Annex A > Chapter 8 - Management and Culture of the UBH and the UBHT > The purchaser-provider split and the establishment of the UBHT > Internal opposition to trust status
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Internal opposition to trust status
34 In the period 1989 to 1990 the UBH were considering the move to trust status. In the July 1990 `Application for NHS Trust Status', the proposed intention of a move to trust status was summarised as follows:
`The proposed United Bristol Healthcare Trust will take the new opportunities offered under the Act to involve local people more and to develop its services to provide not only the best health care for patients but also the best teaching for doctors, dentists and health care professionals of the future. We have chosen to express these aims of the Trust in the two words "Teaching Care".' [48]
35 However, not all consultants and hospital staff supported a move to trust status. In fact a majority of the staff were suspicious of the potential change and whether there would be any associated benefits. [49] Mr Peter Durie [50] recalled:
`... there was considerable concern by doctors in particular that somehow the creation of trusts was going to break up the NHS. Those of us who were putting in the application were absolutely convinced that was not so. We were totally committed to the National Health Service and still are, and did not see that this put the NHS at risk at all. We believed that over the months we would be able to persuade sufficient people that the risk they saw did not exist.' [51]
36 As early as 10 May 1989, at a meeting of the B&WDHA Steering Committee, there was discussion about obtaining the views of medical staff towards a move to trust status:
`Dr Thomas advised that he intended to ballot all medical staff in the Bristol and Weston Health Authority to ascertain their views as to whether they wished to support the option of self-government for the UBH [United Bristol Hospitals]. Mr Wisheart considered that the information at present available was insufficient to allow for any informed opinion but that medical staff should still be balloted.' [52]
37 At the meeting of the B&WDHA on 18 September 1989:
`The Chairman invited Ms Betty Underwood and Mr John Vickery representing the Joint Trade Union Committee of Bristol and Weston staff to talk to the Authority about their views of the Government's White Paper on the future of the NHS.' [53]
38 Amongst the various concerns expressed by these representatives, was whether the views of staff would be heard in the making of major decisions. Mr Vickery said that:
`... the Authority's staff wanted consultation on important matters. At the meetings with general management, the staff side was always passed information but normally there was no chance to influence decisions and he thanked the Authority, therefore, for the opportunity to put before it the Unions views on the White Paper. In developing the theme of consultation he used the analogy of schools where parents could be balloted as to whether they wished their children's school to become self-governing, whereas there was no such choice in the NHS White Paper. He concluded by saying that the Health Service existed for the benefit of the general public to provide health care at the point of need.' [54]
39 In the interim, the NHS required business plans to be put in place and that the DHAs prepare to separate the purchaser and provider functions. Dr Roylance introduced a paper on changes to the management structure to the B&WDHA at their meeting on 16 October 1989. The minutes of the meeting recorded:
`The Secretary of State had asked for business plans to be prepared by the end of March for Bristol health services and Weston health services. These would be the subject of informal consultation during preparation and formal consultation by the Regional Health Authority. It would be submitted to the Secretary of State with the results of consultation and the comments of the RHA.
`Dr Roylance said that he had therefore created three management teams as set out in his paper. No substantive changes to any person's contract would be made until the end of March 1990 and all the changes had been achieved by secondments. Mr Durie said that as a Health Authority, all Members continued to hold the statutory obligations and duties to provide the best health care with the available resources. The White Paper would not be implemented until an Act of Parliament was passed in late 1990 or early 1991.
`... Mr Durie confirmed that the Chairman of the Hospital Medical Committee would remain the Authority's formal advisor. He explained that the instructions now being received from the NHS Management Board meant that the Authority would have to divide into the purchaser and provider roles. This was separate from any moves towards possible self-governing status for any part of the District's services. When the business plans were complete, the Authority would assess whether it considered that self-governing was the correct future for its services.' [55]
40 At a later meeting of the B&WDHA in November 1989, it was noted that:
`Through the Dean of the Faculty of Medicine there were extremely good relations with the University and this would remain.' [56]
41 Professor Gordon Stirrat [57] agreed that great efforts were made to include the University in the move to trust status. He said:
`I know very well that the then Chairman of the authority, Mr Peter Durie, was extremely anxious to make sure that the University was on board as far as this was concerned. They worked very hard and worked hard with my predecessor as Dean and then subsequently myself to try to make sure that we were part of the application. So that really was my main direct contact.
`... I think Mr Durie did a very, very good job of putting the case for the Trust, and I think a great deal of credit goes to him for that, both in relation to my health service colleagues but particularly in the University.' [58]
42 At a meeting of the HMC on 20 December 1989, Mr Stephen Boardman, Director of Planning and Estates, and Mr Nix presented the Bristol Business Plan and discussed it in light of the forthcoming ballot of staff. In the minutes, Mr Boardman is recorded as saying:
`... that the Business Plan was basically an application for a self-governing trust and that Bristol and Weston amongst many other districts had been invited to submit such applications by the end of March 1990. The alternative to non-acceptance of an application was to have a DHA managed provider unit.' [59]
43 Mr Boardman then went on to explain how the directors of a trust would be appointed:
`... the Chairman of the Trust would be appointed by the Secretary of State and the five non-executive directors by the Regional Health Authority. The bill allowed for five executive directors who would be appointed by the Chief Executive and Chairman but four of them had to be from nursing, medical, finance and management leaving only one director who could be appointed without a specific function.' [60]
44 According to Mr Durie, however, it was already known in Bristol who the executive directors would be prior to the inception of the Trust as a `shadow trust' had been established. Mr Durie explained that:
`That was all part of the process of working up the Trust application. Part of it was to show credibility: that if we were given trust status, we had the competence to run this new Trust and those people had already shown their competence in the Health Authority so it was an evolutionary one.' [61]
45 In fact, in the executive summary of Bristol's `Application for NHS Trust Status', much was made of the continuity in leadership:
`The style and structure of management in the Trust will be founded on continuing strong leadership.' [62]
46 Dr Stephen Jordan, consultant cardiologist, described the position within the hospital under the auspices of the `shadow trust':
`... starting April 1990, we had sort of shadow trusts. Everything was worked out in exactly the same way as it was going to be the following year but no money actually changed hands, if you like, and no one actually physically signed contracts and so on.
`For the year before that, that is the year beginning 1st April 1989, we were busy drawing up the shadow contract for the following year. We were instructed to do this on the basis of the workload for the previous two years and on the strict understanding that one thing that would not happen would be any ... expansion of workload in relation to the new Trust status. I mean this was part of the general "aura" of the new status: that although it was going to sort of start off with the ability to change everything, the promise was it was not going to actually change suddenly and therefore it would be related directly to what was going on before.' [63]
47 Dr Roylance described the benefits of the purchaser-provider split as follows:
`When we were at District ... we had a finite sum of money, which everybody, including me, agreed was woefully inadequate, and we had what people have described as an "infinite demand"... And this I tried to say is a fundamental challenge to the health service. You do not resolve it by pretending it was not there or wishing it was not there, you have to address it. I believe one of the major steps which helped in addressing that issue was to separate the very difficult task of deciding what was necessary from the challenge of delivering what was decided. ...' [64]
48 Dr Roylance emphasised his view that it was one of the functions of the purchaser to satisfy itself that the healthcare it was purchasing was producing a maximum benefit for the community. [65]
49 Dr Stephen Bolsin, consultant anaesthetist, wrote to Dr Roylance on 25 July 1990 after having read the `Application for NHS Trust Status'. The evidence as to the significance of a comment in the final paragraph of this letter is reviewed in Chapter 25 - Concerns 1990. He was asked about this letter and his attitude towards a move to trust status in the course of his evidence to the Inquiry. He said:
`I think my attitude was that I was not necessarily sure that they were going to improve patient care and under those circumstances a change would not necessarily be for the better. I think I was reasonably ambivalent to trust status for the hospital.
`... I think I had not been persuaded by any of the meetings that we had had as anaesthetists or doctors that trust status had advantages for us as clinicians involved in the delivery of patient care.' [66]
50 According to Dr Roylance he had many letters of this kind:
`... a lot of people spoke to me, to try and evaluate what the impact of trust status was. This was such a letter. I had a lot of them, of people wanting to know whether trust status would make their aspirations more realistic or less realistic and I told them it would not affect that.' [67]
51 At a meeting of the HMC on 16 May 1990, Mr Durie was invited by the Chairman, Mr Christopher Dean Hart, to speak in favour of trust status, and Mr Geoffrey Mortimer, who was at that time the Chairman of the B&WDHA, was asked to state the case for remaining as a directly managed unit. Mr Durie explained why he and Mr Mortimer had been chosen to talk on the issue:
`Because Mr Dean Hart knew that I was in favour of what is now UBHT ... because of the benefits ... Mr Mortimer was the Chairman who took over from me ... in 1990. He was strongly opposed to the whole concept of trusts anywhere ... Therefore, Mr Dean Hart had somebody who was in favour and somebody who was vehemently against.' [68]
52 The minutes record that Mr Dean Hart said that:
`... consultants in Avon had voted overwhelmingly against trust status on the information then available. Since that time further information had been forthcoming from the Department of Health and from those who had been asked to produce a business plan.' [69]
53 Amongst the reasons cited by Mr Durie in favour of trust status were the following:
`The size of the proposed Bristol Trust was such that it would make an easier working relationship with purchasers whilst it would also, through its board membership, have a direct relationship with teaching matters. With its non-executive members it would have a much stronger marketing base than other providers and these members would act as a sounding board for proposals from the executive members.
`... the proposed management team for the Bristol Trust had a proven financial and managerial record and he felt that it was right to apply for trust status as early as possible as it was unlikely that the government would allow the first ones to fail.' [70]
54 However, Mr Mortimer was concerned that:
`... Trusts were a moving target and the government had brought in more controls on them than envisaged in the White Paper and he believed that the capital freedom amounted to very little.' [71]
`... the advantages of directly managed units were that they existed currently and were still evolving and that the purchaser/provider role in such units had been well proven in industry. The retention of the link at DHA and DGM level provided a means of ensuring the overall interests were given priority.' [72]
56 Mr Mortimer resigned shortly after this meeting, in September 1990. Dr Marie Thorne, Head of the School of Organisational Behaviour, Bristol Business School, in her paper `Cultural Analysis of UBHT' [73] wrote that this period of transition was characterised by the fact that:
`Insecurity, and anxiety increased but solidarity of the Trust group was reinforced by identifying a common enemy. Workloads increased through managing the conflict and attention was deflected from the primary aim.
`... Chairman resigns and opposition becomes far more manageable.' [74]
57 When Dr Thorne was asked about this in her evidence to the Inquiry she said:
`The "common enemy" I suppose were the resisters, because my understanding was that the idea had been started that they would go for trust status and this was supported I think by the Chairman and the Regional Head of the South West Regional Health Authority, and therefore people were trying to go ahead with this ...' [75]
58 According to Mr Boardman, the process of garnering support for the Trust was not just about identifying `common enemies' but neutralising them. He said:
`... the unit becoming a Trust was going through significant organisational change. Dr Roylance had to win over the stakeholders in that organisation, the key opinion formers who were the clinicians, and therefore he needed at the very least to keep important opponents neutral. One way to do that is by making sure that if an important opinion former is in an important department which looks like it is going to be swallowed by a larger one, to ensure that did not happen and to allow those opinion forming departments to stay with some degree of autonomy as clinical directorates. That is how I think Dr Roylance handled that significant organisational change ...' [76]
59 A ballot of consultant medical staff was taken in January 1990:
`... on the question: "With the present information, do you support any attempts to convert your hospitals into the whole or part of a self governing trust or trusts?" On an 88% response, 81% of Bristol consultants voted "No" against 11% "Yes". In a March 1990 ballot, general practitioners in Avon voted on effectively the same question and on an 81% response, 77% voted "No" with only 8% replying "Yes".
`There is little indication of any significant subsequent change in this balance of opinion within the Bristol section of the District.' [77]
60 These figures come from a July 1990 report of the B&WDHA Member Committee to Review Draft NHS Trust Applications. This Committee was appointed by the B&WDHA in April 1990 to review the proposals for trust status and make recommendations. [78]
61 It was noted in the July 1990 report that the following were of concern:
`Absence of a clear strategy for the future in the proposal is a source of concern to many people, particularly those who feel that their specific service interests do not appear to be in the forefront of the sponsor's thinking ... whilst the University clinical professors have noted that "there is very little mention of teaching and almost none of research in the Trust documents". There is a feeling that the sponsors' objectives have not been thought through beyond the achievement of independence and corresponding concern as to where this may lead.' [79]
`... the Committee heard a near-unanimous view that the Bristol Provider Unit is not ready for Trust status against an April 1991 timetable.' [80]
63 In a later ballot in around October 1990, of the 131 votes 66 were still in favour of remaining as a directly managed provider unit. [81] Mr Durie believed this attitude still prevailed as:
`... in the papers there was a lot of very wild statements about the freedom of trusts and what the trusts would do. There was comment about trusts would cut the amount of money paid to nurses and everybody else.
`... Doctors ... they are very busy people. Their main concern is treating patients. They were not involved or wishing to be greatly involved in the real pros and cons, and if they were reacting to what they read in the press, I am not surprised if they were coming out against it.' [82]
64 However, the B&WDHA `Draft Response to South West Region Consultation Exercise on the United Bristol Healthcare Trust Proposal' came to the following conclusion:
`The Authority supports the proposal to establish an NHS Trust for UBHT services and recommends the Regional Health Authority to commend to the Secretary of State that such a Trust to be established to commence on 1st April 1991.' [83]
65 The paper also concluded that:
`... whilst management need to have due regard to continuing anxieties expressed by staff, the ballots should not be regarded as the sole reason for refusing Trust status. In particular, the Authority is not convinced that the Trust issue, for many staff, is clearly understood and separated from more general views about NHS reform.' [84]
66 Other conclusions of the Authority about the proposal to become a trust included the following:
`1. An NHS Trust is the most beneficial environment within which to manage the new contractual arrangements, and offers the greatest opportunity of delivering benefits to patients.
`2. There are financial, personnel and other management benefits which arise out of Trust status. Although these advantages are difficult to predict, and individually may be marginal, they could, taken together, be significant.
`3. The Health Authority has full confidence in the ability of its managers to manage an NHS Trust.' [85]
67 The Trust eventually came into being, despite reluctance on the part of many of the consultant staff. Mr Roger Baird, consultant general surgeon, said:
`... if you are the Chief Executive or whatever and you work out how it has to happen, obviously you listen in a reasonable way to what other people say, but in the end, are responsible for it. ...
`I suspect he [Dr Roylance] worked out with his management team what the best deal was going to be for us, and then he had to sell it to us.' [86]
`The great thing about John Roylance was that at least we all knew where we stood. Quite honestly, most of the clinicians just wanted to get on, and still do, with treating patients. If they trusted him, as we did, and he said this was the way to go, then with one or two exceptions, which he was able to deal with, he was able to get his own way.' [87]
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Footnotes
[48] UBHT 0060 0006; `Application for NHS Trust Status'
[49] UBHT 0074 0253; `Draft Response to South West Region Consultation Exercise on the United Bristol Healthcare Trust Proposal'
[50] Mr Durie was Chairman of B&WDHA from April 1986 to March 1990 and Chairman of the UBHT from April 1991 to June 1994
[52] UBHT 0113 0565; Steering Committee meeting, 10 May 1989
[53] UBHT 0249 0148; B&WDHA meeting, 18 September 1989
[54] UBHT 0249 0149; B&WDHA meeting, 18 September 1989
[55] UBHT 0249 0144; B&WDHA meeting, 16 October 1989
[56] HAA 0142 0091; B&WDHA meeting, 20 November 1989
[57] Professor of Obstetrics and Gynaecology at the University of Bristol and Honorary Consultant at the UBHT from 1982. He was also B&WDHA Chairman of the Division of Obstetrics and Gynaecology from 1988 to 1990, Dean of the Faculty of Medicine from 1991 to 1993, and Pro-Vice Chancellor from 1993 to 1997
[58] T69 p.13-14 Professor Stirrat
[59] UBHT 0098 0366; HMC meeting, 20 December 1989
[60] UBHT 0098 0367; HMC meeting, 20 December 1989
[62] UBHT 0060 0011; `Application for NHS Trust Status'
[69] UBHT 0098 0258; HMC meeting minutes, 16 May 1990
[70] UBHT 0098 0260; HMC meeting minutes, 16 May 1990
[71] UBHT 0098 0260; HMC meeting minutes, 16 May 1990
[72] UBHT 0098 0261; HMC meeting minutes, 16 May 1990
[73] UBHT 0296 0001 - 0008 ; `Cultural Analysis of UBHT'
[74] UBHT 0296 0002; `Cultural Analysis of UBHT'
[77] HAA 0141 0045; report of Member Committee, 16 July 1990
[78] HAA 0141 0043; report of Member Committee, 16 July 1990
[79] HAA 0141 0046; report of Member Committee, 16 July 1990
[80] HAA 0141 0047; report of Member Committee, 16 July 1990
[81] UBHT 0074 0266; October 1990 Ballot
[83] UBHT 0074 0257; `Draft Response to South West Region Consultation Exercise on the United Bristol Healthcare Trust Proposal'
[84] UBHT 0074 0255; `Draft Response to South West Region Consultation Exercise on the United Bristol Healthcare Trust Proposal'
[85] UBHT 0074 0256; `Draft Response to South West Region Consultation Exercise on the United Bristol Healthcare Trust Proposal'