Annex A > Chapter 4 - National Accountabilities and Roles > The National Framework: responsibilities for healthcare
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The National Framework: responsibilities for healthcare
1 The period covered by the Inquiry's Terms of Reference is from 1984 to 1995. The background to that period, in terms of the NHS, has been set out in Chapter 2 - A Historical Background to the NHS. Most of that information is common knowledge. However, the way in which the system actually worked may not be familiar, except to those intimately involved with it. Accordingly, the Inquiry sought evidence as to this. In particular, it was concerned to know who in practice exercised authority, and who in practice accepted responsibility for the parts of the service relevant to the Terms of Reference.
2 The evidence started with a broad overview of the health service, across the nation. It focused progressively on the specific circumstances of Bristol. However, it is always necessary to remember the broader context within which that particular evidence was set, and it is thus with a review of that evidence that this section begins.
3 Across the period, a number of divisions in function and responsibility at national level must be distinguished. First, different Departments of State had responsibility for different aspects of healthcare. At the outset of the period the government department within whose ambit hospitals came was the DHSS. In July 1988 the DHSS was split into two departments: the DoH and the DSS. The DoH was then concerned with care in hospitals, primary care and community health services.
4 Within the NHS itself, a consequence of the Griffiths Report [1] was a separation of `policy' from `management'. The Report had:
`... recommended not only the introduction of general management in the NHS, but also the reform and strengthening of the Department's [2] internal organisation and mechanisms for discharging its responsibilities in respect of the NHS. Although the reform was intended to improve the Department's performance across the board, there was to be a particular emphasis on policy implementation and performance management in respect of the NHS.' [3]
This split between policy and management is sometimes expressed as a division between strategy and operations.
5 The Griffiths Report also said:
`2. The NHS ... still lacks a real continuous evaluation of its performance against criteria such as those set out above [concern with levels of service, quality of the product ...] ...
`3. It therefore cannot be said too often that the National Health Service is about delivering services to people. It is not about organising systems for their own sake. In proposing the NHS in 1944, the Government declared that:
"- the real need is to bring the country's full resources to bear upon reducing ill health and promoting good health in all its citizens;" ...
`7. ... Real output measurement, against clearly stated management objectives and budgets, should become a major concern of management at all levels.' [4]
6 Policy issues were the responsibility of a policy directorate, the Health and Social Services Policy Group, within the Department (DHSS/DoH). [5] Following Griffiths' recommendation, the Health Service Supervisory Board was established:
`... to determine the purpose, objectives and direction for the health service, approve the overall budget and resource allocations, take strategic decisions and receive reports on performance and other evaluations from within the health service'. [6]
The Health Service Supervisory Board `advised on the strategic direction of the NHS'. [7]
7 The NHS Management Board was established at the beginning of 1985 [8] and `had responsibility for the Department's management functions with respect to Health Authorities, particularly finance and performance review'. [9] The NHS Management Board reported to the Health Service Supervisory Board. [10]
8 In May 1989 the NHS Management Board was remodelled to form the NHS Management Executive (NHSME). In the same month, the Health Service Supervisory Board, which had not met for almost a year, was reshaped into the NHS Policy Board chaired by the Secretary of State. [11] The NHSME and NHS Policy Board were parallel bodies: the NHS Policy Board dealt with policy formulation; NHSME with management and policy implementation.
9 The separation of lines of report was, it appears,
`... founded on the assumption, on the belief, indeed, that the Chief Executive role could only be effectively carried out if the Chief Executive was himself an accounting officer in his own right'. [12]
10 A further distinction in function between the Chairman of the NHS Management Board (subsequently Chief Executive of the NHSME) on the one hand and the Chief Medical Officer for England on the other needs to be borne in mind. The Chief Medical Officer (CMO) acted as an advisor to the government but was also concerned with clinical health issues, whereas the Management Board and NHSME were concerned with NHS management issues.
11 The split between policy and management was, in the view of Sir Graham Hart, Director of Operations at the NHS Management Board 1985-1989 and Permanent Secretary, DoH 1992-1997, based upon two beliefs. [13] The first arose from the fact that the Management Board, following Griffiths, was a very new organisation. It had so great a task in terms of getting the Griffiths Report implemented that it was considered wise to keep work such as policy and strategy separate, to ease the load. The second belief was that it would be beneficial to separate policy from management and the implementation of policy, because doing so would clarify the respective issues. This theoretical clarity was, however, clouded by the fact that the Management Board and NHSME nonetheless had responsibility for policy on issues which were essentially those of management:
`... for example, in relation to personnel practice in the NHS, in relation to finance, how the NHS should be financed, how much money it should have, how that should be distributed ...' [14]
12 The division between policy and management was ended in 1995, following the Banks Report in the previous year. [15] Responsibility for all NHS policy matters was transferred to the NHS Executive. (The NHSME consequently dropped the word `Management' from its title.) Sir Graham endorsed the view of Mrs Banks saying:
`... that it would be better to include the policy for the NHS and about the NHS in the Executive'. [16]
13 Sir Graham Hart told the Inquiry that he agreed with this view. He thought that a split between responsibility for management and for policy had not been the best organisation. He said:
`... I always felt it was important for the Executive to be closely involved in ... responsibility for the whole range of NHS policies, which is the position that we achieved in 1995...' [17]
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Footnotes
[1] HOME 0003 0001; the Griffiths Report
[2] At that time, the DHSS
[3] WIT 0040 0001 Sir Graham Hart
[4] HOME 0003 0012 and HOME 0003 0014; the Griffiths Report
[5] WIT 0040 0003 Sir Graham Hart
[6] Edwards, B. `The National Health Service 1946-1994: A Manager's Tale' , (1995), Nuffield Provincial Hospitals Trust
[7] WIT 0335 0004 Sir Alan Langlands
[8] WIT 0040 0001 Sir Graham Hart. Sir Graham said the Management Board was set up in `1984/85', T52 p.21
[9] WIT 0335 0003 Sir Alan Langlands
[10] Edwards, B. `The National Health Service 1946-1994: A Manager's Tale' , (1995), Nuffield Provincial Hospitals Trust
[11] Edwards, B. `The National Health Service 1946-1994: A Manager's Tale' , (1995), Nuffield Provincial Hospitals Trust
[12] T52 p.91-2 Sir Graham Hart
[15] WIT 0040 0006 Sir Graham Hart
[16] T52 p.10 Sir Graham Hart, Director of Operations at the NHS Management Board 1985-1989 and Permanent Secretary, DoH 1992-1997