management arrangements had already begun, and by this time there was little, if any, support for the notion of a chief executive officer; intellectual leadership in this area lay in the Health Services Organisation Research Unit at Brunei University, whose members and those influenced by them concluded that doctors could not be made managerially responsible to non-doctors (see, for instance, Jaques, 1978, p. 141; Naylor, 1971, p. 33). Moreover, by this time the claims of the health professions to managerial roles of their own had been added to by the Hunter Report, which recommended the creation of a new medical specialty of Community Medicine whose responsibilities would include planning and management (Working Party, 1972, p. 23). As Lewis (1986, p. 116) puts it, 'doctors had to be persuaded to become actively involved in the management of the service, and it was in this context that the role of the community physician as a "linkman" [sic], inspiring the confidence of both clinicians and administrators, was perceived as crucial.'
It was, however, the so-called 'Grey Book' (DHSS, 1972b) which set out the definitive philosophy (even though some of its details in respect of paramedical occupations were later modified) for the management arrangements in the reorganised NHS. Produced by a joint group of DHSS and NHS officers and heavily influenced by the Brunei philosophy of role clarity within organisations, the Grey Book recommended a system of consensus decisionmaking by multi-disciplinary management teams consisting of administrator, treasurer, nurse, and doctors. The reorganised structure of the NHS was implemented, along the reorganisation of local government, in April 1974, by which time a Labour government had been returned to office. (For a more detailed account of the structure, see Levitt, 1979.)
The new arrangements preserved non-elected health authorities (Regional Health Authorities and Area Health Authorities in England) with reduced medical membership; the lower tier was coterminous with the tier of local government responsible for social services, and such area authorities were often divided into two or more non-statutory Districts, each nominally based on the catchment area for a district general hospital. Primary care services were not fully integrated; the contracts of GPs and other independent practitioners were, in England and Wales, held by Family Practitioner Committees (FPC) established by each area authority and consisting of members of the relevant professions and of local and health authorities. FPC staff were managed by a single administrator along the lines of their predecessor Executive Councils. Community Health Councils (CHCs) were created to represent the consumer interest.
Management at Region, Area, and District levels was to be conducted by multidisciplinary management teams. Regional Teams of Officers comprised an Administrator, Treasurer, Nurse, Medical Officer (from the new specialty of Community Medicine: see above) and Works (building, engineering and related professions) Officer. Area Teams of Officers comprised the first four of the above. District Management Teams (and Area Teams where there were no Districts) comprised an Administrator, Finance Officer, Nursing Officer and Community Physician, together with a hospital consultant and GP elected to part-time membership by their respective colleagues.
Although individual team members were to have personal responsibility for their own spheres of work, issues or decisions which were multi-disciplinary or strategic were to be handled collectively. The mode of decision making by such teams was to be consensus, 'that is, decisions ... need the agreement of each of the team members' (DHSS, 1972b, p. 15; for a review, see Harrison, 1982). It should be noted that, in England, there was no authority relationship between teams at different levels, only between the Authorities themselves, with team members responsible to their respective Authorities. Rather, the relationship between teams was intended to be one of 'monitoring'; the higher level possessed the right to give advice and obtain information, but not directly to instruct the lower level (Levitt, 1979, p. 48). Disagreements either between teams, or amongst members of a particular team were to be settled by reference to the appropriate health authority, though in practice there was considerable reluctance to use this procedure (Harrison, 1982). The reorganised arrangements are summarised in Figure 2.2.
The 1974 reorganisation can be seen as the culmination of a longstanding trend towards managerial specialisation. Specialist finance and supplies officers had emerged during the 1950s and 1960s, as had specialist managers in such areas as catering, laundry, and domestic work in a period when nurses were increasingly seeking to shed responsibility for 'non-nursing duties'. The professional building and engineering ('Works') function had also developed along with the increasing complexity of health building and technology. In the late 1960s and early 1970s specialist planners and personnel officers had been employed in response, respectively, to activity generated by the Hospital Plan (see above) and to increasing trends in unionisation and employment legislation (Barnard and Harrison, 1986, p. 1220). Reorganisation formalised this trend and added to it managerial hierarchies in a number of health professions not already thus organised: dentistry, chiropody, speech therapy, physiotherapy, occupational therapy and dietetics (Levitt, 1979, p. 144 ff).
The 1974 Reorganisation was completed by the introduction in 1976 of a planning system. This took a cyclical format. DHSS guidelines on national policies and resource assumptions were issued to RHAs, amplified by them and issued to Area Health Authorities, again amplified and issued to District Management Teams (DMTs) who were then responsible for preparing a district operational plan; the resulting plan was fed upwards for approval or review at Area level, aggregated into Area plans fed to Region, and into Regional plans fed to DHSS (DHSS, 1976). The system, though it involved a good deal of consultation with various interests as well as the opportunity for plans at a higher level to be amended as a result of comments from the lower, can be seen as a variety of classic chain-of-command management.
Although substantial numbers of NHS professionals and managers had benefitted considerably from the introduction of the new structure, there was a degree of disillusionment at its complexity and at what proved to be difficult relationships between the various levels of organisation (Ham, 1985, p. 30). This dissatisfaction extended to the relations between DHSS and the NHS, as a result of which the Secretary of State for Social Services, Dr David Owen, invited the Chairmen of three RHAs to report on the matter. The report, completed in the autumn of 1976, concluded that the Secretary of State's personal accountability to Parliament for the detailed conduct of the NHS, coupled with the Permanent Secretary's role as Accounting Officer for all its expenditure, led to administrative complexity that was 'almost totally baffling' with too much Departmental interference in detail, and excessively slow decisionmaking (Klein, 1976, p. 1804). The remedy proposed was to pass a good deal of the parliamentary accountability to RHAs; by this time, however, Mr David Ennals had succeeded Dr Owen and the issue had become a matter for the newly established Royal Commission (see below).
Moreover the period after 1974 was a difficult one for the NHS for other reasons. Firstly, it was a period of relative economic restraint; in 1976 the Treasury introduced the 'cash limits' system of financial allocation to the public sector. This replaced the previous system of allocation in volume terms and meant that NHS hospital and community health services (though not Family Practitioner Services) were no longer automatically protected against inflation in the costs of its manpower or other resources (Klein, 1983, p. 109). A system of central control of management costs was also introduced (Levitt and Wall, 1984, p. 60). The introduction in 1978 of the formula for resource allocation devised by the Resource Allocation Working Party ('RAWP') was intended to procure an equitable geographical distribution of health care resources; its application in a period of financial restraint necessarily .entailed a redistribution from some health authorities to others. (For a detailed account see Jones and Prowle, 1984, pp. 93-99.) Secondly, it was a period of increased militancy amongst trade unionists in the NHS; industrial action became relatively commonplace (Barnard and Harrison, 1986, p. 1220). Thirdly, between 1974 and 1976 the Government and medical profession were involved in what Klein (1983, p. 117) describes as 'the most bitter political struggle since the inception of the NHS': the battle over an attempt to remove private beds from NHS hospitals. (For a detailed account, see Klein, 1980 and the memoirs of the then Secretary of State, Mrs Barbara Castle [Castle, 1980].) Against this background the Royal Commission on the National Health Service was established in 1976 under the Chairmanship of Sir Alec Merrison.
By the publication of the Commission's Report in July 1979, a new Conservative government had been elected; the Conservative Party remained in office throughout the 1980s. Like Guillebaud (see above), the Royal Commission was broadly satisfied with the performance of the NHS, though it made a large number of somewhat piecemeal recommendations. Major proposals included the abolition of the Area or District tier (unspecified) of organisation (Royal Commission, 1979, p. 331), the abolition of FPCs (p. 331), and a strengthening of CHCs (p. 157). It also recommended the introduction of a limited list of drugs available for prescription on the NHS (p. 89) though this was soon rejected by the new Secretary of State, Mr Patrick Jenkin (DHSS, 1979).
A good deal of the Government response to the Report was contained in Patients First, a consultative document published in December 1979; this document proposed the abolition of the Area tier and its replacement by statutory District Health Authorities (DHAs) (DHSS and Welsh Office, 1979, p. 9), the retention of FPCs (p. 14), and (somewhat tentatively) the abolition of CHCs (p. 14). The proposals were therefore more than a little different from those of the Royal Commission. Other proposals in Patients First were the simplification of the planning system (p. 18) and greater delegation of authority to 'units' (levels of organisation such as hospitals, below the District) which would be managed by an administrator, and a nurse 'of appropriate seniority to discharge an individual responsibility in conjunction with the medical staff (p. 7); the administrator at hospital level, rather than a District specialist, was to be responsible for functions such as catering and domestic work. The desirability of a 'chief executive' was explicitly rejected (p. 7). Experimentation with 'management advisory services' within Regions was also announced (pp. 18-19). A later announcement accepted the Royal Commission's critique of NHS information provision and established an investigation under Mrs Edith Korner (DHSS, 1980a).
Most of the proposed changes were subsequently brought into operation, and are summarised in Figure 2.3. With effect from April 1982 DHAs were created, often, though not invariably, on the basis of the former Districts; as a result, FPCs often covered more than one new DHA. At District level consensus DMTs were retained, whilst the Unit level administrator and nurse were to manage in conjunction with a representative of medical staff (DHSS, 1980b, para 26) in a triumvirate along the lines originally legitimised in the Bradbeer Report (see above). Special emphasis was placed on the coordinating role of the administrator (DHSS, 1980b, para 25). CHCs were retained.
In the meantime (from 1981 onwards) the NHS had been expected by the government
to make 'efficiency savings'; this practice consisted of assuming that health
authorities' outturn expenditure would be less than their nominal budget by
a specified percentage, and hence providing an actual budget to match only the
assumed outturn. Since such an arrangement provides no controls over where the
savings are made, it is no more than a convenient assumption that they result
from improved efficiency (Harrison and Gretton, 1984, p. 97). The required figures
were 0.2% in 1981-2, 0.3% in 1982-3 and 0.5% in 1983-4 (Ham, 1985, p. 48).
It is evident from the preceding account that a good deal of concern with the management arrangements for the NHS was exhibited by governments throughout the whole period under review. Despite superficial appearances, the underlying view of what constituted good management and how to obtain it was a very particular one. It had two elements: the belief that it was neither appropriate nor practicable to seek managerial control over doctors, and the belief that better management would result from improving the inputs into the management process. Each of these elements is discussed in some detail.
That between 1948 and 1982 there were few aspirations for managerial control of doctors can be illustrated in two ways. Firstly, the position of doctors throughout the various formal changes can be examined. The position of GPs has not merely remained constant since the inception of the NHS in 1948, but since the introduction of 'panel doctors' in 1912; their insistence upon remaining as independent contractors and upon precluding even a salary option led to the substitution of Executive Councils for the old Local Insurance Committees. As Willcocks (1967, p. 74) expressed it 'this old compromise was to be the new compromise'. The compromise was again maintained (in England and Wales) through FPCs in 1974 and 1982 reorganisations, with apparently little attempt to propose alternatives (see, for instance, Medical Services Review Committee, 1962, pp. 56, 88-92; DHSS, 1970, p. 19), except in the case of the Royal Commission discussed above. In short, there was little management involvement with general practice; perhaps the significant exception was the system of prescribing review by which GPs with exceptionally expensive prescribing habits were identified and asked to modify their practice (Johnson, 1962).
In summary, it is hardly surprising that both the Porritt Report and academic commentators noted the lack of friction between managers and GPs (Medical Services Review Committee, 1962, p. 112; Lindsey, 1962, pp. 83-85). Although the 1974 reorganisation affected the position of MOsH as effectively chief executives of local authority health departments, their status was ostensibly preserved (and in the case of some of their former subordinates, enhanced) by the creation of the specialty of Community Medicine.
In hospital medicine too, doctors were not challenged by the formal organisation, which, despite the recommendations of Farquharson-Lang and the (then) Institute of Hospital Administrators (IHA) (see above) remained collegial in character throughout the period under examination. The clearest manifestation of this was the creation in 1974 of consensus teams: a means of providing the formal right of veto to a group which possessed it in practice anyway (Harrison, 1982, pp. 379-380). Although the post-1974 Health Authorities had a smaller medical membership than their predecessors, this was more than compensated by the formal involvement of doctors elsewhere in the management structure. It is significant that consultant contracts of employment remained at RHA level, (except in the case of Authorities responsible for undergraduate medical education), and that no attempt to introduce American models of hospital management by clinical 'chiefs of service' was made. (This was considered and rejected by the Bradbeer Report: Central Health Services Council, 1954, pp. 27-30). Indeed, hospital beds were allocated to individual hospital consultants in a form of quasi-ownership, giving the individual virtually unilateral control over their use and utilisation. Moreover, the right to engage in private practice, a major source of uncertainty for managers, was retained, and indeed was enhanced in 1980 (British Medical Journal, 15 September, 1979, p. 685).
A second way of illustrating the adherence of successive governments to the notion of clinical freedom is to examine the content of official policy documents; at all periods in the history of the NHS such documents have made explicit references either to the notion itself, or to a model of management which, it is made clear, centres upon providing facilities for professionals. Such references indeed predate the creation of the Service; the 1944 Coalition government White Paper on a National Health Service stated that 'whatever the organisation, the doctors taking part must remain free to direct their clinical knowledge and personal skill for the benefit of their patients in the way in which they feel to be best' (Ministry of Health, 1944, p. 26). These sentiments were on several occasions echoed by Aneurin Bevan, Minister of Health from 1945 to 1951: (see quotations in Allsop, 1984, p. 17 and Watkin, 1975, p. 139). If such a view underpinned the creation of the NHS, it also underpinned its first reorganisation; the Grossman Green Paper (see above) set out a fundamental principle that 'the Service should provide full clinical freedom to the doctors working in it' (DHSS, 1970, p. 1; see also Allsop, 1984, p. 29). The Secretary of State's foreword to the Conservative White Paper which set out the firm plans for Reorganisation assured the reader that
The organisational changes will not affect the professional relationship between individual patients and individual professional workers on which the complex of health services is so largely built. The professional workers will retain their clinical freedom -governed as it is by the bounds of professional knowledge and ethics and by the resources that are available - to do as they think best for their patients. This freedom is cherished by the professions and accepted by the Government. It is a safeguard for patients today and an insurance for future improvements (DHSS, 1972a, p. vii).
The subsequent Grey Book (see above) went further in linking management to medicine:
.... the objective in reorganising the NHS is to enable health care to be improved. Success in achieving this objective depends primarily on the people in the health care professions who prevent, diagnose and treat disease. Management plays only a subsidiary part, but the way in which the Service is organised and the processes used in directing resources can help or hinder the people who play the primary part (DHSS, 1972b, p. 9).
Nor had the philosophy for what was to become the 1982 reorganisation changed much; Patients First had the following to say:
It is doctors, dentists and nurses and their colleagues in the other health professions who provide the care and cure of patients and promote the health of the people. It is the purpose of management to support them in giving that service (DHSS and Welsh Office, 1979, pp. 1-2).
Such quotations are, of course, selective. The same documents also make references to such matters as the need for efficiency, but what is striking is that they are careful never to imply that doctors might need to become more efficient; the inference is rather that it is other, unspecified, groups which need to be controlled in order to maximise resources for medical care. Thus the above quotation from Patients First continues: 'The efficient management of the Service is therefore of the highest importance, not least when resources are tight. The more economical it can be, the more resources there will be for patient care' (DHSS and Welsh Office, 1979, p. 3). It is also true that some of the above documents acknowledge that resources are limited and that priorities need to be established. But here again, there is no challenge to medical autonomy; rather, it is assumed that agreed priorities will somehow emerge from discussions. Thus the Grey Book speaks of mechanisms by which doctors can 'contribute more effectively to ... decision making' (DHSS, 1972b, p. 10), whilst Patients First refers to machinery to ensure that the doctor's voice is fully heard' (DHSS and Welsh Office, 1979, p. 17).
A third way of demonstrating the lack of a managerial challenge to doctors is to look at management practice as revealed in the extensive contemporary empirical research literature. It is clear from this that policymakers and managers were not the most influential actors within health authorities. A number of case studies have instanced the influence of hospital Consultants on specific decisions. Kogan's research for the Royal Commission on the NHS documented the case of a decision to transfer the responsibility for biomedical engineering to the Works Officer, twice overturned as a result of medical objections (Kogan et al, 1978, p. 129 ff). This ability to veto change was capable of persisting over long periods; Rathwell has shown how, in one health authority, attempts to settle the number and distribution of hospital beds for the elderly remained unsuccessful, as a result of medical disagreements, over a period of four years. Even a severe winter, and consequent admissions crisis did not aid resolution, which had still not been achieved at the conclusion of the research (1987, Chap 4). In another study, Linstead has shown how Consultant physicians, on this occasion in alliance with another professional group, were able to veto proposed changes in training arrangements for hospital technicians (1984, p. 11). A further example of the obstructive ability of the medical profession is provided in Forte's (1986, p. 43) case study of one district; clinicians were able to delay the implementation of the whole operational plan by withdrawing their earlier agreement to acute service 'rationalisations'. The ability of doctors to impose their definition of a particular situation upon others has been well illustrated by Ham's example of proposed alterations to bed allocations between hospitals being seen as a lack of suitable case material for medical teaching rather than as a need to provide a good service for the elderly (Ham, 1981, pp. 147-149).
Perhaps more important than such single instances are findings which show the influence of the medical profession on the strategic shape of services delivered by the NHS. Haywood and Alaszewski (1980, pp. 104-106) have examined the pattern of inputs to, and outputs from, the NHS during the 1970s, showing that whilst real resources available (staff, money) rose considerably, output in terms of the number of cases treated (as inpatients or outpatients) rose much more modestly. Although this discrepancy is to some extent due to improvements in staff conditions of employment, the major explanation is increased intensity of diagnosis and treatment, a conclusion confirmed by increases in the workload of pathology, radiology and physiotherapy departments, and by the rising ratio of total attendances to new outpatients. This can be seen as implying a decision, not taken by politicians or managers but by individual clinicians, to devote the majority of additional resources to greater intensity of care rather than to treating larger numbers of patients. That is, the decisions which underlie these aggregates are individual clinicians' decisions about admission, diagnosis, therapy, and discharge. (It should be appreciated, of course, that these conclusions involve no judgement about the value or otherwise of such trends.) These observations, together with an analysis of failures to implement national priorities, also led the authors to comment that 'the power of [central government] to effect change is limited, even when only a modest change in emphasis is envisaged' (p. 61), a conclusion supported in Stocking's study of the pattern of introduction of day case surgery (1985, pp. 223-228).
This strategic influence of the medical profession can also be discerned in the arrangements for the education and supply of professional manpower, a crucial resource for the NHS. Harrison's study of this area concluded that the arrangements were to varying degrees dominated by professional organisations rather than by managers or even by DHSS. Underneath a complex surface pattern of many official and professional bodies was, however, a dominant medical influence; 'the whole mechanism is not nearly as pluralistic as the mere listing of the bodies involved may convey; not only is the medical profession dominant within most of them, but the same sections of the profession ... are represented within many' (Harrison, 1981, p. 94). Kogan et al (1978, p. 174) have pointed out that decisions by bodies such as the Royal Colleges can result in the non-recognition of hospital training posts which in turn can result in hospital closure.
Conclusions about strategic medical influence are also supported by research into the management and policy process in specific NHS Regions. Elcock and Haywood (1980, pp. 77, 97) note that 'in both Regions, the medical profession fought vigorously against changes in priorities intended to favour the [official priority groups of patients] at the expense of the acute sector.' Nor do such conclusions relate solely to the post-reorganisation period. Ham's historical study concluded that legal and financial controls were not an effective means of securing change; 'the capacity of the central [government] department to ensure that its policies were implemented was limited' even though 'its style became more promotional and interventionist as the 1960s progressed' (Ham, 1981, pp. 191-192). Stocking's 1985 study of such longstanding central priorities as Regional Secure Units and the revision of waking times for hospital inpatients confirms this conclusion.
How far are such conclusions supported by evidence about the perceptions of NHS managers? In an interview study of eighteen management teams, Schulz and Harrison found that
on twelve...teams...there was overwhelming agreement that consultants had the primary influence on the pattern of health care delivery in the area. Only two teams ascribed the primary influence to themselves, with the remaining four ... either divided on the issue or ascribing equal influence' (Schulz and Harrison, 1983, p. 33).
The same respondents reported that RHAs and DHSS were relatively uninfluential (pp. 30-33). These perceptions were replicated in another interview study of administrators, medical and nursing officers, who were 'particularly aware of the power consultants had to cause and prevent change. They saw the individual professional largely in control' (Glennerster et al, 1983, p. 260).
The chairpersons and members of health authorities were no more influential, either individually or collectively, than the managers they employed. For instance Brown et al (1975, pp. 11-14) found that managers gave the authority members very little information about ongoing issues about which there were disagreements. Haywood's initial study of six DHAs concluded that 'in general, there were few decisions influenced by members' (Haywood, 1983, p. 44), a finding confirmed in a follow-up study which also indicated that, within HA membership, chairpersons were relatively influential (Haywood and Ranade, 1985). These findings have been confirmed by Ham; the general lack of member influence on policy was partly the result of medical influence manifest through 'creeping development in acute specialties' (1986, pp. 123-126). Scottish members similarly lacked influence on resource allocation (Hunter, 1980, p. 198); one respondent perhaps summed it all up when he said 'as far as I can see, the health board is a rubber stamp' (Hunter, 1984, p. 50). Managers interviewed by Glennerster et al (1983, p. 261) and Schulz and Harrison (1983, p. 30) confirmed these assessments of member weakness.
If managers were not pre-eminently powerful, they were not predominantly proactive either. The process of planning is where, perhaps, one might most expect to find proactive behaviour; studies of NHS planning show that this was rarely possible. For instance, Barnard et al (1979, Vol 3, p. 16) document the way in which a London health authority's attempts to assess the health care needs of its population were rapidly abandoned in order to produce 'defensive' information to demonstrate the perceived unfairness to the authority of the RAWP formula. The northern health district studied by Forte (1986, pp. 24-25) experienced similar difficulty in sustaining proactive behaviour. In Scotland, Hunter found '... plans thwarted by the flare-up of a crisis, such as occurred in both [health boards where fieldwork was conducted] over nursing staff establishments' (1980, p. 151), whilst even within the Scottish Home and Health Department planning was reactive and ad hoc (Wiseman, 1979, pp. 106-107).
It might also be expected that proactive behaviour would be found in the activities of chief officers of health authorities, and the management teams of which they were members. In their study of District Administrators, Stewart et al (1980, p. 76) note, however, that few were able to play the more proactive roles of shaping plans, innovating new practices or of managing the total organisation; rather the evidence (pp. 149-171) of how the research subjects spent their days shows little sign of interest in strategic issues but a preoccupation with ad hoc referrals of issues. Nor was the content of management team agendas any different; Schulz and Harrison (1983, p. 37) note that a major item of team work was 'tackling of issues which in some way presented themselves as problems to the team or its members'. Hay wood's systematic classification of the agenda items of several management teams shows the prevalence of non-strategic items (Haywood, 1979, pp. 54, 57); 90% of items consist of information exchange, deciding to whom issues should be referred ('process'), or routine decision-making. Yet the teams were created in order to take 'decisions for the totality of health care' (DHSS, 1972b, p. 15). Haywood summarises by describing chief officers as 'directors of process.... reactors rather than initiators ....' (1979, p. 59).
If top managers were reactive, it is hardly surprising that their subordinates perceived their own jobs in the same way. Harrison, Haywood and Fussell took a population of upper-middle NHS managers all attending university continuing education courses (and perhaps therefore to be expected to be more textbook-oriented than the average) and gave them a free choice of how to make a written characterisation of their own job roles. The respondents overwhelmingly chose to typify their jobs as tackling problems referred to them by other actors who had expressed some dissatisfaction; the main consideration was to satisfy the complaint without creating further dissatisfaction elsewhere (Harrison, Haywood and Fussell, 1984, p. 186).
It is not surprising, therefore, that managers and doctors were rarely in conflict (Green, 1975). Moreover, studies of managers' behaviour indicate that their problem-solving efforts were strongly focused within the organisation rather than outwards. Stewart et al (1980, pp. 172-7) traced all the issues with which District Administrators dealt over a three-day period, almost none of which did not originate within the health authority. Similarly, all the examples of decisions quoted in Hay wood's study (1979, pp. 57-8) are internal in origin. The Howe Report into the scandal at Ely Hospital had shown a closed community with no awareness of standards elsewhere and an inbuilt resistance to complaints (Committee of Enquiry, 1969, p. 115 ff) (and this was not the first or last such scandal), so that Thompson's comment from a study conducted in the early 1980s is apposite:
One of the more sobering features of the study was an apparent lack of interest in consumer responses, even the relevance and significance of patients' complaints (Thompson, 1986, p. 57).
The same kind of introversion is evident in the responses to the study by Harrison, Haywood and Fussell; administrators' agendas were largely defined by other actors within the health authority, whilst the nurses' agendas seemed dominated by problems of organisational formalities. The authors concluded that:
the...study suggests...that the typical dissatisfactions which NHS managers perceive as problems are related not to formal organisational objectives as set out in statute, nor...to the kind... (such as quality, access, acceptability and equality) suggested by the Royal Commission on the National Health Service, but to organisational process and internal relationships... The material counsels against any expectations of logical or causal links between formal organisational objectives, managers' perceptions, and managerial action (Harrison, Haywood and Fussell, 1984, p. 1987).
The preceding few pages have shown NHS management in the 1950s, 1960s and 1970s as it both was and was supposed to be. Managers were, and rightly so, 'diplomats' (Harrison, 1988a, p. 51). Rather than being responsible for shaping and controlling the service, they were engaged in
... a process concerned to conciliate, in as coordinated a fashion as possible, all the sub-groups within an organisation (Harrison and Hallas, 1979a, p. I486)... In the context of diplomacy there is rarely a meaningful overall objective; more often there is a set of partially, or sometimes completely, contradictory objectives held by groups or individuals (1979b, p. 1523).
The other dominant assumption about management in the period, it will be recalled, was that improvements would come from changes in inputs to the management process, particularly changes in organisational structure and in training provision; this view was not, of course, peculiar to the NHS and, for instance, underpins the Fulton Report (Committee on the Civil Service, 1968). Better management career structures were seen as the answer to the problem, almost irrespective of what the problem was. Indeed, in the extreme case the absence of managerial careers was seen as the problem; the Salmon Report took it as axiomatic that nurses' status was too low, and all its proposals flowed from this (Ministry of Health and Scottish Home and Health Department, 1966, p. 7). Increasing managerial specialisation (see above) was another manifestation of the same assumption, as was the increased attention paid to training and education of managers (see, for instance, King's Fund Working Party, 1977).
Claims for managerial roles and equality of status with administrators therefore became the strategy by which the health professions other than medicine sought to advance themselves;
each professional group - which was of course heavily represented on the working party concerned with its particular specialty - was naturally ready to welcome a form of organisation which provided more numerous and more lucrative opportunities of promotion for its members (Watkin, 1975, p. 349).
Both the Royal Commission (1979, p. 29) and, more critically, Brown (1979, p. 31) agreed that consensus management teams were both a reflection and a cause of such professional aspirations to managerial autonomy.
Of course, these claims did not go entirely without challenge; the content of the Farquharson-Lang and Institute of Hospital Administrators Reports has already been discussed. But as the 1974 reorganisation approached, such formal opposition became more muted and disappeared. Its last vestige may be found in Naylor's influential study of the possible forms of new organisation; having dismissed the possibility of management control over clinicians, he continues:
....could the remainder of the health professions and all the other groups of workers be subordinated to one director? ....the answer is probably in the affirmative [though]....as the strength of the other health professions grows nearer to the doctors, there may be pressure for equality of status (Naylor, 1971, p. 33).
This concern with managerial inputs coincided with the aspirations of various occupational groups; the professions other than medicine can in particular be seen to have derived considerable benefits. The corollary of concern with inputs is a lack of concern with outputs, that is, a lack of evaluation. Such a lack of evaluation is very much evident in the empirical studies of NHS management to which reference has already been made. For instance, studies of planning show a strong emphasis on hospital beds; thus Rathwell (1987, Chapter 4) has shown how planning for the elderly in one authority was largely confined to beds, notwithstanding the existence of official priority for community care. (In the same study, planning for the mentally handicapped, where no beds existed, was not so constrained.) Similarly Ham (1981, p. 147) has shown how in another city the problem of the elderly were perceived as a problem of 'bed blocking', and Glennerster et al (1983, p. 261) have shown the importance with which national norms were treated. Planning options also showed a strong emphasis on what Brown et al termed 'shopping lists of deficiencies' in existing services:
When the.... district teams submitted their.... priorities for long-term development... .over half concerned the development of primary care ....[but] when it came to concrete proposals....'community' projects did not fare quite so well.... They received....their pre-organisation share of-the share-out (Brown et al, 1975, pp. 103-104).
According to Thompson (1986, p. 20), things had not changed by the 1980s. Such ad hoc planning was also to be found in Scotland (Wiseman, 1979), though planning documents sometimes sought to conceal this by the inclusion of large quantities of symbolic information unrelated to actual proposals for change (Schulz and Harrison, 1983, p. 38). Glennerster et al (1983, p. 264) note that most of the respondents in their study 'still thought of planning as what to do with the increment' and also provide an insight into why this should be so; 'in theory, people favoured a change in priorities but only on the basis of "you can do it so long as you don't touch me" ' (p. 260).
A further characteristic of planning options follows closely from this. Hunter (1980, pp. 145, 184) notes that development funds were not merely regarded as important, but for many actors were the answer to planning problems; the tendency was always to seek more resources rather than to question the value of existing resource use, most developments were the result of building schemes, and most also meant 'more of the same'. He goes on to explain:
At best, allocations of [development funds] reflected a compromise between.... simply plugging gaps in existing services and.... initiating new services.... Often there was no choice.... Pressures from existing services presented officers with little or no alternative but to plough more funds into them to relieve the pressures (Hunter, 1980, p. 184, emphasis added).
The same absence of evaluation or review was prevalent in managerial behaviour more generally. The management teams in Schulz and Harrison's study allocated resources incrementally; when asked individually about their objectives, respondents overwhelmingly replied that they were concerned, firstly, to keep existing services intact, and, secondly, to respond if possible to internal demands for expansion. Movement towards national priorities came only in third place (Schulz and Harrison, 1983, p. 37). Nor surprisingly, therefore, Barnard et al (1979, Vol 3, p. 32) found that 'little attention was paid to collecting information on resource use.... or on outcomes'. To some extent, however, the illusion of scrutiny was maintained by such devices as frequent visits to institutions by senior officers, though these were in practice quite un-critical in approach (Schulz and Harrison, 1983, p. 37). In a more recent study Thompson (1986, p. 57) was surprised to observe 'the noticeable absence of any systematic monitoring.... of policy formulation and implementation'.
The same approach to management was manifested in Harrison, Haywood and Fussell's study of upper middle managers; respondents were given the opportunity to choose a problem related to their work, and to state how they would tackle it and what would be a satisfactory solution. The tendency was for responses to ignore the last section of the brief, that is to treat the action taken to attack the problem as being a solution in itself, rather than to suggest criteria by which the results of that action might be judged (1984, p. 186). In the light of this varied evidence, it is difficult to disagree with the conclusion that the managerial changes of the 1970s failed to make NHS decisionmaking less incremental (Brown, 1979, p. 205; Lee and Mills, 1982, p. 179).
It is now possible to summarise the character of NHS management before 1987, that is, before Griffiths. Firstly, rather than conforming to textbook models of authoritative, proactive management (Stewart, 1979, pp. 66-7), the NHS manager was for the most part a diplomat acting to smooth out conflicts and procure resources with which professionals could perform their tasks. It follows that there was relatively little medical-managerial conflict (Green, 1975) and that authors such as Heller (1979, pp. 1, 45) and Petchey (1986, p. 100) are mistaken in asserting that such conflict was a major determinant of the shape of the service. And whilst Klein (1985) is no doubt correct in asserting that doctors and managers had different value systems, there was also considerable overlap and homogeneity (Schulz and Harrison, 1983, p. 44; Brown, 1979, p. 191).
Secondly, despite a certain amount of discontent and frustration amongst managers (Klein, 1984, p. 1708; Stewart et al, 1980, pp. 30, 66, 113; Haywood et al, 1979, pp. 26, 35, 39; Schulz and Harrison, 1983, p. 17; Fairey et al, 1975, pp. 25-6), it was widely understood that the prevailing situation was pragmatically desirable (Naylor, 1971, p. 33; Jaques, 1978, p. 141; Kogan et al, 1978, p. 45 ff). There seems to be little evidence for the inference made by Haywood and Alaszewski (1980, p. 87) that managers suffered from the delusion that they had, or ought to have, decisive control of the service. It is true that there were managers who displayed exceptional behaviour; some were proactive (Stewart et al, 1980, p. 78 ff; Schulz and Harrison, 1983, pp. 40-3; Rathwell, 1987, ch. 4). But these were minority examples.
General management was not the first management initiative to mark a radical departure from the preceding management arrangements. On 22 January 1982, about nine months before the Griffiths Inquiry was commissioned, the Secretary of State for Social Services, Mr Norman Fowler, announced arrangements to 'improve accountability' in the NHS. There were two elements to these arrangements: a review process and a set of performance indicators (PIs).
The review process was intended to secure greater adherence to national policies and priorities than had previously been the case;
... each year Ministers will lead a Departmental review of the long-term plans, objectives and effectiveness of each Region with the Chairmen of the Regional Authorities and Chief Regional Officers. The aims of the new system will be to ensure that each Region is using the resources allocated to it in accordance with the Government's policies - for example giving priority to services for the elderly, the handicapped and the mentally ill - and also to establish agreement ... on the progress and development which the Regions will aim to achieve in the ensuing year (DHSS, 1982a, pp. 1-2).
A similar process was to take place between regional authorities and DHAs within the region. The new process commenced immediately, in January 1982, with a review of the Mersey Region.
Performance Indicators were to be developed on a pilot basis in the Northern Region. To be employed in conjunction with the review process, they would
....enable comparison to be made between districts and so help Ministers and the Regional Chairmen.... to assess the performance of their constituent.... authorities in using manpower and other resources efficiently (DHSS, 1982a, p.2).
Unlike earlier attempts to use comparative data (see, for instance, Yates, 1983), the new indicators were therefore to be compulsory. The first national (English) package of indicators (DHSS, 1983a) was issued on 22 September 1983, in a form which allowed any health authority to be compared with all others in terms both of absolute values of the indicators used and of rankings within the region and the country. The package contained some seventy indicators relating to clinical work, finance, manpower (sic), support services and estate management, all constructed from already available data. The clinical indicators related mainly to the use of clinical facilities within broad specialty groups, rather than to the outcomes of treatment, consisting of such efficiency measures as average length of hospital stay, throughput of patients per bed per annum, turnover interval between cases occupying a bed, and the ratio of return outpatient visits to new outpatients. They were, however, all measures which are largely determined by the aggregate of doctors' behaviour rather than by managers' decisions.
Less than two months after the original review process/ performance indicator announcement, Mr Fowler announced two further initiatives (DHSS, 1982b). Firstly, a national enquiry was established with the aim of 'identify[ing] underused and surplus land and property, and, where appropriate dispos[ing] of it' (p.l). The subsequent Ceri Davies Report (DHSS, 1983b) recommended a system of notional rents for NHS property as the basis of a performance measure of estate utilisation and the disposal of unused and underused assets; it was accepted by the Government in November 1983 (DHSS, 1983c). The other initiative was the experimental use of private firms of accountants to audit the accounts of health authorities (DHSS, 1982b).
Only three weeks from this announcement, on 1 April 1982, came the announcement of yet another initiative: the extension of 'Rayner Scrutinies' from the Civil Services to the NHS. Named after Sir Derek Rayner, Managing Director of Messrs Marks and Spencer and part-time efficiency adviser to Government, such scrutinies involved intensive study of a particular area of expenditure by an officer seconded from normal duties (DHSS, 1982c). The chosen topics were later announced as vacancy advertising, the storage of supplies, catering costs, the cost-effectiveness of meetings, NHS residential property, the recovery of aids loaned to patients, ambulance service control systems, collection of income due to health authorities, and the administration of project briefs for hospital building schemes (DHSS, 1982d).
Further initiatives followed. On 27 August a Review of NHS Audit arrangements was announced; the results, promulgated a year later, emphasised the need for greater attention to be given to 'value for money' rather than to narrow financial propriety (DHSS, 1982e; 1983d). On 7 October 1982 it was announced that a firm of chartered accountants were to study the possibility of cash-limiting Family Practitioner Committee budgets (DHSS, 1982 f). On 19 January 1983 central control of NHS manpower numbers was announced (DHSS, 1983e) and on 4 February came the first public suggestion that the Government was seriously considering restrictions on doctors' rights to prescribe (DHSS, 1983 f); in November 1984 the withdrawal occurred from NHS prescriptions of a range of proprietary drugs which had been previously freely available (DHSS, 1984a). On 8 September 1983, health authorities were instructed to engage in competitive tendering for laundry, domestic, and catering services (DHSS, 1983g), and on 19 December the Minister for Health announced proposals to place restrictions on the use of deputising services by off-duty GPs (DHSS, 1983h).
On 3 February 1983, towards the conclusion of the spate of initiatives outlined
above, a development occurred which was to crystallise and symbolise the post-1982
policy for managing the NHS. The Secretary of State announced that
Four leading businessmen are to conduct an independent management Inquiry into the effective use and management of manpower and related resources in the National Health Service.... we are setting the Inquiry two main tasks; to examine the way in which resources are used and controlled inside the health service, so as to secure the best value for money and the best possible services for the patient [and] to identify what further management issues need pursuing for these important purposes.... Mr Griffiths has not been asked to prepare a report.... we could simply have set up another Royal Commission and then sat back for several years to await its lengthy report, but on past experience that would not lead to effective action. Instead, we have gone straight for management action, with the minimum of fuss or formality (DHSS, 19831).
Mr Roy Griffiths was Deputy Chairman and Managing Director of Messrs J Sainsbury, and his colleagues the Personnel Director of British Telecommunications (Michael Bett), Group Finance Director of United Biscuits (Jim Blyth) and Chairman of Television South West (Sir Brian Bailey, a former NALGO official). The Team's final report, in the form of a twenty-four page letter (NHS Management Inquiry, 1983), was sent to the Secretary of State on 6 October 1983, the full text being made public on 25 October.
The Team's recommendations were baldly stated in eight pages. Firstly, changes within DHSS were proposed: the creation of a Health Services Supervisory Board (chaired by the Secretary of State, and including the Minister for Health, the Permanent Secretary, the Chief Medical Officer, the Chairman [sic] of the NHS Management Board [see below], and two or three non-executive members with general management skills and experience) with strategic responsibility for the objectives and resources of the NHS, and, responsible to it, a full-time, multiprofessional NHS Management Board to oversee implementation of the strategy (NHS Management Inquiry, 1983, p.3). Hence the Management Board would assume all pre-existing NHS management responsibilities located in DHSS, and its members would include some from outside the Civil and Health Services (p.4). Incentives and sanctions in management were held to require attention, and accordingly great stress was placed on the role of a personnel director as a Board member (pp. 4, 7).
Secondly, general managers were proposed for RHA, DHA and Unit levels of organisation; regardless of discipline, such persons were to carry overall management responsibility for achieving the relevant health authority's objectives, and were to have substantial freedom to design local organisational structures. Functionally-based management structures were to be minimised and day-to-day decisions taken at Unit level rather than higher up the organisation (pp. 4-5).
Thirdly, the review process (see above) was to be extended to unit level, and efficiency savings (see above) replaced by 'cost-improvement programmes', aimed at reducing costs without impairing services (pp. 4-5).
Fourthly, clinical doctors were to become more involved in local management. The prime vehicle for this was a proposed system of 'management budgets': the allocation of workload-related budgets to consultants (pp. 6-7). The locus of consultant contracts was, however, to remain unchanged (p. 19). Finally, the Report urged that more attention be paid to patients' and community opinion, expressed through both Community Health Councils and market research methods (p. 9). The Report also spoke approvingly of some of the earlier initiatives such as performance indicators, the disposal of surplus property, Rayner Scrutinies, and annual reviews (pp. 1, 8, 13).
On the same day as the release of the Report, the Secretary of State for Social Services told the House of Commons that the Government welcomed the thrust of the recommendations and accepted those applicable within the DHSS; the remainder were to be the subject of a short period of consultation (DHSS, 1983J). In the event, this period included an investigation by the House of Commons Social Services Committee, whose conclusions were by no means wholly supportive (Social Services Committee, 1984). In general, the comments of medical, nursing and ancillary staff representative organisation were unfavourable (see Harrison, 1988b) whilst those of administrators' and treasurers' organisations were favourable. Unsurprisingly, most comment was directed at the proposal to appoint general managers.
On 4 June 1984, the Secretary of State promulgated the Government's decisions on the Griffiths Report (DHSS, 1984b). Some changes, including those within DHSS and pilot schemes for management budgets, were confirmed as in progress already (p.l), and the principle of individual general managers in place of consensus teams accepted:
....The Management Inquiry Team recommended that the general management function should be clearly vested in one person (at each level) who would take personal responsibility for securing action. We accept this view; and believe that the establishment of a personal and visible responsibility.... is essential to obtain a guaranteed commitment.... for improvement in services.... In reaching this conclusion, we do not undervalue the importance of consensus in a multi-professional organisation like the NHS. But we share the Report's view that consensus, as a management style, will not alone secure effective and timely management action, nor does it necessarily initiate the kind of dynamic approach needed in the health service to ensure the best quality of care and value for money for patients (p.2).
General managers were therefore to be appointed at Regional, District and Unit levels of organisation by the end of 1985; the posts were to be open to NHS managers of all disciplines, to doctors, and to persons from outside the Service. Appointments were to be on the basis of fixed-term contracts of three to five years with renewal for further fixed terms by mutual agreement and, by implication, dependent upon an assessment of the incumbent's performance. Any costs incurred by appointments were to be offset by savings on other management costs (Appendix C).
The Health Services Supervisory Board and the NHS Management Board took a slightly different form from that envisaged in the Griffiths Report. Pressure from the nursing profession led to the early addition of the DHSS Chief Nursing Officer to the Supervisory Board (DHSS, 1984c), and only one non-executive outsider, Mr Griffiths himself, was appointed (Chaplin, 1987, p.2). Mr Victor Paige, formerly Chairman of the Port of London Authority was appointed as Chairman of the NHS Management Board in December 1984 (DHSS, 1984d), but resigned in June 1986 (DHSS, 1986a; Davies, 1986a). A revised arrangement resulted, with Mr Tony Newton, the Minister for Health as Chairman of the Management Board, (by then Sir) Roy Griffiths as Deputy Chairman (with direct access to the Prime Minister), and Mr Len Peach (Personnel Director of Messrs IBM [UK] as Chief Executive (DHSS, 1986b). The composition of the Management Board varied during 1984 to 1987, with roughly one-third of its members from commercial backgrounds, one quarter from the NHS, and the remainder from the Civil Service (Chaplin, 1987, p.2; Health Service Journal, 29 January 1987). The Management and Supervisory Boards remained a part of DHSS rather than separate tiers of management. (For an outline of the then internal organisation of DHSS, see Health Trends, 1986, Vol 18, pp. 32-36.)
General Managers were appointed by RHAs and DHAs and at Units, though subsequent general manager appointments were on rolling, rather than fixed-term contracts, and a system of individual performance review (IPR) and performance-related pay (PRP) were introduced (DHSS, 1986c, 1986d). The Review Process operated at all levels of the service, and was modified to consist at regional level of a management meeting between the NHS Management Board and Officers of each RHA at which progress on plans and cost-improvement programmes is reviewed; this was followed by a ministerial meeting with chairpersons of individual RHAs at which more strategic and long-term issues are discussed, along with major issues arising from the management meeting (Mills, 1987).
Management budgets were not introduced on a widespread basis. Four health districts were chosen as 'demonstration sites' even before the publication of the Griffiths Report, but despite the involvement of management consultants not all of these were successful at the technical level of establishing the necessary information systems. Moreover, they did not gain the widespread support of clinicians (see, for instance, Arthur Young, 1986a; 1986b). A second generation of demonstrations began in 1985; it was intended that this would pay more attention to the behavioural aspects of such systems (DHSS, 1985a). Nevertheless, there remained problems in convincing doctors of the value of the innovation and a further set of pilots proved to be necessary; these were launched in November 1986 under the new rubric of 'resource management' (DHSS, 1986e). (For a review of the various pilots, see Pollitt et al, 1988; Buxton et al, 1989). Figure 2.4 summarises the post-Griffiths structure.
It may be noted that the general context of developments in information technology during the early 1980s met a necessary, though not sufficient, condition of several of these managerial developments. It is hard to imagine, for instance, a system of dispersed management budgets without computerised information (Arthur Young, 1986a, p. 1), whilst the second, computerised, package of performance indicators was much more 'user-friendly' (and hence, likely to be used) than the original manual of typescript tables (Fairey, 1985). The role of such technology in public sector management has been neatly summarised by Pollitt:
Finally, computers: they have played a significant permissive role in the introduction of performance assessment systems. The advent of dispersed, multi-access systems with cheap desk-top VDUs has permitted the storage, rapid retrieval and display of the vast quantities of data that most performance assessment schemes appear to need. Computers obviously didn't produce the wave [of such schemes in the public sector] but they have allowed it to flow more swiftly and to deposit less paper (Pollitt, 1986, p. 160).
General management was radical in two senses. Firstly, it reversed a strong trend towards multidisciplinary management by groups of equals. Multidisciplinary management at hospital level had been introduced in 1948 and subsequently endorsed by Bradbeer. The advocacy of Salmon for such an arrangement to be extended to 'group' level was successful, and the consensus teams introduced in 1974 represented the apotheosis of such a view. The fortunes of the occupations other than administration, nursing and medicine were more variable over time, initially prospering through reports such as Noel Hall and Halsbury (see above), and through the 1974 Reorganisation, but later losing a little ground as a result of the 1982 Reorganisation's suspicion of District-level 'functional' management.
Moreover, the reversal was a sudden one. Patients First, the policy document which underpinned the 1982 Reorganisation was unequivocal about the desirability of team management:
The Government has rejected the proposition that each authority should appoint a chief executive responsible for all the authority's staff. It believes that such an appointment would not be compatible with the professional independence required by the wide range of staff employed in the Service. Instead, each authority should appoint a team.... (DHSS and Welsh Office, 1979, p. 7).
And despite Griffiths' truism that a general manager would need 'to harness the best of the consensus management approach and avoid the worst ...' (NHS Management Inquiry, 1983, p. 17), the reversal was real. It was the general manager with whom the buck (whatever one of those is!) was intended to stop. Early decisions were taken to place them on limited-term contracts and to open the posts to persons of any occupational background. Subsequently, management development schemes (NHS Training Authority, 1986, p. 2) and career structures (Owens and Glennerster, 1990, p. 103) were built in such a way as to institutionalise a new and virtually exclusive route to the top: through general management rather than through a profession.
In particular, the introduction of general management constituted the first major and systematic threat to clinical freedom, a doctrine which, as has been shown, pervaded the NHS from even before its inception. The abolition of consensus decision-making teams entailed the abolition of a formal medical veto. Clinical performance indicators reflect the way in which hospital consultants manage their beds and their workload and therefore allows this limited aspect of their performance to be visible to others (Shortell et al, 1976). Direct management access to consumer and community opinion (through market surveys, for instance) represents a challenge to the widespread assumption that only doctors may legitimately speak on behalf of patients or be aware of their needs. Systems of management budgets could, if managers chose and if measures of casemix severity were introduced, be used as a vehicle for imposing management priorities on clinicians and for controlling the costs of each type of case (Harrison, 1986, pp. 8-9).
In these ways, the potential for greater managerial control over doctors was created: the potential
to move from a system that is based on the mobilisation of consent to one based on the management of conflict - from one that has conceded the right of groups to veto change to one that gives the managers the right to override objections (Day and Klein, 1983, p. 1813).
Thus the Griffiths and related reforms set out to challenge forty years of professional domination of the NHS (Petchey, 1986, p. 100), though it was not to be expected that members of the government would put it in such blunt terms. In opening the House of Commons debate on the Griffiths Report, the Secretary of State said
Of course doctors and nurses will continue to make their own decisions about how they treat their patients. But equally it would be foolish to deny that there are practical constraints imposed on consultants in a world of necessarily limited resources (House of Commons Debates, 4 May 1984, Col. 649).
The truism that clinical freedom cannot be absolute serves to obscure the fact that it may have degrees.
The medical profession itself certainly saw general management as a threat. The immediate response of the British Medical Association (BMA) to the publication of the Griffiths Report was to complain at the perceived lack of time for consultation, to challenge the concept of a non-medical general manager, to demand the retention of District Management Teams, and to seek the provision of an appeals mechanism against managers' decisions (British Medical Journal, Vol. 287, 1983, pp. 1321-1322, 1643, 1811). It also sought, in place of the general manager proposed by Griffiths, the election from within existing teams of a Chairman [sic], and a trial period for any changes adopted (Social Services Committee, 1984, pp. 1-13; British Medical Journal, Vol. 288, 1984, p. 84). It was further argued that management at the unit level of organisation was best left to doctors, and that the proposed Supervisory and Management Boards should include clinicians. (The results of these protestations will be examined in Chapter 3.)
The second sense in which general management was radical was that it definitively broke the old assumption (which had been under some strain since 1979: Webb and Wistow, 1985, pp. 210-15; Klein, 1985, p. 197) that better inputs to management produced better management. The introduction of short-term managerial contracts, together with the paraphernalia of review and incentives constituted a new focus on results, rather than inputs.
General management, then, was radical in that it represented a major break with past practice. But it was not a novel idea in relation to the NHS. It had been practised to some extent between 1948 and 1974 in the office of the local authority MOH, though without the use of the title of general manager or chief executive. But the creation of the NHS had already eroded it, and further erosion took place as a result of the Mayston Report (the local government equivalent of the Salmon Report) even before the role was abolished in 1974.
The hospitals had never had a chief executive officer or general manager since the creation of the NHS, despite the existence of the Group Secretary (see above) and the persistence for some years in some places of the role of hospital Medical Superintendent. But, as has been noted above, the proposal was made seriously on two occasions: once from official sources and once from the Administrators' pressure group (the then IHA) in conjunction with an academic foundation. The official source, the Farquharson-Lang Report suffered the suppression in England of its references to the desirability of a chief executive officer. That such ideas were out of kilter with the times was recognised by two of the architects of the 1974 Reorganisation:
It is not possible to have a 'managing director' ... clinical doctors could not be made subordinate ... (Naylor, 1971, p. 33).
No such solution is realistically available (Jaques, 1978, p. 141).
The authors of the IHA Report recognised this too, but were more optimistic that the climate of opinion might change:
We also understand that it will take some time for the medical profession to consider our suggestion ... Nevertheless we think that the logic of our argument ... will prevail in the end (Joint Working Party, 1967a, p. 42).
This chapter presents, as far as possible without interpretation, data related to the formal adoption of general management as government policy in June 1984. As noted in Chapter 1, the policy's immediate origins were in the Government's decision in October 1982 to establish what subsequently became the Griffiths Inquiry into NHS management. This earlier decision needs to be examined in its wider context, and for this reason the organisation of the first several sections of this chapter are thematic: demand for health care resources, the economic (i.e. supply) context, and the political context. Obviously these are not wholly discrete.
From October 1982 onwards, the account is more closely concerned with specific events close to the NHS, and is therefore presented chronologically.
The two main contextual variables which are held to imply increasing demand for health care resources in the U.K. are demographic change, and developments in health care (in practice, medical) technology. The term 'imply' is used advisedly; in order to form part of any plausible explanation for government policy, such variables would have to be shown to have been recognised by policymakers. In the case of each variable, relevant trend data are presented, followed by evidence of their political recognition at the appropriate time.
Although the U.K. population has now grown continuously for almost two centuries, growth has been relatively slow in recent years as a result of what appears to be a long term decline in the birth rate. Coupled with increased life expectancy, this has produced a population in which increasing proportions are in the older age groups (Central Statistical Office, 1983; DHSS, 1987).
The point was readily conceded by NHS policy makers (see also Fowler, 1991, pp. 165-6):
In fact the 1980 public expenditure white paper, the first produced by the new Conservative government contained a table of estimated current NHS expenditure per capita by age group , and a statement implying that a calculation of the cost of demographic change had been made (HM Treasury, 1980, p. 105) though without stating an explicit figure. Nevertheless, a table of the increasing numbers of the elderly through to 1984 was included. It is clear from this that in 1980 the government knew that it faced a rapidly increasing resource demand from this source.
Table 3.3
|
Persons Aged 75 years and Over UK (Millions)
|
||
| Year | Total UK Population | Persons Aged 75 years and Over |
| 1981 | 56.4 | 3.3 |
| 1991 | 57.5 | 4.0 |
| 2001 | 59.4 | 4.4 |
| 2011 | 59.4 | 4.4 |
Source: Social Trends no 18 (1988) Table 1.2
This situation has changed little since the early 1980s. Table 3.3 shows that it will be the turn of the century before demand abates. Little change has occurred in relative per capita expenditure between age groups (H.M. Treasury, 1991), though the disaggregation of the 85 year and above age group means that the apparent 21st century plateau of Table 3.3 continues to imply increasing demand. Table 3.4 shows the official cost estimates throughout the 1980s and into the 1990s.
Table 3.4
| Demographic Change: Required Increase in Total NHS Funding over Previous Year | |
| Year | Percentage |
| 1980/1 | 1.1 |
| 1981/2 | 0.4 |
| 1982/3 | 0.4 |
| 1983/4 | 0.5 |
| 1984/5 | 0.6 |
| 1985/6 | 1.3 |
| 1986/7 | 0.9 |
| 1987/8 | 1.4 |
| 1988/9 | 1.0 |
| 1990/1 (est) | 0.8 |
| 1991/2 (est) | 0.6 |
Source: Public Expenditure White Papers for relevant years
The second source of implied demand for additional health care resources is technological development. This includes not just equipment and drugs, but techniques of diagnosis, therapy and care more generally (Stocking, 1985, p. 5). The pressures for the utilisation of whatever new technologies are developed is very much an international phenomenon (Aaron and Schwartz, 1984) and not easy for governments to control:
innovations may have diffused readily because there was no need to define explicitly the uses to which staff and equipment were being put. For example, neural tube defect screening [that is, for spina bifida] with its various components of blood tests, amniocentesis, counselling, and abortion is costly. However, it seems to have been able to diffuse relatively rapidly because in its initial stages in any particular locality, no new equipment or funds needed to be requested. It is only as the service builds up that it becomes necessary to ask for additional laboratory equipment, etc (Stocking, 1985, pp. 67-68).
Indeed, the working party responsible for producing the booklet Expensive Medical Techniques was able to go so far as to develop a typology of strategies by which such technological 'cuckoos' turned up in the health authority 'nest' (Council for Science and Society, 1982, pp. 18-21). Moreover, the expectations of the public can generate quite high expectations of technological availability (Stocking, 1985, p. 48).
Such technology tends to be both expensive in itself and rarely labour-saving, so that its diffusion places considerable pressure on government. It includes new developments in care (including social care) just as much as it includes high technology (Klein, 1989, p. 182). At the same time, however, UK governments have often seemed to wish to take a degree of political credit for keeping up with new developments (see, for instance, DHSS, 1979c; 1983k) and have therefore had to acknowledge them as a legitimate source of demand:
[if unit costs rise] it is in fact a product of advancing medical technology and advancing systems of care which enables that to happen (Mr Patrick Jenkin; Social Services Committee, 1980, p. 105).
The cost implications of both the ageing population and of technological developments were comprehensively recognised in the DHSS publication Health Care and its Costs in 1983 (DHSS, 1983k), since when the government has continued to accept both as pressures which must be accommodated within spending plans. (Demography costs are shown in Table 3.4; technology costs are assumed to be a convenient one-half percent of revenue in real terms per annum.)
The Conservatives entered office in May 1979 with a commitment to honour the awards made by the (Clegg) Standing Commission on Pay Comparability, two of whose reports related to NHS staff. These reports were not completed until after the election (Standing Commission on Pay Comparability, 1979; 1980). Even after a contribution by health authorities (which an incoming Labour government would also have required) the cost was some £360 million in cash (Social Services Committee, 1980, p. 20).
Yet the Conservatives had also come to office with a commitment to control inflation as the prime item in their manifesto, as well as with a commitment to achieve such control by control of the money supply. In addition, and linked in an obscure and uncertain way to the control of inflation (Allsopp and Mayes, 1985, pp. 424, 433-5), public expenditure was to be controlled:
To master inflation, proper monetary discipline is essential, with publicly stated targets for the rate of growth of the money supply. At the same time, a gradual reduction in the size of the Government's borrowing requirement is also vital. ( ...).
The State takes too much of the nation's income; its share must be steadily reduced. When it spends and borrows too much, taxes, interest rates, prices and unemployment rise so that in the long run there is less wealth with which to improve our standard of living and our social services (Conservative Party, 1979, p. 8).
This mixture of monetarist and supply-side economics was to take precedence over welfare state expenditure: as the first Secretary of State for Social Services under the new government put it
a sound and thriving economy must be the foundation of all welfare provisions (Mr Patrick Jenkin; DHSS, 1979b).
no-one stands to gain more from a strengthening of the economy and the resumption of growth than the people whom my programmes are intended to serve; because it is only in that way that we will get the increasing resources which are necessary to pay for the services which we provide (Mr Patrick Jenkin; Social Services Committee, 1980, p. 85).
The operational policy for this macroeconomic stance, the Medium Term Financial Strategy (MTFS), launched on 26 March 1980 (Smith, 1987, p. 91). As envisaged in the Manifesto (see above), the MTFS had two elements, the first of which, control of the money supply (Sterling M3) is outside the scope of this study. The second element was a fiscal strategy of restricting the public sector borrowing requirement (PSBR) to a reducing proportion of gross domestic product (GDP) (Jackson, 1985, pp. 51-5).
Table 3.5 (not reproduced) summarises the government's intentions and the eventual outcomes.
It is evident from the Table that the Government experienced difficulty in making forecasts (hence the difference between columns 2 and 3); this was largely due to inaccurate forecasting of unemployment, and hence of benefits payments (Jackson 1985, p. 53). Hence the progress planned in the 1980 budget was not made (cf columns 2 and 6). The greatest difficulty was experienced, as it transpired, over the period 1980 to 1981, when (see column 5) the absolute GDP was falling. In spite of all this, fiscal policy was extremely tight and the objective of reducing PSBR as a percentage of GDP was eventually met (column 6), even though the original targets were not. Given that the 1981-82 improved figures (columns 5 and 6) would not have been evident before quite late in 1982, the situation in late 1981 and early 1982 would have looked unpromising to policymakers (Thain, 1985, p. 275; Holmes, 1985, p. 108). (The fiscal strategy of the MTFS was subsequently weakened to aim for a constant ratio of Public Expenditure to GDP and, after 1990 further weakened to the achievement of stability over the medium term. By the late 1980s the PSBR no longer existed and public expenditure was at its lowest as a proportion of GDP [Thain and Wright 1992, pp. 198-9]; by 1990 the PSBR had reappeared and by 1992 was regarded once again as a serious problem.)
Table 3.6
| Shares of UK Government Expenditure 1979/1992 - % of General Government Expenditure | |||||
| 1979/80 | 1984/5 | 1989/90 | 1990/1 | 1991/2(est) | |
| Social Security | 25.9 | 30.2 | 29.7 | 30.1 | 31.7 |
| Health | 12.1 | 12.7 | 13.8 | 14.2 | 14.4 |
| Education and Science | 14.5 | 13.3 | 14.6 | 14.5 | 14.2 |
| Defence | 11.9 | 13.0 | 11.7 | 11.2 | 10.5 |
| Law & Order | 4.1 | 4.7 | 5.6 | 5.8 | 5.9 |
| Housing | 7.3 | 3.5 | 2.9 | 2.5 | 2.7 |
Source: derived from The Guardian 12 March 1992
In principle, of course, none of this need necessarily affect the allocation of financial resources to the NHS; expenditure could be curtailed elsewhere in the public sector. Indeed, this has to some extent occurred, as Table 3.6 makes clear. However, the predominance of social security expenditure (most of which is not cash limited) in accounting for one-quarter to one-third of all public expenditure, and the presence of health as the next largest programme (Guardian, 12 March 1992) made it difficult for health ministers to hold out indefinitely against the Treasury:
the Government is determined to stand by its economic policy. This means that health authorities' cash limits will not be increased this year for the effect of excess price inflation (Mr Patrick Jenkin, 1979, emphasis original).
every nation must adjust to the economic realities of the time the National Health Service is not immune from these realities .... That is why the NHS had to make its contribution to the exercise which the Government undertook [the 'Lawson' cuts] to bring public expenditure as a whole back to the course which we had planned for it (Mr Norman Fowler, 1983).
Indeed by the end of the 1981/82 financial year, the health programme was the only one of the largest four government programmes that had suffered only minor cuts in planned expenditure (see Thain and Wright, 1991, p. 19).
This section considers, in separate subsections, public opinion, parliamentary activity, pressure group activity, and executive (government) activity in the years up to 1982.
In considering the impact of public opinion upon government behaviour towards the NHS, it is convenient to separate opinions about the NHS in general from those about specific places: doctors, bureaucrats, and trade unionists. The evidence cited in this section is derived entirely from opinion polls (and is therefore subject to all the criticisms of polling as a technique: see Taylor-Gooby, 1985a, p. 74 ff), but does not attempt to give a complete review of relevant findings. Moreover, it has not been possible to show that ministers were aware of these specific findings, though they were certainly aware of the general trends indicated. (The Conservative Party conducts private polls, but the results of these remain confidential for some fifteen years after collection of the data.) For these reasons, this evidence is strongly suggestive rather than wholly conclusive. However, there is no shortage of evidence that Secretaries of State for Health in general (Guardian, 20 February 1989, p. 19; 5 July 1989, p. 24) or Mr Norman Fowler in particular (Fowler, 1991, p. 145) habitually concern themselves with opinion poll findings. (The latter point was confirmed by several respondents to the present study.)
Very general poll questions about the popularity or importance of the NHS tend to produce evidence of massive public support; for instance, Taylor-Gooby (1985b, p. 76) cites a 1984 poll in which 93 percent of respondents considered the continuation of the Service to be 'very important'. Such general evidence can be objected to, on the grounds both that it takes no account of public opinion about taxation, and that it merely taps attitudes concerning the broad notion of a health service, rather than respondents' concrete experiences with the NHS.
Nevertheless, poll questions concerning NHS finances have also produced responses strongly in favour of additional financial resources for the Service. The British Election Surveys for 1974 and 1979 show, respectively, 84 percent and 87 percent of respondents saying it to be 'very important' or 'fairly important' that more money be provided to the NHS (Sarlvik and Crewe, 1983). Similarly, MORI polls throughout the two decades up to show increasing proportions of respondents (70 percent by 1980) considering 'too little' to be spent on the NHS (New Society, 4 December 1980, pp. 464-465),a finding confirmed in Gallup Polls (Webb and Wybrow, 1981, p. 50).The trend continued after 1980 (Economist, 8 October 1983, pp. 18-21), and more recent Marplan polls confirm the implication (unsurprising in respect of health services free at the point of delivery) that extra funds should be derived from additional taxation or fromadjustments in government priorities rather than from increased charges (Davies, 1987, p. 382; Elmore, 1989, p. 122). Finally, Taylor-Gooby's survey of the Medway area seems to confirm the universalistic principle of the NHS, with 66 percent of respondents saying that services should not be restricted on grounds of income (Taylor-Gooby, 1985b, pp. 30-31).
Predictably, poll questions which focus on the public's actual experiences of the NHS do show some dissatisfactions and specific complaints. Nevertheless, a survey conducted on behalf of the Royal Commission on the National Health Service showed that over 80 percent of inpatients thought the service 'good' or 'very good' (Royal Commission, 1979, p. 13), findings subsequently confirmed in a series of polls conducted on behalf of the National Association of Health Authorities (Halpern, 1985a; 1986; Davies 1987a). Reviewing the decade's opinion polls subsequently, Solomon concluded that 'Feelings of dissatisfaction with the running of the NHS itself as a political institution are far more widespread than discontent with specific services' (Solomon, 1992, p. 76).
In comparison with other occupations, health professionals (doctors and nurses) are held in high public esteem; Table 3.7 summarises the findings of three relevant MORI polls. In the earliest (1980), doctors are easily the most highly rated (in terms of ethics) of a list of occupations, whilst in the second (1987) they are only narrowly beaten as a result of the addition of the clergy to the list of occupations. In the third (1987), it is the addition of nurses which once more leaves the medical profession narrowly in second place. Since these polls do not ask identical questions or provide identical lists of occupations (no such comparable data are available), they cannot be interpreted as a trend, but they do serve to illustrate the high level of public popularity enjoyed by doctors and nurses. Despite this high level of relative popularity, however, there are some suggestions that public confidence in the medical profession has weakened slightly since the 1960s as a result of greater public exposures to the reports of 'scandals' (Pollitt, 1984), or simply as part of more critical public attitudes towards authority (Harrison, Haywood and Fussell, 1984).
Table 3.7 Public Opinion and Health Professionals
| February 1980: How would you rate the honesty and ethical standards of the people in these different jobs? Would you say they were high, average or low? (%) | ||||
| High | Average | Low | Don't Know | |
| Doctors | 73 | 21 | 3 | 3 |
| Members of Parliament | 17 | 49 | 25 | 10 |
| Police Officers | 51 | 38 | 7 | 4 |
| Trade Union leaders | 10 | 33 | 46 | 11 |
| Business Executives | 17 | 49 | 19 | 15 |
| Local Councillors | 16 | 50 | 54 | 10 |
| Solicitors | 49 | 33 | 7 | 11 |
Source: MORI, Commissioned by Sunday Times
| December 1983: For each (of the following types of people) would you tell me whether you generally trust them to tell the truth or not? (%) | |||
| Tell Truth | Do Not | Don't Know | |
| Business Leaders | 25 | 65 | 10 |
| Clergymen/priests | 85 | 11 | 4 |
| Civil Servants | 25 | 63 | 12 |
| Doctors | 82 | 14 | 4 |
| Government Ministers | 16 | 74 | 10 |
| Journalists | 19 | 73 | 8 |
| Judges | 77 | 18 | 5 |
| Ordinary man/woman on the street | 57 | 27 | 16 |
| Politicians generally | 18 | 75 | 7 |
| Police | 61 | 32 | 8 |
| Teachers | 79 | 14 | 7 |
| Television newsreaders | 63 | 25 | 11 |
| Trade Union Officials | 18 | 71 | 11 |
Source: MORI, Commissioned by Sunday Times
| May 1987: Which two or three groups of people on this list do you yourself have most respect for (%) | |
| Civil Servants | 3 |
| Company Directors | 3 |
| Doctors | 70 |
| Journalists | 1 |
| Members of Parliament | 4 |
| Nurses | 75 |
| Policemen | 50 |
| Scientists | 12 |
| Social Workers | 14 |
| Teachers | 20 |
| Trade Union Leaders | 3 |
| None of these | 1 |
| Don't know | 2 |
Source: MORI
Public attitudes towards the NHS and to health professionals are, however, unlikely to extend to health service managers and administrators, at least if attitudes to public sector bureaucrats in general are any guide. Thus a MORI poll amongst Southwark residents revealed that 69 percent of respondents felt that the local authority 'wasted' a lot of money, 42 percent that it spent money on the 'wrong things', whilst seven percent objected more generally to 'bureaucracy' (New Society, 4 December 1980, p. 465). According to the same source, Conservative Party private polls in 1979 revealed similar attitudes nationally.
The same attitude can, of course, be discerned amongst politicians. The constant concern of the House of Commons Select Committees with administrative manpower in the NHS (see below, and, for instance, Committee of Public Accounts 1981, pp. 6-7) is one manifestation of this, whilst others may be found in ministerial speeches:
if we can slim the management structure of the service, we can switch tens of millions of pounds out of administration and directly into the care and cure of patients (Mr Patrick Jenkin: DHSS 1979b).
Mr Fowler, too, was noted for his slighting references to the NHS's 'administrative tail' (Halpern, 1987), a view which is all of a piece with what Fry (1984, p. 325) somewhat euphemistically terms Mrs Thatcher's 'irreverent' attitude towards public servants. Such anti-statism is, however, not a wholly distinctive Conservative view, for politicians of the left (such as Barbara Castle, Richard Crossman and Tony Benn) have also often felt their efforts to have been thwarted by the bureaucracy (Hennessy, 1987).
If bureaucrats are unpopular, so were trade unions, at least over the period with which this study is concerned. The public distrust of union officials is evident in Table 3.7, whilst other polls show dislike both of unions as organisations and of their activities. Thus, between 1979 and 1980 the proportion of respondents who felt that unions were 'a bad thing' rose from 29 percent to 43 percent (Webb and Wybrow, 1981, p. 65), whilst contemporary Gallup polls showed increasing public hostility towards what was perceived as trade union 'political' activity (pp. 67-71). In a 1980 poll, 78 percent of respondents considered that British trade unions had 'too much power' and showed 'too little responsibility' (Times, 21 January 1980). Such data, of course, refer to trade unions in general, but there seems no reason to conclude that they do not apply equally to those unions organising within the NHS.
In the early 1980s, the House of Commons began to display an unprecedented level of interest in the management of the NHS, and, in particular, the size of its workforce. Some of this interest was from individual Members, especially backbenchers on the right of the party. Young and Sloman (1982, p. 32) quote the following example, describing it as atypical only in being 'calm, civilised and well-briefed':
I divide this into two parts: first of all, the total number of civil servants, the ones who work in our ministries up and down the country, and then there are the other civil servants, who are workers in the National Health Service and under our education authorities. And it is the latter, let us say the workers in the field, who have expanded so enormously during the last twenty years. Let me give you one example of the scale of movement: between 1960 and 1978 a million people moved out of the private sector and one and a half million people moved into public-sector employment. Now that is a vast change by any standards; it makes a demographic revolution in some senses (Mr Peter Hordern, Conservative MP for Horsham and Crawley, speaking in 1981).
Another example, said to have the ear of Mrs Thatcher, is Mr Ralph Howell, Conservative MP for North Norfolk; on his own account he asked
hundreds of parliamentary questions .... aimed at proving there is no proper management in the NHS (personal communication 1987; see also Howell, 1982).
Indeed, Mr Howells asked nine such questions between May and July 1982 (Hansard, Written Answers, 6 May 1982, Col. 118; 19 May 1982, Cols. 126-7; 10 June 1982, Col. 154; 21 June 1982, Col. 12; 22 June 1982, Cols. 67-8; 22 July 1982; Col. 285; 29 July 1982; Col. 674; 30 July; Cols. 850- 1).
However, it was House of Commons Select Committees which were most prominent in castigating the management of the NHS: the Social Services Committee and the Public Accounts Committee.
In its Third Report for the Session 1979-1980 the Committee made its first examination of DHSS expenditure plans. As part of a general critique of what it saw as a failure by the Department to maintain strategic control of the NHS (Nairne, 1983, pp. 250-252), the Report endorsed the need and scope for greater efficiency in the NHS, but went on to comment on the Secretary of State's claims that the expenditure cuts of the preceding year had been partly offset by increasing efficiency:
We must, however, express forcibly our disquiet that the Department, whilst embracing the rhetoric of greater efficiency, does not appear to be in a position to measure its actual achievement ....we accordingly recommend that the DHSS should give high priority to developing a comprehensive information system which would permit this Committee and the public to assess the effects of changes in expenditure levels or patterns on the quality and scope of services provided (Social Services Committee, 1980, p. x).
Though the Committee made no cross reference, and did not use the term, it was, in fact reviewing a proposal which its predecessor, the pre-1979 Expenditure Committee, for the development of 'indicators of performance' of local health authorities (Klein, 1982, p. 399).
The Government's immediate reply to the Committee forcibly rejected the general critique, and indeed seemed to miss the point that was being made:
Perhaps the most disturbing aspect of this Report is its assumption that everything should be managed at Whitehall level and that Ministers should preside over every detailed decision. I reject that view. It is the Government's firm policy that detailed planning and management of resources are best left to those on the spot who know local needs and priorities (Mr Patrick Jenkin; DHSS, 1980c).
(The formal Government reply simply repeated the point at greater length [DHSS, 1980d].) The Social Services Committee returned to the attack in the following year; drawing attention to the dangers of assuming that falling costs per acute case implied increasing efficiency, and went on:
if the health authorities do not succeed in squeezing out waste, then they may economise by cutting either the scale or quality of the services we recommend that as a matter of urgency, every effort should be made to find a way to measure the savings flowing from improved efficiency (Social Services Committee, 1981, p. xiii).
Again, in 1982, the Committee remarked that 'there is some suspicion that "efficiency savings" are becoming a regular euphemism for "expenditure cuts'" (Social Services Committee, 1982, p. xiii), and still in 1986 it remained sceptical:
Whilst endorsing the Government's determination to improve efficiency and management in the NHS, we recommend that the Government monitor closely the effect on health services of cost-improvement programmes, to ensure that such programmes do not lead to a reduction in overall health care (Social Services Committee, 1986, p. xix).
The Social Services Committee had not been alone in showing interest in the management of the National Health Service. In his annual report on the appropriation accounts for 1979-80 the Comptroller and Auditor-General noted wide discrepancies in staffing levels and other variables as between health authorities, commenting that his observations raised
.... the question of the right balance, in the interests of economy and efficiency, between the necessary central direction and oversight of the NHS and a system of delegation and discretion appropriate to a locally-based and managed service (quoted in Committee of Public Account, 1981, p. 1).
The Committee of Public Accounts (PAC) took up this matter in a series of hearings in the spring of 1981. Throughout these, members of the Committee stressed the NHS's accountability to Parliament and emphasised their perceptions of a lack of DHSS control over health authorities. As one member (Mr Michael Morris) put it to the DHSS Permanent Secretary, Sir Patrick Nairne:
.... you have made it clear to the Committee that Ministers settle the national policies, but it does seem to me .... that the Department has got a very relaxed approach to monitoring and implementation of these policies .... [Y]ou are relying, it seems to me, almost entirely on cash limits as the control from the centre. I am still not clear why it is that the Department is against issuing firm instructions (Committee of Public Accounts, 1981, p. 56).
In response, the DHSS witnesses maintained that detailed central control was
not necessary, though they referred on several occasions (Committee of Public
Accounts, 1981, pp. 5, 53-54, 58) to the Korner working group (see above, Chapter
2), implying that this would in due course provide comparative performance data.
(The Korner Group's terms of reference make no reference whatever to the development
of information for central monitoring purposes: Steering Group on Health Services
Information, 1982,
P- 1).
However, the Committee were apparently finally persuaded of the undesirability of detailed DHSS control, and contented themselves, with a call for greater upward flow of information as a means of monitoring the comparative performance of different health authorities. Their Report concluded that the mere existence of cash limits was not, as DHSS witnesses had argued, sufficient discipline upon health authorities:
arrangements will be satisfactory in practice only if accountability upwards is matched by a flow of information about the activities of the districts, which will enable the regions, and in turn DHSS, to monitor performance effectively and to take necessary action to remedy any serious deficiencies, or inefficiency, which may develop (Committee of Public Accounts, 1981, p. xvii).
By the time the PAC came to review matters again, in the Spring of 1982, the Review Process, Performance Indicator, surplus land, and private audit initiatives had already been announced (see above, Chapter 2), marking something of a departure from past government reluctance to be drawn into such complexities (Graham, 1984, p. 182). In his announcement of them, the Secretary of State acknowledged that the first two were a response to the Committee's criticisms (DHSS, 1982a, p.3). Welcoming the developments, the PAC concluded that much remained to be done and that it would continue to observe progress (Committee of Public Accounts, 1982, pp. vii-viii). Both the PAC and the National Audit Office (NAO) continued to monitor the NHS closely; in its sixteenth Report for the session 1983-84 the PAC welcomed the management changes of 1982 (see Chapter 2, above) but continued to criticise NHS manpower levels (Committee of Public Accounts, 1984, p. xi).
In 1986, the NAO produced a report questioning whether cost-improvements in the NHS had really been achieved without damage to patient services (NAO, 1986, p. 9), a matter which was subsequently taken up by the PAC in its forty-second Report for 1985-86 (Committee of Public Accounts, 1986). A good deal of adverse publicity, including the naming by an MP of the District Health Authorities where such cuts had occurred, resulted (Davies, 1986b, p. 850). The Committee concluded
We cannot emphasise strongly enough that both the NHS and the Department should keep fully to their policy that [Cost-Improvement Programmes] should not include savings from cuts in services And we note that, despite their increasingly robust scrutiny of CIPs, DHSS could not give an absolute assurance that service cuts had not been included (Committee of Public Accounts, 1986, p. x).
By 1988, the Social Services Committee had begun to make its own calculations, rather than simply relying on Departmental assurances. The following quotation serves as a summary of the stance adopted by the Committee in several of its reports at this time:
DHSS has recently sought to dissuade us from calculating the extent to which growth in expenditure on HCHS [Hospital and Community Health Services] has been sufficient to meet increased demand. The Department does not accept that to achieve its objective of an approximate two per cent increase in services, to meet demographic, technological and service pressures, a concomitant growth in resources of two per cent per annum is needed. According to DHSS, other efficiency gains between 1983-84 and 1986-87 can be quantified. If unit costs had remained at their 1983-84 levels (apart from the effect of inflation), it would have cost nearly £900 million more to maintain 1987-88 service levels than was actually the case. About two-thirds of this figure was attributable to specific cash-releasing cost improvement programmes, so the Department's figure for the other efficiency gains achieved is of the order of £300 million.
Between 1980-81 and 1987-88 resources for HCHS have grown by 10.3 per cent (taking into account cash-releasing cost improvement programmes) - that is, by about 1.5 per cent per year. To the extent that this is less than two per cent per annum we believe that this represents underfunding although we appreciate that DHSS disputes the Committee's description of such underfunding as 'cumulative'. Even after taking account of the extra efficiency gains identified by DHSS, which the Department acknowledges to be "a less precise and certain figure than for cash-releasing cost improvements", and of cash-releasing cost improvements, in our view the underfunding of the Hospital and Community Health Services between 1980-81 and 1987-88 has been in the region of £1.5 billion at 1987-88 prices (Social Services Committee, 1988, p. viii).
A number of groups saw in the election of a Conservative government in 1979 the opportunity to press their various interests in relation to the NHS. Thus, the decision in 1982 to experiment with private audit of the NHS (see Chapter 2 above) was a response to pressure fro