Annex A > Chapter 8 - Management and Culture of the UBH and the UBHT > The scope of this chapter > General management
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General management
4 General management was introduced in Bristol in 1985. Dr Roylance was appointed as District General Manager (DGM) of the Bristol & Weston District Health Authority (B&WDHA) on 1 April 1985. He noted:
`The creation of the post of District General Manager ("DGM") was in response to the reorganisation of the NHS as recommended in the Griffiths Report. It was my responsibility as DGM to introduce the "general management function" in place of the then existing consensus management system.' [2]
He was `instructed ... to produce a management structure for B&WDHA by 30 April 1985.' [3]
5 At this time the B&WDHA was divided into two `Units', known as Central and South. The Bristol Royal Infirmary (BRI) and the Bristol Royal Hospital for Sick Children (BRHSC) were both part of the former (see Figure 1). [4] The BRI was itself a sub unit and the BRHSC and the maternity hospital were (together) another sub unit.
Figure 1: Bristol and Weston District Health Authority unit structure
Figure 2: Management structure of B&WDHA, 1985 [5] Click the image above to view full-size
Figure 3: District Health Authority circa 1985 [6]
Click the image above to view full-size
Figure 4: District Health Authority circa 1987 [7] Click the image above to view full-size
6 In May 1985 the B&WDHA approved the new general management structure. [8] In oral evidence, Dr Roylance explained the new organisation represented by general management, and his part in it:
`So in 1985, being appointed the first Director 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.
`To relate that to the financial issues that I have just mentioned, the district had been overspending annually by something of the order of a million pounds, which was at that time well over 1% of budget. Until that time, there had been various sources of what the Health Service calls non-recurring money which bailed out the districts at the end of each year and those sources had by then dried up. So in addition to introducing the general management function, it had the very real task of redressing the overspending and ensuring that the health district provided the best possible care from within the finite resources allocated to it.'
`... It goes without saying that the business we were in was treating patients, was preventing ill health, was diagnosing and treating ill-health that occurred, and offering palliative care where curative care was not possible; that is the business we were in. I was taking it as read that in the reorganisation, that was directed to improving the quantity and quality of that patient care. But my appointment was contingent upon a particular form of management to achieve that, and so the answer to your question; what was the business we were in, what was the organisation to which I had been appointed the District General Manager? It was a healthcare organisation. Therefore, the responsibility of the organisation was my responsibility; that was patient care.' [9]
8 Mrs Margaret Maisey [10] described the reasoning behind the directorate system in oral evidence:
`A. The whole philosophy behind the introduction of Clinical Directors and directorates was to involve medical people in management. Even at the introduction of general management, medical management had stayed the same as it had since 1948, so far as I can make out. It was a separate entity. It managed itself. Clinical directorates was an effort to move those people into a management role, to understand why they could not have the money that they thought they ought to have; why management had to address the issues to satisfy the Department of Health, to whom we were all accountable, which I have to say, doctors did not always believe.
`Q. I understand one of the key features of the directorate system was that the Clinical Directors who were clinicians were going to be responsible for managing a directorate, they were going to be "in charge of their own show" to a large extent?
`A. That is right.' [11]
9 Mrs Maisey also described the personal effect of the changes:
`The effect on my own career was significant. For example, the introduction of General Management meant that if I was to influence policy and resourcing I had to give up my full-time vocational nursing career which I did when I became a Unit General Manager at the B&WDHA South Unit.' [12]
10 Mr Graham Nix, Director of Finance and Deputy Chief Executive, UBHT, described the effect of the introduction of general management as `making the top of the pyramid sharper' [13] because:
`Prior to this, you would have actually had a district management team with a District Administrator, District Treasurer, public health doctor, and the Chairman of HMC would have actually managed the organisation as a team, working to the Health Authority, rather than in this situation, when Griffiths was making one person responsible for the organisation and its delivery.' [14]
11 Dr Roylance explained that, in the early days of general management, doctors were not part of the management structure (although Dr Roylance was himself a radiologist):
`... we had not, at that time, incorporated the medical staff into the management structure. That was fairly standard throughout the Health Service, which first of all started to create a general management structure, but it did not include the doctors. We evolved this slowly because there was a considerable reluctance and anxiety on a number of the functional management, shall we say, professions allied to medicine, who, up until that time, had a district manager of their professional staff as a separate hierarchy within the trust, and it took time to determine how that could be changed into a professional advisory structure and the members of the profession to be incorporated appropriately into the sub units.' [15]
12 Miss Catherine Hawkins, South Western Regional Health Authority (SWRHA) Regional General Manager from August 1984 to December 1992, did not endorse the selection of Dr Roylance as DGM. She said:
`I think it is sufficient to say that he would not have been my first choice for the district management job in 1984 ... John Roylance was a brilliant doctor and a very, very good Medical Director, but I did not see him as a General Manager in the true sense of management.' [16]
`... it was more difficult for him as a doctor managing doctors, and therefore, because he had been there for quite some time, it was very hard for him to appreciate the real role and function of a manager as opposed to being one of the colleagues in a set up of a teaching hospital, which is a very different climate to a non-teaching authority.
`... he did not fully understand the role of a General Manager. He did the best he could, to the best of his ability, but he was not a trained manager in the real sense.' [17]
14 On the other hand, Dr Ian Baker, then District Medical Officer, thought:
`... that John Roylance was a reassuring District General Manager of longstanding within the District, and I think that helped where other senior managers may have required support ... Dr Roylance himself saw himself as a doctor and felt it was appropriate to lead healthcare, health services, provision as a doctor, to accept the general management challenge and position, and I think he viewed doctors as being in a similar position when it came to clinical divisions and directorates.' [18]
15 In the late 1980s, Dr Roylance was involved in a research project undertaken by Dr Sue Dopson [19] in relation to management matters. Dr Dopson provided the Inquiry with various notes and transcripts of interviews she conducted with Dr Roylance. One extract which discusses the power of his role illustrates Dr Roylance's view of himself as DGM:
`It's more in other people's minds than mine. I do my best to tell everybody that I haven't got power, they must do it, but I can actually bully anybody to do anything. I have enormous power which I'm not prepared to use except in very specific situations. I can hire and fire anybody, I don't need to ask anybody's permission for anything.' [20]
`He exercises power primarily through influencing other people, not directly.'
`He is comfortable with the power, "I believe democracy is a myth, it's based on the belief that the majority have some monopoly of wisdom and they usually haven't. The second thing is people think they understand and they don't."' [21]
17 In Judith Smith and Professor Christopher Ham's paper, commissioned by the Inquiry and entitled `An Evaluative Commentary on Health Services Management at Bristol: Setting Key Evidence in a Wider Normative Context' (the Ham/Smith paper), they commented on the fact that it was unusual that Dr Roylance was appointed General Manager. They wrote:
`The decision to appoint a doctor (Dr Roylance) as a district general manager was unusual as only 15 of 188 DGMs in England in 1986 came from a medical background (Ham, 1999). Even more unusual was the decision to appoint a doctor from a clinical background to this post. Most of the clinicians who became general manager were appointed at the unit level rather than to district posts; and the doctors who were appointed as DGMs tended to come from public health backgrounds or related posts.' [22]
18 Dr Roylance agreed that he was unusual in being a clinical consultant in general management. He explained that clinicians in general management tended to have a community physician background. [23] He had a wealth of experience in the district and had at one time been the Chair of the Hospital Medical Committee (HMC). He said:
`I really had very intimate knowledge of the district at the time, how it had got there, what the past history was, what the aspirations of people were ... I think I knew all the consultants personally. I knew a large number of other people personally, too.' [24]
19 Dr Roylance told the Inquiry that, before general management, the exercise of clinical freedom was independent of resources, and management had to use quite crude measures to try to prevent overspending. He said:
`The exercise of clinical freedom ... was entirely independent of resources and ... 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.
`That is what the general management function was intended to address.' [25]
20 Dr Baker described the management chain in the era of general management, with particular reference to paediatric cardiac services. He said:
`With the advent of District General Management in 1985 management of services was from the District General Manager, Dr J Roylance to the Unit General Manager of the Central Unit (initially Mr J Watson followed by Mrs M Maisey) to Sub Unit General Managers who existed separately for the BRI and BRHSC. Professional advice at District level was given by the Chair of the Hospital Medical Committee. He was fed advice by Chairs of the Clinical Divisions of which there was one for paediatric services and one for surgical services.' [26]
21 In his statement Mr James Wisheart, consultant cardiac surgeon and Medical Director UBHT (1992/94), set out a description of the managerial and medical advisory structures prior to 1990-1991. [27] In relation to management during this period, Mr Wisheart's description was:
`Within the management structure lines of responsibility were upward through more senior managers, through the General Manager and the District Management Group to the Health Authority. The medical structure was advisory and in management terms did not have any executive responsibility. In practice, of course, the clinicians and the managers worked very closely together.' [28]
22 On the management side, communication was along the lines established by general management. On the clinical side, lines of communication would operate in various ways dependent on the circumstances, for instance outpatient clinics, ward rounds, formal and informal clinical meetings and, where necessary, clinico-pathological conferences. [29]
23 Dr Hyam Joffe, consultant cardiologist, thought that:
`Within the BCH [Bristol Children's Hospital] cardiac unit, communication among doctors and between doctors, nurses, radiographers and technologists was entirely satisfactory' [30] and `Communication between consultant cardiologists at BCH and the consultant paediatric cardiac surgeons at BRI were effective and harmonious.' [31]
24 Mrs Fiona Thomas, Clinical Nurse Manager, in her written statement to the Inquiry, described the arrangement from the point of view of nurses:
`As staff nurse, 1986-1988, my reporting lines would have been first to the sister in charge and then to the In-Service Manager. I had very little or no contact with the managers during this time. I do not recall the managers visiting the Unit. The Unit was very much run by the surgeons.' [32]
25 Dr Stephen Jordan, consultant paediatric cardiologist, described the service as:
`... consultant run and there was little perceived need for outside management involvement except in terms of nursing staff, technical staff and support services.' [33]
26 Dr Joffe described the organisation at the BRHSC when he joined in 1980:
`On my arrival in England in 1980, I was surprised to find that there was no hierarchical system among consultants. All consultants were considered equal in status, whether very senior or newly appointed, apart from a certain deference to age. This continued throughout the 1980s until the reforms of 1991, when those consultants appointed as Medical or Clinical Directors gained status and executive power, but only in managerial terms.' [34]
27 As to medical and nursing staff, Dr Joffe said that they:
`... contributed very little to management during the 1980s. Following the establishment of trust status in 1991, their involvement in managerial issues has been much greater.' [35]
28 On paediatric cardiac services in the 1980s, as a whole, he said:
`... the medical and surgical elements were placed managerially into the departments of general paediatrics and general paediatric surgery, respectively.' [36]
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Footnotes
[2] WIT 0108 0004 Dr Roylance
[3] WIT 0038 0009 Ms Charlwood
[4] WIT 0106 0012 Mr Nix
[5] WIT 0038 0067 Ms Charlwood
[6] WIT 0108 0040 Dr Roylance
[7] WIT 0108 0041 Dr Roylance
[10] Mrs Maisey's roles were: South Unit General Manager and District Nurse Adviser (1986-1989); Central Unit General Manager and District Nurse Adviser (1989-1991); UBHT Director of Operations and Trust Nurse Adviser (1991-1996); and UBHT Director of Nursing
(1996-1997)
[12] WIT 0103 0002 Mrs Maisey, who also sets out at WIT 0103 0046 - 0057 a brief history of management in the NHS 1980-1992
[19] Dr Dopson is a university Lecturer in Management Studies and a Fellow in Organisational Behaviour at Templeton College, Oxford University
[20] INQ 0027 0023; interview with Dr Roylance, 5 June 1987
[21] INQ 0027 0023; interview with Dr Roylance, 5 June 1987
[22] INQ 0038 0004; Ham/Smith paper
[26] WIT 0074 0010 Dr Baker
[27] WIT 0120 0011 - 0012 Mr Wisheart
[28] WIT 0120 0011 - 0013 Mr Wisheart
[29] WIT 0120 0013 - 0014 Mr Wisheart
[30] WIT 0097 0166 Dr Joffe
[31] WIT 0097 0167 Dr Joffe
[32] WIT 0114 0003 Fiona Thomas
[33] WIT 0099 0011 Dr Jordan
[34] WIT 0097 0138 Dr Joffe
[35] WIT 0097 0139 Dr Joffe
[36] WIT 0097 0139 Dr Joffe