Final Report > Chapter 4: The Changing NHS 1984 - 1995 > A series of initiatives > The introduction of general management

The introduction of general management

7 The second initiative which we must refer to is the Griffiths Report and the consequent introduction into the NHS of the notion of the general management.

8 In February 1983 the then Secretary of State for Health and Social Security, Norman Fowler, established an inquiry into the effective use of manpower and related resources in the NHS. A team led by Roy Griffiths, Deputy Chairman and Managing Director of Sainsburys, presented their report, which was very short (25 pages), in October 1983. Its findings are often summarised in the well-known quotation:

`In short if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge.' [4]

9 Roy Griffiths and his team took the view that the NHS had no coherent system of management at a local level. It lacked any real continuous evaluation of its performance against normal business criteria: levels of service; quality of product; operating within budgets; cost improvement; productivity; motivating and rewarding staff; research and development. Precise objectives for management were rarely set and there was little measurement of health outcomes. There was little evaluation of clinical practice and even less evaluation of the effectiveness of clinical interventions.

10 In June 1984 Norman Fowler announced to Parliament that he accepted the recommendations of the Griffiths Report. During the 1980s, he and his successors introduced the following:

• General managers: drawn from inside and outside the NHS, were to be introduced into health authorities as soon as possible and into hospitals and units by the end of 1985.
• Management budgets: were to be introduced into hospitals as soon as possible, together with a further strengthening of the processes of financial accountability, which was to be extended to hospitals and units.
• Value for money: existing initiatives and audits were to be extended and the savings ploughed back into improving services for patients.
• Management training and education: the NHS Training Authority was established and programmes were to be increased, particularly for doctors. [5]

11 The introduction of general management brought to an end the health authority's district management team (DMT) and the philosophy of `management by consensus'. This approach had existed since the previous reorganisation of the NHS in 1974, but Griffiths saw it as reactive and concerned with crisis management. A general manager and line management within hospitals replaced the DMT. The general managers of hospitals were operationally and professionally accountable to their counterparts in the district health authority (DHA). General management represented a radical change to both organisation and management across the NHS. It was intended to offer active, strategic direction and to devolve responsibility through a clear structure of line management and devolved budgets.

12 A crucial element in the introduction of general management was the recognition of the need to find a way of involving doctors, in particular senior doctors, in the
day-to-day management of the NHS. Throughout the 1980s various models were tried. None was successful until the model of the `clinical directorate' attracted interest and support.

13 Clinical directorates were developed in 1972 at the Johns Hopkins Hospital in Baltimore, USA. The model was championed in the United Kingdom by Professor (later Sir) Cyril Chantler of the United Medical and Dental Schools of Guy's and St Thomas' Hospitals.

14 The model suggested that clinical services should be organised into a series of directorates. Each directorate would have a clinical director or lead consultant, usually chosen by the other doctors within the directorate, to act on their behalf. The clinical director was expected to assume responsibility for providing leadership to the directorate and to represent the views of all the clinical specialties. The clinical director was expected to initiate change, agree workloads and resource allocation with the unit general manager, and act as the budget holder for the directorate.

15 The relationship between the clinical director and colleagues was not seen as one of line management. Rather, the clinical director was expected to negotiate and persuade colleagues. Equally, the relationship between the clinical director and the unit general manager was seen as one of negotiation and persuasion.

16 The pace at which hospitals introduced clinical directorates varied widely. By 1989, a clinical directorate system was beginning to develop in Bristol, in response to national encouragement [6] and in preparation for the establishment of the UBHT. The model adopted by Dr Roylance, Chief Executive of the UBHT and previously District General Manager, was based on 13 clinical directorates [7] each managed by a clinical director, who was a consultant, and by a general manager. The aim was for the clinical director to be `in charge of' the doctors and the general manager to be responsible for everyone else. [8]

17 Another feature of the approach advocated by Griffiths and reflected in the new arrangements, challenged what had hitherto been basic values of the NHS: the translation into the public sector of the idea of focusing on producing satisfied consumers. Indeed, the recipients of public services began to be described as consumers, or customers. This constituted a major challenge to the notion that the standards and the outcomes (or outputs) of the NHS were the preserve of the healthcare professionals.

18 A fundamental difficulty in implementing the Griffiths Report lay in the simple fact that an organisation in the public sector such as the NHS is not like a commercial business. There were no major incentives available to persuade those working in the NHS to change their ways of working. Nor were the economic sanctions of the private sector available. If a business failed to perform adequately it was taken over or made bankrupt. The hospital had to continue to offer a service; it could not just be closed down.