Final Report > Chapter 24: A Health Service which is Well Led > Messages from Bristol

Messages from Bristol

• The national leadership of the NHS, as between government and professional organisations, was confused and fragmented. No one was really clear about who was ultimately responsible for standards and the quality of care.
• Accountability of the UBH/T to local health authorities and to the Department of Health was confused. Within the hospital, mechanisms of accountability between the central management and the clinical directors, and between clinical directors and clinicians, were unclear and ambiguous. In particular, no one was entirely clear who was responsible for maintaining and improving the quality of care for patients.
• Leadership in Bristol was fragmented: clinical leaders were expected to take responsibility for discrete areas of clinical care; managers were expected to focus on non-clinical matters. A separation was created which was hard to sustain. Delegation of authority from the Chief Executive to clinical directorates created `silos' (discrete organisational units with very little communication between them) within the Trust. These were almost separate organisations. Strategic leadership from the centre was weak. Communication was up and down the system but not across it.
• There was a contradiction at the core of the organisation in Bristol: a rigid formal system of management, which separated clinical and non-clinical issues, coexisted with an actual system in which the Chief Executive and a small group around him really managed all aspects of the hospital. Those working in the hospital found this difference between the declared system and the actual system confusing and unsettling. The workforce felt alienated if they did not belong to the `inner circle'.
• There was an insular `club' culture, in which it was difficult for anyone to stand out, to press for change or to raise questions and concerns.
• The Trust Board, from its inception, was remote from the main activity of the hospital, which was, caring for patients. The Chair of the Board and non-executive directors were not routinely or systematically involved in formulating policy or monitoring the performance of clinical care.

1 In this chapter we argue that the highest priority still needs to be given to improving the leadership and management of the NHS, at every level. By this we mean that there needs to be a consistent effort from government and from the top of every NHS organisation to ensure that the NHS is organised for and works in the interests of patients, and to ensure that the quality and safety of care are central. It also means that there must be clarity as to who is responsible and accountable for the quality and safety of care. This applies at the level of organisation and at the level of individual healthcare professionals. In what follows, we address the issue of leadership in stages. First, we review, briefly, the recent history of how quality of care has been regarded in the NHS, including the changes introduced in the last three years. Secondly, we consider what further changes may be needed, in the light of Bristol, to the strategic framework for the quality of care provided by the NHS. Thirdly, we consider the arrangements for management and accountability within the NHS and ask whether these are such as to enable those directly responsible for managing NHS organisations to be able to deliver care of a good quality to patients. Fourthly, we examine in more detail the external checks and balances that are required to ensure that patients can have confidence in the quality of care.