Annex A > Chapter 8 - Management and Culture of the UBH and the UBHT > The development of the clinical directorate structure
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The development of the clinical directorate structure
69 By 1989 a clinical directorate management structure was beginning to develop in Bristol, in response to national encouragement [88] and the impending introduction of the purchaser-provider split and NHS trusts as the providers of acute healthcare.
70 In the Ham/Smith paper, the reason behind the adoption of the clinical directorate structure was explained:
`The principle behind the clinical directorate model is that these "semi-autonomous units", based on a medical specialty or group of specialties, enable full budgetary and clinical decision making to be combined in a single entity ... The model was believed to offer the most appropriate way of building on the principles of the Griffiths Report in relation to devolution and accountability, and to offer a way of properly engaging medical and other professional staff in the management of NHS trusts.' [89]
71 The paper went on to describe what was happening at the time in the national context:
`In the early 1990s, some large NHS Trusts elected to have as many as sixteen clinical directorates (Disken et al., 1990), the rationale for this being to maximise the involvement of senior medical staff in the management of the Trust. In these cases, directorates were usually grouped into collectives of directorates sharing a general manager and other administrative functions. The more usual number of directorates, however, was between six and ten, the reason being that most organisations felt they could not afford the management costs associated with a greater number of directorates, along with concerns about coordination and control.' [90]
72 In conclusion, Ham and Smith said that the UBHT had gone further in emphasising the involvement of clinicians in management in two ways:
`First, the approach adopted was one of maximum delegation to directorates from an early stage in their evolution. And second, the central management of the trust was kept light to give the directorates as much scope as possible to take on their new responsibilities.' [91]
73 In due course, with the introduction of the purchaser-provider split and with the institution of the UBHT, the clinical directorates came to acquire a key role in the managerial structure of the UBHT.
74 As to the local view, Dr Roylance said:
`In the 2 years of preparation before the establishment of Trust status, a number of further management changes were made. The most significant of these was the creation of some 12 Clinical Directorates, each managed by a Clinical Director, who was a consultant, and a General Manager ... 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.' [92]
75 The change from general management to trust status with clinical directorates took place with many of those who had held responsibility in the general management structure remaining in management positions. It was said by Ham and Smith in their paper that:
`The management arrangements put in place for the shadow trust, and subsequently the NHS trust, built on those that had gone before, and there was continuity of personnel between the pre and post trust structures. The main change implemented during this period was the further development of a clinical directorate approach as part of the changes to management arrangements that stemmed from the introduction of management budgeting and resource management across the NHS as a whole.' [93]
76 The view of the purchasing DHA was given by Ms Evans in her written statement:
`Prior to UBHT becoming operational in April 1991, a management system of clinical directorates was proposed. This was an approach which became almost universal across acute Trusts in the NHS, and may have stemmed from a widely publicised initiative to involve clinicians in management at Guy's Hospital, London (described in "Managing Clinical Activity in the NHS", C Ham and DJ Hunter, Kings Fund 1988).' [94]
77 This clinical directorate system was a significant change in that it deliberately drew clinicians into management. The UBHT had a system involving some large directorates with sub-directorates within them:
`... from the point of view of a purchasing Health Authority, this directorate system provided us with clear managerial and clinical points of contact.' [95]
78 Dr Thorne's evidence emphasised that the clinical directorates were intended to be one of only three formal layers of organisational structure in the Trust. The others were the Trust Board and the individual ward level. She described the changes as follows:
`The commitment to put patients first was reflected in the way that the changes in organisation structure were described - as an inversion of the normal managerial hierarchy. The staff at HQ were presented at the bottom of the hierarchy acting as a support to the other layers, whilst patients were placed at the top with all the front line staff who "served their needs". This was an attempt to signal that the senior managers saw the delivery of healthcare as the most important part of the organisation's work. The organisation structure was reduced to three formal layers: Trust Board; Clinical Directorate; and ward level. This was to create clear lines of accountability, improve the speed of decision making and communication and to speed up the rate of change.' [96]
79 Mr Durie was asked about the directorate system:
`Q. Let us take the most important manager in the directorate, the General Manager of a directorate; their objectives would be met, therefore, by the Clinical Director in conversation with the General Manager, against a background of the ethos set by the Trust Board. Is that a fair summary?
`A. I am not sure. Why I am saying that is that I would not be directly involved in that process, so I am guessing exactly what the Chief Executive and the Personnel Director and Clinical Directors decided they would do. They would be meeting monthly and I would expect them to be talking about this objective-setting at some of those monthly meetings.
`Q. So you cannot tell me exactly what went on, but that is what you would have expected?
`A. I would have expected that it was not done in isolation at Clinical Director level: there would be input certainly from personnel and probably from the Chief Executive as well.
`Q. So the key concept in the actual running of the Trust was the clinical directorate system?
`A. They were essentially - yes. By having the clinical directorates, they were the people treating patients and providing the healthcare.
`Q. And the Clinical Director was given this new role as I think in your analogy, which Mr Wisheart says is a reasonable analogy, but like all analogies not perfect, they were the Chairmen of the directorate and the General Manager was the Chief Executive of the directorate?
`Q. So the leadership qualities of the Clinical Director, managerial and leadership qualities, would be very important to the success of a directorate?
`Q. How did the Trust satisfy itself that the Clinical Directors or assistant Clinical Directors had the necessary leadership as opposed to clinical qualities?
`A. The Chairman of the Hospital Medical Committee and the Medical Director, who quite often were the same person, and Dr Roylance as Chief Executive with his medical knowledge and background, knew well the strengths and weaknesses of the various consultants in all the specialties. It was important initially to try to ensure that the person who became the Clinical Director was somebody who was respected by his peers.
`You also try to ensure that that individual was also ready to be numerate and likely to be a good leader, so there were really three factors all interwoven in deciding who should the right person be.
`Q. That decision was Dr Roylance's decision?
`A. He made the final decision, but in fact again the process came about from a lot of talking and discussion with the people concerned who knew what was happening in that area.
`Q. Did you as Chairman or the Non-Executive Directors have any role in the appointing of Clinical Directors, in the selection of them?
`A. No. I say "no"; as Chairman you are overall responsible for everything, but I do not remember - I cannot recall now being involved in discussions, although I might have been. If there was a discussion about should it have been A or B in a certain specialty, I could have been brought in on that discussion informally, but I do not recall it.
`Q. To what extent is it fair to say that the Clinical Directors of the Trust in 1991 were all existing senior clinicians at the - let us take the Bristol Royal Infirmary - at the Bristol Royal Infirmary with whom Dr Roylance had worked closely for a number of years?
`A. The answer is, "yes"; because he had been there a long time, the answer to the second half is "yes", too.
`Q. There was no Clinical Director who did not fall into that description?
`A. Not initially. I think it is worth enlarging why not. There was considerable suspicion among consultants in particular about the move to Trust status. I think they had some reason, because there had been very wild remarks being made politically about what might happen in Trusts and the freedom they might have.
`That being so, it was important to try to ensure that the Clinical Directors had the confidence of those working under them.' [97]
80 Professor John Vann Jones [98] compared the relative positions before and after the institution of the UBHT. He stated:
`The new Directorate structure gave some financial freedom to Directorates, to determine how their resources would be utilised, and to determine their own priorities for developing services, benefiting directly from cost savings and efficiencies within the Directorate ...
`Before the advent of Trusts it was necessary to put forward a case for any development. This was very cumbersome and slow because it had to be considered at area or regional level, and it had to be fitted into area or regional policy. The concept of Trusts produced a little more flexibility. For example Clinical Directors identified their own priorities.' [99]
81 Ham and Smith in their paper argued that:
`The board took an approach of delegating authority as far as possible, confirming the clinical directorates as the core units of management in the trust. [100] For this purpose, the trust was divided into thirteen clinical directorates, the clinical director of each directorate was a medical consultant, and this role was seen as that of a "non-executive chairman of the directorate" ... The trust board sought to delegate to directorates the authority they needed to manage their services, wishing to avoid becoming bogged down in operational detail and hence having time to focus on major issues.' [101]
82 Mr Wisheart described the directorate system after 1991 in his statement:
`The Directorates or, perhaps, the sub-directorates were "the functional units of the Trust", inasmuch as they provided an identifiable package of service to the patient, or for the purpose of contracting. The Clinical Directors and the Associate Clinical Director had the main role of leadership within this framework together with their Directorate General Manager and Nurse. Their duties included management responsibilities for which they were formally responsible to the Chief Executive. Clinical Directors initially were usually senior doctors but, in principle, could have been from any discipline, medical, nursing or the professions allied to medicine. The Clinical Directors exercised leadership in the management of the Directorate including the organisation of its clinical work. However the Clinical Director was not responsible for the manner in which consultant colleagues exercised their clinical freedom and responsibility in relation to the care of their individual patients.
`Within each Directorate or sub-directorate the executive group of three would meet as required and in addition it was usual for there to be a larger meeting of the staff working within that Directorate. In cardiac surgery, this larger meeting was called the Cardiac Surgical Board. It was a more formal expression of the teamwork that had existed before and ... included at least representatives for all the groups working within the Directorate. This board, therefore, gave the non-medical voices a stronger say than they had before.' [102]
83 Mr Boardman told the Inquiry that he thought that 13 (the initial number of directorates) was too many :
`Through my subsequent experience with the NHS management executive, and as a specialist management consultant, it was clear that many Trusts operate with fewer directorates. In my opinion 13 was too many and consequently Dr Roylance did not appear to have proper control over them. He almost encouraged directorates to be loosely affiliated to the Trust. For example, each directorate formulated its own business plan with little central direction, and essentially all 13 plans were then bundled together. There was no real overall corporate strategy/planning ... UBHT always delivered financially (Dr Roylance was known to run a tight ship and thus UBHT appeared to be well managed), but in other aspects the plan was not coherent.' [103]
84 Mr Boardman went on to say in his supplementary statement to the Inquiry:
`... I should now like to say that with hindsight I realise it would have been possible to structure the organisation with a smaller number of clinical directorates. I remain of the view that overall there was no real overall corporate strategy or planning and in this sense, Dr Roylance did not appear to have control over the clinical directorates.' [104]
85 Dr Roylance rejected this criticism. He said:
`It is not true to say there was any difficulty because of numbers in supporting and developing 13 Clinical Directors and their General Managers.' [105]
86 Further, when asked if he could have had fewer directorates within the UBHT, Dr Roylance said:
`No. If there had been an anxiety about numbers, the only managerial step I could have taken would have been to put an intervening level of management and put an assistant chief executive managing six seats, so to speak. There was no way I could put together two directorates and pretend they had a single interest.' [106]
87 When Mr Boardman was asked whether a smaller number of clinical directorates would have been better, he replied:
`That is a value judgement. I am not saying it would be better. I am saying there were other ways of doing it, and there are benefits but also non-financial costs to doing it with a smaller number. I think with a smaller number, some of the coordination would have been easier ... it is not for me to say which is better or worse, but rather that there are other ways of organising and you have to weigh up the costs and benefits of that way of organising.' [107]
88 Mr Robert McKinlay, Chairman of the UBHT Board 1994-1996, agreed with Mr Boardman `that coordination would be a problem with such a large number of directorates'. [108]
89 Bristol traditionally had had small central management with devolved management units. Ham and Smith in their paper described Bristol in the era of general management thus:
`... a structure of two main units and eleven sub-units was preferred to a structure of say five units ... BWHA apparently preferred to have a smaller general management core (the district general manager and two unit general managers [UGMs]) and a greater number of devolved sub-units of management.' [109]
90 One of the reasons advanced to explain why Dr Roylance did not find it difficult to support and develop the 13 clinical directorates was that all of the responsibility for running the directorates rested with the clinical directors and their general managers. One of the general managers, Mrs Rachel Ferris, recounted:
`My experience led me to believe that it was accepted in management circles that Dr Roylance was known for saying "don't give me your problems, give me your solutions." All my peers were told that responsibility for dealing with issues must be pushed back to the Directorates. My perception was that if this did not happen, then it was seen as a failure on the part of the Manager ... I saw Mrs Maisey's role as controlling the General Managers in order that Dr Roylance could get on with other things ...' [110]
91 Ms Evans explained that the clinical directorate structure at the UBHT was more fully developed in the period 1991-1995 than in some other trusts. The reasons for this, she felt, were:
`Two things, really: one is in terms of a system whereby clinicians were the Clinical Directors responsible for a specialty or group of specialties, and were thereby very much involved in the management of those specialties, but also very much involved in the dialogue with purchasing health authorities about what the Trust should be providing and how that might work ...
`The second one would be something about the implications of a clinical directorate structure for the management of a trust, and, in the UBHT's case, being such a large trust with so many specialties, that led to a fairly federal structure of clinical directorates ... it made good sense to have strong local management at directorate level.' [111]
92 There were regular meetings between the various levels of management. This was reported in the Ham/Smith paper as follows:
`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 in the executive management group. The trust's executive directors met in the executive directors group ... on a weekly basis.' [112]
93 Further, `The director of operations did take on a key role on behalf of the chief executive in working alongside directorate general managers.' [113]
94 As for the clinical directors, they:
`... met on a monthly basis with the chief executive and medical director in the clinical policy board/management board. The involvement of the clinical directors in the mainstream management of the trust appears to have been dependent on the role of the chief executive as go-between and lynchpin between the directorates and the central management.' [114]
95 Mrs Ferris, as the General Manager of Cardiac Services from November 1994, described how she saw the lines of accountability:
`Within cardiac services, I perceived that I was working very closely with the Clinical Director, the relationship with the Clinical Director was such that ... we considered ourselves to be sort of a unit; we worked together very closely, so I was obviously accountable to the Clinical Director, but it was not like that in terms of our general work. I did not see a line management relationship between me and the Clinical Director of cardiac services. I perceived us as a unit that worked closely together. Beyond that, I saw myself as accountable to Margaret Maisey, and I saw the Clinical Director as accountable to John Roylance.' [115]
96 As for other groups, physiotherapists were responsible through their professional head to the Trust's Director of Nursing who was also responsible at Trust level for the Professions Allied to Medicine. Perfusionists were responsible to both the surgeons and, particularly, to the anaesthetists. [116]
97 Mr Wisheart's view was that, from the time of setting up the Trust, there were defined lines of responsibility and accountability from the Associate Clinical Director to the Clinical Director to the Chief Executive. This included management of the framework structure within which patient care was provided but did not include details of how an individual patient was cared for nor how any individual consultant exercised their clinical duties. In relation to accountability, Mr Wisheart was of the view that:
`... in the period 1990-95 accountability increased for doctors in relation to their management responsibilities. Each consultant was responsible to the Associate Clinical Director, who in turn was responsible to the Clinical Director, the Chief Executive, etc. Each doctor became more conscious of their obligation to openly review their clinical work within the audit process, but there was no routine requirement to report the findings of audit outside the audit group.' [117]
98 Dr Roylance described the development of the system of devolved management:
`In the many discussions about the interrelationship between the Directorate General Manager and the Clinical Director, the suggestion emerged - I remember who made it - that we should not argue about who was accountable to whom; that was a sterile conversation; we should put them in the managerial bubble and say between them, they would manage the directorate. That is how it started. The bubble was accountable to me.
`As time went on, over the next three years or so, it became clearer that the Clinical Director would be accountable to me and the Manager would support the Clinical Director, so that was an evolutionary thing, but it was in order to overcome considerable anxieties. You will remember that for the very first time we were introducing consultants into the general management function.' [118]
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Footnotes
[89] INQ 0038 0011; Ham/Smith paper
[90] INQ 0038 0012; Ham/Smith paper
[91] INQ 0038 0023; Ham/Smith paper
[92] WIT 0108 0006 Dr Roylance
[93] INQ 0038 0007; Ham/Smith paper
[94] WIT 0159 0010 Ms Evans
[95] WIT 0159 0010 Ms Evans
[96] WIT 0171 0006 - 0007 Dr Thorne
[98] Consultant cardiologist, BRI; Professor Vann Jones was the Clinical Director for General Medicine from 1 October 1989 until 30 September 1993
[99] WIT 0115 0002 Professor Vann Jones
[100] INQ 0038 0008; Ham/Smith paper citing WIT 0086 0006 Mr Durie
[101] INQ 0038 0008; Ham/Smith paper citing WIT 0086 0006 Mr Durie
[102] WIT 0120 0016 Mr Wisheart
[103] WIT 0079 0007 Mr Boardman
[104] WIT 0079 0281 Mr Boardman
[108] WIT 0079 0279 Mr McKinlay
[109] INQ 0038 0005; Ham/Smith paper
[110] WIT 0089 0032 Mrs Ferris
[112] INQ 0038 0008; Ham/Smith paper
[113] INQ 0038 0013; Ham/Smith paper
[114] INQ 0038 0017; Ham/Smith paper
[116] WIT 0120 0021 Mr Wisheart
[117] WIT 0120 0026 Mr Wisheart (emphasis in original)