Final Report > Chapter 15: The Culture and Management at the UBH/T > The approach to management
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The approach to management
2 We have already set out in Chapter 7 what we take to be the style and culture of management which dominated the UBH/T from the late 1980s until 1995: a clinician-management divide; an excessively devolved system of management; an oral culture; a commitment to turning questions back on the questioner. While adopted with due consideration and considerable dedication by Dr John Roylance, we take the view that this approach to management resulted in a concentration of power combined with a fragmentation of responsibility. This militated against the provision of an adequate standard of care. Not least, it meant that early warning signals of problems were less likely to be picked up if the care provided by some unit of the organisation were to become less than adequate.
3 We focus here for the most part on the period from 1989 onwards, as the move towards trust status began. But we point out that Dr Roylance was District General Manager (DGM) of the UBH from 1985 onwards and then Chief Executive of the UBHT, and had been a senior figure in the healthcare community for a number of years before 1985. Moreover, many others who occupied positions of influence in the UBH/T had been in place for a long time: Mr Wisheart, Mrs Maisey, Mr Nix and Dr Joffe. This undoubtedly brought the advantage of continuity and camaraderie. It also, however, posed the risk of creating a `club culture' whereby some belong and others are excluded: a risk which in our view became a reality.
4 The move to trust status and the internal market, begun in 1989 and completed when UBHT became a `first wave' trust in 1991, was welcomed by Dr Roylance. He saw it as an opportunity to resolve the conflicts over scarce resources which had traditionally existed between managers and clinicians, by bringing clinicians into management. In this way, as presaged in the Griffiths Report, clinical expertise would be brought to bear directly in the making of hard decisions. As a corollary, clinicians would also bear some of the responsibility for those decisions. But for this responsibility to be acceptable to the clinicians, it was recognised that it would need to be accompanied by assurances to clinicians that they would be free from interference in the exercise of their clinical activities. `Clinical freedom' was not to be trespassed upon by management. Dr Roylance considered himself ideally suited to this approach. He took the view that, as a doctor, he understood the boundary between the clinical and managerial, and could be trusted by his fellow doctors not to cross it. This view was not shared by all. Miss Catherine Hawkins, Regional General Manager (RGM) of the South and West Regional Health Authority (SWRHA), 1984-1992, told the Inquiry that she felt that it was difficult for Dr Roylance to perform the DGM role: `It was more difficult for him as a doctor managing doctors, and ... 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.' [1] On the other hand, Dr Ian Baker, a clinician, described Dr Roylance as `a reassuring District General Manager'. [2]
5 Dr Roylance had worked in Bristol since 1963 (beginning as a senior registrar in diagnostic radiology at the BRI). In 1985 he was one of only 15 clinicians among the 188 district general managers appointed to a DGM post, following the Griffiths Report. [3] He provided a valuable element of continuity during the transition to trust status. His experience equipped him well to develop a management system based on clinical directorates, each led by a clinical director to whom the directorates' general managers were to be accountable. The system of clinical directorates was set up in 1989. Such a system was not unusual at the time, although the size of the Trust may have added to the difficulty of devising an appropriate management structure. Thirteen directorates were established. [4] Even taking account of the size of the Trust, this was a large number of distinct, separate units. We consider that the UBHT might have benefited from an additional tier of management for this large group of directorates. [5] Unfortunately, but perhaps predictably, the clinical directorates at the UBHT in practice became isolated from each other. This led in turn to a lack of effective means of communication between them. We have described this as the development of `silos', channelling activities into separate and distinct compartments which did not effectively communicate with each other. This `silo' effect created the environment in which it was difficult for managers at the centre to learn of developments, and particularly of problems, in the different parts of the organisation at an early stage before they became intractable.
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Footnotes
[3] See Annex B, 10l Smith J and Ham C (2000): An evaluative commentary on health services management at Bristol
[4] They were anaesthetics, community services, dentistry, medicine, mental health, medical physics, obstetrics and gynaecology, oncology, ophthalmology, paediatrics, pathology, radiology and surgery
[5] See Figure 3 in Chapter 5 showing a diagram of the structure of the UBHT