Annex A > Chapter 8 - Management and Culture of the UBH and the UBHT > The development of the clinical directorate structure > Mrs Margaret Maisey's dual role
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Mrs Margaret Maisey's dual role
167 Mrs Maisey was both Director of Operations and Chief Nurse Adviser of the UBHT from its inception on 1 April 1991 until mid-1996 when she became the Director of Nursing. She then held this post until she left the UBHT in September 1997.
168 Mrs Maisey held a position of some significance within the UBHT. She said:
`... certainly I had influence, I had John Roylance's ear when I wanted it, I could speak to the Board if need arose. I do not think it ever did, particularly, but I did have influence, and I could make sure that works went up the road and, I do not know, did the work they said they would do and had not got round to doing. I could make some of these departments, lean on them to do things.' [198]
169 Mr Durie was asked about Mrs Maisey's relationship with Dr Roylance in the following exchange:
`Q. So it was known throughout the Trust that Mrs Maisey was, to put it in legal language, Dr Roylance's "agent"?
`A. I think I understand that in legal language. If I do, yes.
`Q. It might be more colloquially put in terms of her being Dr Roylance's "eyes and ears" throughout the Trust?
`A. Not only eyes and ears. She was also a doer.
`Q. When Mrs Maisey would express a view about a matter, the person to whom the view was expressed would believe or would understand that the view Mrs Maisey expressed was liable to be Dr Roylance's view also.
`A. That is right.' [199]
170 An article in `Private Eye' dated 18 June 1993 described Mrs Maisey as `Dr Roylance's sidekick'. [200] Mrs Ferris described Mrs Maisey as playing:
`... a very particular role for the Chief Executive ... She herself, I think, on many occasions, described herself as the Rottweiler of the Trust, so I think her own view was consistent with that.' [201]
171 Ms Janet Maher, General Manager UBHT, [202] described Mrs Maisey's power or influence as being due to her closeness to Dr Roylance. According to Ms Maher, Mrs Maisey had:
`... a very strong power base and was seen as being strongly linked with Dr Roylance. I believe that some General Managers were frightened of her, although I do not believe she meant to be frightening to them. I would say that she always had the best interests of staff and patients at heart.' [203]
Mrs Maisey as Director of Operations
172 Dr Thorne told the Inquiry that Mrs Maisey's role, as Director of Operations, was different from that which she had carried out as a Unit General Manager in the pre-trust days. She said:
`... as far as I understood it to be, she was Director of Operations and sort of Chief Nursing Adviser, in a professional capacity, which was why she was on the Board as the chief kind of Nurse Adviser. ... she had moved from having this enormous kind of hierarchical management role as a General Manager to having a Board level role where she was actually supporting people and fire fighting, beetling around, trying to help people, solve problems, identify issues before they became very problematic.' [204]
173 Mrs Maisey had little guidance about what was expected of her in her role as Director of Operations. In her evidence to the Inquiry she said:
`I think what you have to remember is that there had never been a Director of Operations before in the Health Service to my knowledge ... these titles were new ... We did not have a hang up with titles in UBHT; we were concerned that the things that needed to be done got done.' [205]
`What would you say were the main areas of responsibility, the main three or four areas that defined your role as Director of Operations as it subsequently developed?'
`Quite a lot of my time was spent with individual General Managers and/or Clinical Directors, discussing how they were going to develop their directorates. Sometimes that was about geographical moves, sometimes it was about financial problems, sometimes it was about staffing, all sorts of things, some of which they would have had experience with, and some of which they might not have.' [206]
175 Ham and Smith in their paper discussed Mrs Maisey's role in relation to general managers:
`The general managers in the clinical directorates, who were accountable directly to the chief executive, met regularly with the director of operations/chief nursing adviser [Mrs Maisey] in the executive management group.' [207]
`The director of operations did take on a key role on behalf of the Chief Executive in working alongside directorate general managers but the evidence suggests that the way in which this role was performed was not always viewed positively.' [208]
177 Ms Maher recalled Mrs Maisey's role as follows:
`The Director of Operations was there to support General Managers but not to manage them as such. I would say that Margaret Maisey, as Director of Operations, had a lot of influence and power, but no direct management responsibility for the General Managers of the Directorate ... General Managers of Clinical Directorates met with Margaret Maisey as the Director of Operations once a month.' [209]
178 Dr Roylance explained that at these meetings, Mrs Maisey gave the general managers `a great deal of managerial support'. [210]
`I felt unable to talk to Mrs Maisey or Dr Roylance because there was a history of lack of support or guidance. Although I attended the monthly General Managers' meetings and the weekly Management Development Group, I did not feel able to be open or to confide in my immediate colleagues and managers. It seemed to me that managers would watch to see who was "in favour" and those who were not were avoided. I felt that there was a culture of fear and blame.' [211]
`The Director of Operations had a personal management style of "management by fear" rather than encouragement. Although I challenged her on a number of occasions, I felt I did so to my own detriment.' [212]
181 When Mrs Ferris was asked to elaborate on these comments in her evidence to the Inquiry, she said:
`The General Managers were in fear of the action that would be taken by Mrs Maisey if they did not fit into the perceptions or requirements that she had of them, which I think is different to being worried and performing well in their post, in that they are worried about what would happen. There was a real fear of the arbitrary way in which some managers were in favour and some managers were out of favour.' [213]
182 When Mrs Maisey was asked about Mrs Ferris' perception of her style of management, she said:
`Of all the management styles that I might have considered adopting, it is not one that I would want to be labelled as, and I cannot conceive that the team with which I worked would not have put me right if they thought that that was how I was being perceived. There was an openness and a frankness and an honesty and a preparedness to "say it as it feels" about our team working ... particularly amongst the executive group. They would have given it to me straight, if they thought that is how I was comporting myself.' [214]
183 Miss Salmon said she felt she had:
`... very little influence or authority as either an Associate General Manager or a General Manager with [Margaret Maisey] or [Dr Roylance]. The culture at the time was one in which personal relationships with an individual executive director [were] possibly more important than hierarchical relationships.' [215]
184 Mrs Ferris felt that there was no support provided to general managers and that:
`... the attitude of Mrs Maisey and Dr Roylance when asked to help deal with particular problems, was either to ignore them, or to make the manager feel inadequate for having raised them, or to respond aggressively. My experience was that Mrs Maisey's approach was particularly aggressive.' [216]
185 Mrs Maisey confirmed that it was not usual to set objectives for the general managers of the clinical directorates. She said:
`I did not see it as essential that Clinical Directors set objectives for their General Managers. If their General Managers wanted objectives then it might be that the Clinical Director could help them, but I cannot conceive of the Clinical Directors that I can think of now, of any who would feel that they ought to sit down and work out themselves the objectives of General Managers. I think they would probably be happy to be involved in a debate with the General Managers about objectives that the General Managers themselves had set in the same way that I would.' [217]
186 Some, such as Ms Sheena Disley, did not see Mrs Maisey as having a significant input in their day-to-day activities. Sister Disley was asked what impact Mrs Maisey had in her capacity of Nurse Adviser to the Trust from 1991, on her work as a ward sister. She replied, `I think we were a fairly self-contained unit. Clearly we knew who she was, clearly I think she was not a significant presence on the unit at that time.' [218]
Mrs Maisey's nursing responsibilities
187 Mrs Maisey was appointed Unit General Manager of the South Unit in the B&WDHA in 1985 and took up post `early in 1986'. She also assumed the role of Nurse Adviser to the Health Authority.
188 Mrs Maisey explained the change which the introduction of general management brought about to the management of nurses:
`When general management came in, it swept away all those nurse managers. Most specifically, it swept away ... 17, 000 nursing officers in England and Wales ... They were replaced with ... General Managers, most of whom were not nurses and many of whom have never managed nurses. But the nursing officers used to monitor everybody.' [219]
189 The introduction of general management meant that nurses were managed not by nurses, but by general managers.
190 When the UBHT came into being, it was required to have a nurse as one of its executive directors.
191 Mrs Liz Jenkins, the Assistant General Secretary of the Royal College of Nursing (RCN), agreed that it was important to have someone with a nursing role at trust board level. [220]
192 When Mrs Jenkins was asked what she saw as the purpose and function of a director of nursing, she replied:
`I have to say, it will depend on what their job was, and there were all sorts of hybrid jobs. Some Directors of Nursing had responsibility for the budget, for the nursing and the accountability for that; others did not ... Some had personnel functions added to their jobs. So there were many different jobs during that period of time [1984-1995] that were described as or incorporated the person who sat as the "nurse" on the Board.
`My own personal view is that whether you had the management of nursing and the finance for it in your power or not, you were on that Board to provide the best possible nursing advice for the benefit of patients to that Board and that therefore, my own view is that you would have a strong responsibility for ensuring that patient care within your domain was as safe and as good as it possibly could be, given the financial constraints that you would have.' [221]
`... the nursing role on a Trust Board has a responsibility for ensuring that the other colleagues on that Trust Board understand the issues of patient care and that they therefore ensure that they are not making decisions that conflict with patient care or safety.' [222]
194 However, it was not entirely clear what the ambit of the nursing director's responsibilities should be. Dr Roylance said:
`You will recognise that if you introduce the general management function, then there is no managerial role for a District Nurse, because nurses are managed by General Managers. When we became a Trust, along with other trusts - large trusts - there was a problem of what an appropriate role would be for the nursing director, the Director of Nursing, on the Trust Board, because ... by definition she could not manage nursing. That and the general management function could not co-exist.' [223]
`A number of solutions were produced across the country on how to develop a role for the Director of Nursing, so when we became a Trust, which is after we created directorates, we agreed ... that an appropriate role for her would be a Director of Operations.' [224]
196 Mrs Maisey explained her role in these terms:
`The title of Director of Operations and Chief Nurse Adviser ... meant that as each Directorate had its own Nurse Adviser, I became the focal point for the Trust as a whole for these Nurse Advisers. This was the main change in my nursing role from before 1991. I was not Director of Nursing. Director of Operations was a new role to provide support and guidance to the General Managers in setting up their new Directorates and to manage the Trust's support services such as catering, maintenance and capital building works, patient information, information technology and complaints.' [225]
197 Thus within each clinical directorate there was a nurse advisor who could be approached for advice by any nurse within that directorate. If a matter needed to go further, Mrs Maisey was `the professional link to the Department and to the policy making bodies for the profession.' [226] Mrs Maisey said:
`In all the different roles I had, I always expected to be approached if there were problems with nurses, whatever the problems were. I would always expect to be involved, assuming they were serious and unsolvable by any obvious route.' [227]
198 Ham and Smith in their paper outlined a drawback of Mrs Maisey's having this dual role:
`The responsibility given to the director of operations/chief nursing adviser by the chief executive meant that de facto she acted as a third deputy to the chief executive. A further consequence of this was that the operational aspects of the director of operations/chief nursing adviser role were significant and to some degree took time away from the role of chief nursing adviser.' [228]
199 The Inquiry heard evidence of a perception among ward nurses that Mrs Maisey was seen as an inaccessible figure. Ms Sheena Disley, a ward sister at the UBHT, said in her witness statement:
`I think I saw Margaret Maisey twice in all: I didn't feel she was someone I could confide in or expect to act on the problems I may have had.' [229]
200 Sister Disley's oral evidence included this exchange:
`Q. Was it the case that you did not feel you could confide in Mrs Maisey because she was in a separate building, or was it that you did not feel you could confide in her because she was not the type of person you could confide in, or both?
`A. I think because she was obviously very thinly spread about a large area, we saw less of her. I think it is difficult to confide in somebody that you are not familiar with, you do not have a relationship with them.
`Q. ... You would have liked more support from higher up the nursing chain?
`A. I think as a group of nurses, as a hospital full of nurses, I sometimes felt that we lacked direction, that we lacked a clear leader, and I think ... since Lindsay Scott has been in post, [230] that there is a much more significant voice for nurses now ... There have been arenas for nurses to meet Lindsay Scott and for nurses to identify their concerns about where they work, about what is happening in the Trust. She has also been very active in the development of the nursing strategy.' [231]
201 However, according to Mrs Fiona Thomas, [232] there was not often any call for her to seek out the help or assistance of Mrs Maisey in the latter's nursing role:
`My responsibility was to the Associate General Manager, and to ... the Clinical Director. And we were very much kept in that sort of remit. We did not really need to go elsewhere, apart from certain bits and pieces, so there was very little time I needed to actually think that I needed to have a Director of Nursing at that time.' [233]
202 When Mr Ross assumed the role of Chief Executive in 1995, Mrs Maisey's role changed. From 1996, she was the Director of Nursing rather than Director of Operations and Trust Nurse Adviser. Mr Ross himself assumed a lot of the responsibility that Mrs Maisey had previously had as Director of Operations. According to Mrs Maisey, this difference in roles meant that she:
`... got more involved in the nursing issues of the day ... I got more involved with the College, the University, to which we had contracted out the basic nursing training. I was drawn into nursing policies and processes in a much more detailed way than I had been previously.' [234]
Mr Ross explained the rationale for his reorganisation of the role of the Nursing Director on the UBHT Board:
`I felt strongly the right standards of patient care could only be achieved with a contribution from a nursing professional. So the Director of Nursing's role now is essentially ... around professional standards, care, development, teaching, training, a whole range of issues around standards of service and so on.' [235]
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Footnotes
[200] SLD 0002 0007; `Private Eye'
[202] Ms Janet Maher held several positions in Bristol. From 1989 she was the shadow General Manager of what was to become the Directorate of Medicine at the BRI. From 1991 she was the General Manager for the Directorate of Medicine. In April 1993 she became the General Manager for the Directorate of Surgery. In March 1998 she was appointed General Manager at the BRI responsible for Medicine, Surgery, Anaesthesia, Bristol General Hospital and Keynsham Hospital. She held this post until she left the NHS in March 1999
[203] WIT 0153 0010 Ms Maher
[207] INQ 0038 0008; Ham/Smith paper
[208] INQ 0038 0013; Ham/Smith paper
[209] WIT 0153 0003 - 0004 Ms Maher
[211] WIT 0089 0025 Mrs Ferris
[212] WIT 0089 0034 Mrs Ferris
[215] WIT 0109 0014 Miss Salmon
[216] WIT 0089 0035 Mrs Ferris
[220] T34 p.54 Mrs Jenkins. The NHS Trusts (Membership and Procedure) Regulations 1990, SI 1990 No. 2024 state at Reg. 4(i)(c): `The executive directors of an NHS Trust shall include ... a registered nurse or a registered midwife ...'
[225] WIT 0103 0022 Mrs Maisey
[228] INQ 0038 0023; Ham/Smith paper
[229] WIT 0085 0004 Ms Disley
[230] Ms Lindsay Scott, the Director of Nursing at the UBHT from 1997 to date
[232] Fiona Thomas was Clinical Nurse Manager of Cardiac Surgery from November 1993 to December 1996. She is currently Clinical Nurse Manager of the Cardiothoracic Clinical Directorate