Annex A > Chapter 5 - Regional, District and Trust Management > Management structures throughout the period in question > The Bristol & Weston District Health Authority (B&WDHA)
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The Bristol & Weston District Health Authority (B&WDHA)
93 In 1982 the B&WDHA consisted of 22 hospitals, 12 health centres and eight clinics, divided up for management purposes into seven units. The BRI was included in the Central Unit and the BRHSC was included in the Children's and Obstetric Unit. The other units were the South Unit, Weston Unit, Winford Orthopaedic Hospital, Mental Illness Services and the Mental Handicap Service. [102]
94 The management structure of the B&WDHA that had existed prior to 1984 continued in place until the introduction of general management during 1985. There was a separate managerial hierarchy for each individual group of staff, so the professional, technical and administrative staff all had their own management trees. [103]
95 The consultants, on the other hand, were all viewed as equals and `occupied what can best be described as a managerial plateau'. [104] Each consultant was a member of the Hospital Medical Committee (HMC). The HMC was supported by its Steering Committee, which was a smaller elected medical executive committee, and was also supported by the specialist divisions. The Steering Committee would act as a general steering group reporting to the HMC as a whole, and the specialist divisions comprised the medical advisory function reporting to the HMC. [105]
96 Each of the units within the B&WDHA contained its own management group made up of a unit administrator, a doctor and a nurse. These groups were accountable to the District Management Team, which included in its membership the District Administrator, the District Finance Officer, the Chief Nursing Officer, the District Medical Officer, the Chairman of the HMC, a general practitioner and a representative from the University of Bristol. Each unit management group managed by consensus, wherein decisions could only be made with the agreement of all members of the group. This gave each member of the group the ability to exercise an individual veto over any decision. Of the District Management Team, the District Administrator [106] managed all the District's administrative staff and services, the Finance Officer managed all the finance staff, and the Chief Nurse managed all the nurses, but the consultant member (the Chairman of the HMC) and the general practitioner member acted in a representative capacity only, expressing the opinions of their colleagues. [107]
97 When required, professional advice was received by the District Management Team, in particular by the Chairman of the HMC, and the District Medical Officer (DMO). [108] For example, Dr Stephen Jordan and Dr Hyam Joffe, consultant paediatric cardiologists, gave professional advice on cardiological services, and Mr James Wisheart, consultant cardiac surgeon, advised on surgical services at the BRI and BRHSC.
98 The first major change at district level occurred following the publication of a DHSS Health Circular [109] in 1984, which required health authorities to appoint a general manager. This was in response to the Griffiths Report, [110] which had been published the previous year and recommended changes in the management structures of the NHS.
99 In January 1985 B&WDHA complied with this requirement with the appointment of a DGM, [111] and required him to produce a management structure for the DHA by 30 April 1985, [112] to be approved by the B&WDHA and subsequently submitted to the SWRHA. According to Dr Ian Baker, Consultant in Public Health Medicine, this proposal [113] put the DGM as `directly and visibly responsible' [114] for the management of the district, being directly accountable to the DHA. He was the overall budget holder and was responsible for the development of policies within the DHA and for monitoring their implementation.
100 Dr Roylance was appointed as the first DGM of the B&WDHA (a post he was to retain until he became Chief Executive of the UBHT in 1991). He explained his main responsibilities on being appointed as follows:
`So in 1985, being appointed the first District General Manager, I had two primary responsibilities; there were others, but the two primary responsibilities were to introduce the general management function, by which I mean getting rid of functional management, nurses being managed by nurses, physiotherapists by physiotherapists, administrators by administrators. It could be said at that time when I took up the District General Management role there were about nine different health services in the District coming together only at District level.
`In introducing the general management function, it was expressly required to delegate operational management decisions as near to the bedside as possible.' [115]
101 He explained further what general management was intended to address:
`Until this form of management was introduced, the exercise of clinical freedom, I regret to say, was entirely independent of resources and that management, up until that point, had to use quite crude measures to try and prevent the major overspending of a service, things like closing operating theatres, closing wards, so it was not possible to overspend, because there was a complete separation of the exercise of clinical freedom from the responsibility of staying within budget.' [116]
102 After the introduction of general management and the replacement of the old consensus management system, the hospital and community services were restructured. The structure of the B&WDHA changed in that the seven different units that had existed before were now rationalised into two: the Central Unit and the South Unit. The Central Unit comprised six sub units and the South Unit five sub units. The BRI Sub Unit and the Children's and Maternity Sub Unit were both contained within the former. [117]
103 All the professional, technical and administrative staff were amalgamated into this unit system, with their pre-existing hierarchies remaining only as advisory structures for the general managers. The consultant staff retained their advisory structure and their clinical independence. [118]
104 Due to problems of size and the wide area that they covered, each of the two units had a unit general manager who was directly accountable to the DGM. [119] They assisted the DGM in co-ordinating, planning and monitoring the performance of the sub units. Each of the 11 sub units also had their own general managers. [120]
105 In addition to these there were also the following officers, all of whom were directly accountable to the DGM: [121] two assistant district general managers (ADGMs), who were managerially accountable to the DGM but had direct access to the B&WDHA on matters of their respective professional responsibilities; and an ADGM (Information), who carried on the service planning role of the previous post of DMO under the pre-existing management structure. [122] This ADGM was accountable via the DGM to the Policy, Planning and Resource Committee for strategic and operational planning.
106 Strategic planning from 1984 addressed the DHSS's guidance contained in the document `Care in Action', [123] which set out Government priorities in service planning. [124] The ADGM (Information) developed plans for the priorities adopted by the SWRHA from such Government proposals and submitted them via the DGM to the Policy Planning and Resource Committee. [125] This ADGM's role continued with strategic planning, although Dr Roylance's proposals under general management saw the initial planning process taking place at the sub unit level, with plans then being reviewed, discussed and integrated into a full District Plan. [126]
107 In addition, the role of the ADGM (Information) was that of a director of information, covering such matters as epidemiology, patient-care statistics, systems information and the District computing service, as well as assessing the desires and perceptions of the public.
108 The other of these ADGMs was the District Treasurer, who was responsible for the District Finance Department and the Divisional Supplies Service. He provided professional financial advice to the DGM and to the B&WDHA.
109 There was also a Personnel and Training Manager who reported to the DGM and was responsible for all matters relating to human resources. The Commercial Manager would deal with all the competitive tendering requirements.
110 In addition to the management structure there were four advisory committees which gave professional advice on their particular areas of expertise to the general managers at both unit and district level. These committees were the HMC, the District GP Committee, the Nursing Committee, and the Professional and Technical Staff Committee.
111 The majority of professional advice at district level was channelled through the Chair of the HMC. He was advised by Chairs of the clinical divisions. There was a division for paediatric services and one for surgical services. [127] It was through this structure of clinical divisions that the medical staff had direct involvement in the management of services.
112 There were also two free-standing committees that reported directly to the DHA. They had no executive functions, but discussed and developed policies independently to be presented to the DHA meetings. These were the Finance Committee and the Policy, Planning and Resource Committee.
113 Two further committees were added in 1985: the Performance Assessment Committee [128] and the Research and Education Committee. In 1986 the Finance Committee was expanded to become the Finance, Property and Computing Committee.
114 The basic structure of the DHA otherwise remained unchanged until the start of the transitional period to the separation of the purchaser and provider functions in mid-1989, and the creation of the B&DHA in October 1991.
Transition of the Bristol & Weston District Health Authority (B&WDHA) into the Bristol & District Health Authority (B&DHA)
115 In 1989 the Government White Paper `Working for Patients' was published. [129] This proposed the creation of an internal market in the NHS through the separation of purchaser and provider responsibilities. It recommended the establishment of self-governing NHS trusts and GP fundholders, with funding being allocated to the purchasers (DHAs and fundholders) rather than to the providers. The philosophy behind these changes was that the internal market would arise due to funding following the patient, rather than being granted as a fixed budget from the health authority. In addition, management arrangements were altered at local level,
re-organising health authorities along business lines.
`In 1990 the SWRHA issued Planning and Review Principles for 1991 onwards [130] and guidelines [131] to accompany the separation of the purchaser and provider functions within the NHS. This change meant that B&WHA was required to plan for the needs of its own population and commission services to meet these needs within its own resource allocation.' [132]
117 From mid-1989 the DGM and the Board of the B&WDHA produced and reviewed the proposals for the changes in the management structure. Two new committees were set up and remained in existence between 1989 and 1991, the Purchaser Committee and the Bristol Provider Committee, which dealt with the planning of both halves of the split. The proposals for the split were submitted to the RGM of the SWRHA at the end of August 1990. [133] The relevant legislation took effect on 1 April 1991, at which point the UBHT officially came into existence. The new Chief Executive of the UBHT [134] had been appointed in December 1990 in anticipation of the changes that were to take place. The B&WDHA continued in existence until 1 October 1991, when it officially became the B&DHA. However, by this time all its pre-existing provider functions had been delegated to the UBHT and it was left with its residual purchaser-based roles and responsibilities.
118 In 1990 the executive managers were also divided into those in the District purchaser unit and those in the provider unit. The post of District Medical Officer/Assistant District General Manager (Information) became the Director of Public Health Medicine, [135] and was linked to the purchaser unit. The main responsibilities became those of strategic planning and advice for the commissioning of services for, amongst others, cardiac services. [136]
119 The purchaser unit also had a Director of Health Development and Appraisals, as well as a Director of Finance and a Director of Quality and Monitoring. [137] The Director of Finance, Mr Anthony Parr, initially led the purchaser unit. Mr Parr left the District in early 1991, when the Director of Public Health Medicine became Acting District General Manager until October 1991, and the District was merged with the other DHA to form the B&DHA. [138]
120 The management structure in the DHA from April 1991 no longer had a need for the units and sub units that had existed previously. The DGM [139] now had six main officers reporting to him. Two of these centred on finance, one being the District Treasurer and the other being the Director of Contracting. In addition, there was the Consultant in Public Health Medicine, [140] the Consultant in Communicable Disease Control, the Policy and Planning Analyst and the Senior Planning Officer.
121 The B&DHA also retained a committee advisory structure and had a number of committees that advised on matters within their own particular areas of expertise. These were the Health Policy Committee, the Health Information Committee, the Finance and Contracting Committee, and the External Relations and Personnel Committee.
122 The B&DHA came to an end when it formally merged with the Avon FHSA on 1 April 1996, to become the Avon Health Authority (Avon HA). This was a result of legislation [141] to effect the merger of all the DHAs and FHSAs. The same legislation also abolished the SWRHA. In its place was created the South and West Regional Office of the NHSE.
123 In effect, the Avon HA inherited the planning, purchasing and commissioning role of the B&DHA (which in turn had formerly been enjoyed by the B&WDHA) and the Avon FHSA. The South and West Regional Office of the NHSE inherited some of the functions and responsibilities of the SWRHA. The provider functions that had devolved to the trusts in April 1991 remained vested in the UBHT.
124 From its creation in October 1991 the B&DHA continued with a strategic planning function and set up a planning group, `the Strategic Cell', to develop a framework which was responsive to national and regional requirements, and assessments of local needs and local service responses. Dr Baker led this group and it was within this framework that the purchasing function of commissioning and contracting for individual services took place. [142] Dr Baker told the Inquiry:
`I used a planning and advisory network of clinicians, GPs, Clinical and Associate Directors, General Managers and others in NHS Trusts, Local Authorities, and the University with which I worked ... A similar network covered my support function to the commissioning managers of the Health Authority in developing specifications and, negotiating annually, service contracts.' [143]
Provider functions taken on by the UBHT
125 The transition to the purchaser-provider split involved two years of preparation before the establishment of trust status, and in this time there were a number of further management changes. Twelve clinical directorates were created, each managed by a clinical director, who was a consultant, and a general manager. Dr Roylance explained that the larger directorates were further split into associate directorates, with associate clinical directors and associate general managers. [144] He told the Inquiry:
`The aim was for the Clinical Director to be "in charge of" the doctors and for the General Manager to be responsible for everyone else, and to ensure that the necessary administration and support services were in place for the directorate to run efficiently. In the discussions which took place before this change it was agreed that the most appropriate way forward would be to view the Clinical Director and General Manager as being in a managerial "bubble", jointly sharing the managerial responsibilities; thus, neither was directly responsible to or for the other. These two were assisted in their management roles by the chief nurse of the unit, a directorate personnel officer and a senior member of the Finance Department.
`The only other level in the management was that at operational level with ward sisters or their equivalents taking full responsibility for wards or their Units.' [145]
126 Dr Roylance explained the transition period further in his oral evidence:
` ... before we had completed the introduction of General Management, it was decided to add to it the purchaser/provider split, and by 1989 we were beginning to introduce shadow contracts or work agreements, service agreements, and we were endeavouring to flex the management in a way that responded to that new requirement. It was also a way of endeavouring for the first time to bring the consultant body within the general management function, so it was partly the continued evolution of General Management, I think it is fair to say precipitated by the new thinking of purchaser/provider split.' [146]
127 It was the responsibility of the DGM in 1991 to divide the District into a continuing DHA purchasing authority, and into trust provider units for the Bristol and Weston parts of the District. [147]
128 Originally, it was the intention that the general manager would support and be directly accountable to the clinical director, [148] but this view changed and they were both enclosed in what Dr Roylance described as a `managerial bubble', [149] running the directorate in a joint capacity.
129 Eventually it was clear that their roles were that the clinical director took the final responsibility for policy within the directorate and the general manager took responsibility for effectively implementing management policy. So the `managerial bubble' evolved with the clinical director reporting to the DGM pre-trust status, and the chief executive afterwards, and the general manager of the directorate reporting to the clinical director. This happened over a broad period of time, according to Dr Roylance, some time between 1990 and the time he retired in 1995, with each directorate evolving at a different rate. [150]
130 The new management arrangements were such that clinical directors led the services and held the budgets. The clinical directors negotiated, signed and implemented contracts for services from the purchaser authorities, and were responsible for turning these contracts into the policies and programmes for their directorate. The general managers supported the clinical directors in the implementation of these programmes, and were accountable to, and supported by, the Central Unit's Director of Operations. [151] The general managers provided the whole of the management function in implementing these contracts and managing the budgets. After the introduction of trust status, the general managers and clinical directors were accountable individually to the chief executive and, ultimately, to the Trust Board. [152]
131 Dr Roylance explained that initially the Director of Operations met on a monthly basis with the general managers to give them managerial support in the evolution of their roles. [153] The clinical directors reported to monthly meetings of what became the UBHT's Management Board, which after a few months became chaired by the Chief Executive [154] of the Trust. [155]
132 Dr Baker explained that, in the Central Unit, the Clinical Director for Children's Services was Dr Joffe and the Clinical Director for Surgery was Mr Roger Baird, whose directorate contained the Associate Directorate of Cardiothoracic Surgery headed by Mr Wisheart. [156]
133 This arrangement continued after the changes of 1991 and the purchaser-provider split, and the above people continued in their posts.
134 The changes led to an alteration in the management role of the medical staff. From 1985 onwards, medical staff had been involved in the management of services through the clinical divisions structure. From 1990 medical staff who became clinical directors or associate clinical directors were in a position to negotiate changes in services through planning or contracting. General managers working alongside clinical directors and associate clinical directors had a supportive role and had influence in particular on non-medical staff within services. [157] Dr Baker told the Inquiry:
`This system of management was conceived to give doctors lead responsibilities with back-up from those with general management experience and skills. This system was reflected at all levels in the District (and later UBHT). The system was headed by a District General Manager and later UBHT Chief Executive John Roylance, who was himself a doctor.' [158]
135 The clinical directorate structure adopted before the formal purchaser-provider split continued in place within the UBHT, with each directorate being led by its own clinical director. Some of the larger directorates contained a number of smaller associate directorates, each with their own associate director. The Directorate of Surgery [159] contained the Associate Directorate of Cardiothoracic Surgery, [160] covering both adult and paediatric cardiac surgery at the BRI and the BRHSC.
136 The system of clinical divisions was retained after the purchaser-provider split, although not all of the specialty groups retained them in full or in some cases at all, and their functions were altered. The clinical directorates were made responsible for organising the services which the specialty provided and for the contract-making process, but, as Dr Trevor Thomas, consultant anaesthetist, explained:
`... it was perceived that that was only part of the activity and responsibility of specialty groups, and that there was a continuing need for, if I may call it a professional network which addressed problems of education, interfacing with Royal Colleges, and the like.
`So, for some time, and indeed, in some instances there is still a divisional system within some specialties. Some specialties, I know, felt that that was inappropriate and did away with their divisional structure very early on...' [161]
137 Thus, Dr Thomas told the Inquiry that the divisional structure continued in existence in certain specialties after the purchaser-provider split and was still in place in 1995. [162]
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Footnotes
[102] HAA 0130 0019 - 0021 ; draft consultative district operational and forward programmes 1983-1985 `Your future health care - our concern', produced by the B&WDHA in July 1982
[103] This includes the nursing management and the professions allied to medicine, e.g. pharmacists and physiotherapists
[104] WIT 0108 0004 Dr Roylance
[105] WIT 0108 0004 Dr Roylance
[106] Mr V C Harral held this post until it disappeared under general management, when he became Acting General Manager of the South Unit until he retired in March 1986
[107] WIT 0108 0004 Dr Roylance
[108] WIT 0074 0010 Dr Baker
[109] HAA 0164 0004; DHSS Health Circular HC (84) 13
[110] Griffiths R. `NHS Management Inquiry. Report to the Secretary of State for Social Services' (1983), London: DHSS
[111] HAA 0126 0075 - 0084 ; minutes of the meeting of B&WDHA on 21 January 1985
[112] HAA 0126 0084; minutes of the meeting of B&WDHA on 21 January 1985
[113] WIT 0074 0424 - 0428 Dr Baker
[114] WIT 0074 0425 Dr Baker
[117] WIT 0108 0004 - 0005 Dr Roylance
[118] WIT 0108 0005 Dr Roylance
[119] The Unit General Manager for the Central Unit was initially Mr John Watson, who was followed in the position by Mrs Margaret Maisey
[120] Mrs Marion Stoneham was Sub-Unit General Manager responsible for the BRHSC and the Bristol Maternity Hospital; Miss Janet Gerrish and then Ms Deborah Evans were General Managers with responsibility for the BRI
[121] WIT 0038 0058 - 0067 Ms Charlwood
[122] Dr Baker was the DMO at the B&WDHA, and continued as the ADGM (Information) when the post was created in July 1985 until October 1991
[123] DHSS. `Care in Action - A Handbook of Policies and Priorities for the Health and Personal Social Service in England' (1981), London: HMSO; WIT 0074 0081 - 0140
[124] WIT 0074 0004 Dr Baker
[125] WIT 0074 0004 Dr Baker
[126] WIT 0074 0010 Dr Baker
[127] WIT 0074 0010, 0424 Dr Baker
[128] For details of the functions of the Performance Assessment Committee, see Chapter 18
[129] Department of Health. `Working for Patients' (1989) (Cm 555)
[130] HAA 0066 0003; minutes of the SWRHA RGM/General Managers meeting on 7 March 1990
[131] WIT 0074 0385 Dr Baker
[132] WIT 0074 0005 Dr Baker
[133] HAA 0047 0020 - 0022 ; letter from Dr Roylance to Miss Hawkins dated 31 August 1990
[134] Dr Roylance
[135] Dr Baker continued in this post throughout the period of the Inquiry's Terms of Reference
[136] WIT 0074 0005 Dr Baker
[137] The titles of offices changed as the purchaser unit evolved - HAA 0047 0020; cf. HAA 0144 0027
[138] WIT 0074 0011 Dr Baker
[139] Dr Baker was Acting DGM until 1 October 1991
[140] Dr Baker's permanent role
[141] The Health Authorities Act 1995
[142] WIT 0074 0005 Dr Baker
[143] WIT 0074 0005 Dr Baker
[144] WIT 0108 0006 Dr Roylance
[145] WIT 0108 0006 - 0007 Dr Roylance
[147] WIT 0108 0005 Dr Roylance
[148] HAA 0047 0021; letter from Dr Roylance to Miss Hawkins dated 31 August 1990
[149] The `managerial bubble' is discussed in detail in Chapter 8
[151] Mrs Margaret Maisey
[152] WIT 0170 0004 Ms Orchard
[154] Dr Roylance became the first Chief Executive of the UBHT, officially from 1 April 1991
[156] WIT 0074 0010 Dr Baker
[157] WIT 0074 0011 Dr Baker
[158] WIT 0074 0011 Dr Baker
[159] Mr Baird was Clinical Director for Surgery until November 1993, when Mr Patrick Smith succeeded him. See UBHT 0081 0131
[160] Mr Wisheart was Associate Clinical Director for Cardiac Surgery until 1992, and was succeeded in this post by Mr Dhasmana, who held it until 1995