CONTENTS

SUMMARY

INTRODUCTION

CONCLUSIONS AND RECOMMENDATIONS

CONCLUSIONS

Members of the Inquiry

Proposed Organisational Changes

Deciding Policy and Decision Making

Role of Doctors

Role of Nurses, Technicians and Ancillary Staff

Estate Management

Conditions of Employment

Role of Personnel Director

Function and Responsibility

Comparison with 1974 Reorganisation

Terms of Reference and Inquiry Report

OVERALL CONCLUSIONS AND RECOMMENDATIONS

REPORT

MEMBERS OF THE INQUIRY

PROPOSED ORGANISATIONAL CHANGES

Health Services Supervisory Board

General Management

NHS Management Board

Regional Health Authorities

District Health Authorities

Units

ROLE OF DOCTORS

ROLE OF NURSES, TECHNICIANS AND ANCILLARY STAFF

ROLE OF OTHER FUNCTIONS

Estate Management

Works Function

Family Practitioner Services

RESPONSIBILITIES AND ACCOUNTABILITY OF MANAGERS

ROLE OF PERSONNEL DIRECTOR

CONDITIONS OF EMPLOYMENT

ROLE OF EXECUTIVES

FUNCTION AND RESPONSIBILITY

DECIDING LOCAL POLICY

At Present

Proposed

Consultation

Organisational Effectiveness

COMPARISON WITH 1974 REORGANISATION

NOTES <..> and REFERENCES {..}

Relevant Current and Associated Works

Relevant Subject Index Pages and Site Overview

SUMMARY

This report was published in January 1984 (closely following the publication of the Griffiths report) and correctly predicted the devastating consequences which would result from accepting the Griffiths proposals.

Manfred Davidmann based his conclusions on General Management principles which are discussed in some detail. His report has become a classic study of the application and effect of General Management principles.

It is a comprehensive evaluation of the changes proposed in the Griffiths report and of their likely effects. The proposed changes amounted to a fundamental and far-reaching reorganisation which, working from the top downwards, could be expected to completely alter the style of control and management in the National Health Service.

Manfred Davidmann's report cuts through all the jargon to give a clear understanding of the way work in the NHS would be affected and how services to patients would deteriorate as a result of the Griffiths report's proposals.

The effects of the proposed changes on the work and career prospects of doctors, administrators, nurses, technicians and ancillary employees are discussed. The report also includes sections on organisational changes, on conditions of employment, and much else.

INTRODUCTION

The 'Griffiths report' is a letter from the NHS Management Inquiry's members to the Secretary of State for Social Services in which they report conclusions and recommendations for action. In other words it is a report written in the form of a letter which was submitted to the Secretary of State as a basis for action.

The impact of the proposed changes would be enormous. They would affect medical staff from top to bottom of the Health Service, they would fundamentally alter the relationship between administrators and other staff, they would affect the whole population. Hence the need for an independent evaluation of the proposed changes.

This report is an independent evaluation of the proposed changes as well as of their effects, from the point of view of NHS management and staff, of patients and of the community.

The process of evaluating the Inquiry's document {1} was made difficult both by its brevity and by the absence from the document of detailed back-up material supporting the proposals.

CONCLUSIONS AND RECOMMENDATIONS

CONCLUSIONS

MEMBERS OF THE INQUIRY

The four members of the Inquiry were backed by three supporting staff and they worked at this inquiry from 3/2/83 to 6/10/83, a period of about eight months, the report being published on 25th October 1983.

What is completely missing from the Inquiry team is grass-roots representation of any kind from all those who would be affected by the Inquiry's findings, namely from doctors, nurses, technicians, ancillary staff, NHS patients, the community at large, the Civil Service, Community Health Councils and Trade Unions.

PROPOSED ORGANISATIONAL CHANGES

What is proposed is a fundamental restructuring of the NHS organisation structure and a fundamental reorganising of duties and responsibilities, accountability and control.

Accountability, within responsibilities and reporting chains, is to be reviewed right down to the level of unit managers and the roles of chief officers redefined accordingly. It is the "functional management structures" which are to be reviewed and reduced.

DECIDING POLICY AND DECISION MAKING

Each Authority's part-time Chairman is to appoint <5> a new full-time 'Executive' who is to make the day-to-day decisions.

In the case of 'Authority meeting' members who might possibly raise objections to policy proposals or decisions made by the chairman, it seems that the chairman would in effect have power to direct them since he is apparently to lay down what individual members may do in relation to particular areas of interest.

This seems to indicate that organisation would change fundamentally. It also seems to me that the changes would facilitate markedly the obtaining of agreement to policy decisions made or proposed by the part-time chairman and to day-to-day decisions made by the Executive he has appointed.

It further seems to me that the changes would also facilitate the implementation of decisions made by the Supervisory and Management boards, since apparently the method and process of selecting and appointing chairmen and members of Authorities is to be reviewed by the NHS Management Board as a consequence of the way in which responsibilities are allocated between chairman, Executive, Authority meeting and individual members.

The job of the proposed executives would appear to be checking up on how money is being spent, comparing expenditure with predetermined budgets. Judging by sanctions which are to be "more easily available", they are apparently also to ensure adherence to these budgets.

Management (that is executives) are apparently to provide patients and the community with what management and higher authority think is good for them. Hence higher authority is apparently to decide what is to be done for patients and community instead of reacting to their needs. That is instead of trying to ensure by a process of consultation and participation at all levels that management allows for and provides the kind of effective treatment and service needed by patients and the community, whose needs are expressed by and through the various Community Health Councils, Joint Staff Consultative Committees and community organisations.

A manager's performance is apparently also to be judged by the extent to which he accepts the new style of management and by the extent to which he can persuade his subordinates to accept the new style of management and its objectives, the ultimate sanction for failing to perform efficiently being dismissal.

It seems that the Inquiry report's recommendations would reduce functional management, consultation and teamwork in the NHS, would move decision making to the top and interpose another five levels of management into the reporting chain.

This does not appear to make sense from a management point of view and it is possible for the Inquiry report's recommendations to have the effect of creating a more authoritarian organisation with a tougher style of management.

In my opinion the Inquiry report's proposals as a whole would have the effect of considerably reducing the effectiveness of the NHS.

ROLE OF DOCTORS

Functional (medical, nursing, technicians, ancillary) management structures are to be reviewed and reduced. At each level functional managers are to be responsible primarily to Executives who are to be appointed <5> by Authority Chairmen. The Executive is also to be the final decision maker for decisions made by teams at present, including decisions which involve more than one function.

It seems that the management functions of doctors are to be reduced and that they are to be given tight budgets. It seems also that they are to be given rules, procedures and performance targets devised by what can be non-medical managers, that is executives.

Doctors, and particularly those in more senior positions, are apparently to be held responsible and accountable to executives for adhering to spending limits decided by others at higher levels.

It also appears that they would be set standards of performance such as number of patients to be treated every hour, or how many diagnoses are to be made per clinic, or how many operations have to be carried out at what sort of speed on what sort of patients.

The proposed executives are to set the programmes and priorities for the work of what are in effect their subordinates, in this case functional chief officers. The executive's work also includes monitoring of the professional aspects of professional work at other levels.

The new executives are apparently to take over from functional managers such as doctors the really interesting and responsible decision making part of their work, which would in the end amount to downrating top professional work and skill to the monotonous routine of a place on a production line without real say in directing and managing the national health service, or about the type and extent of the service to be provided, with even their own work and speed in effect outside their control, determined and laid down by someone else.

ROLE OF NURSES, TECHNICIANS AND ANCILLARY STAFF

Roles of functional chief officers are to be redefined, "functional management structures" are to be reviewed and reduced, and functional managers <4> are to be responsible first and foremost to the newly appointed executives instead of to their own functional managers.

Not only are each Unit's nursing levels to be fundamentally re-examined, but manpower levels in other staff groups are also to be reviewed.

Much of what has been said in the immediately preceding section 'Role of Doctors' applies also to the other functions. Here also decision making is apparently to move to higher levels backed by tight budgets with emphasis at all levels on measuring output against "stated management objectives and budgets".

In the same way as for doctors so apparently the professional work of other functions would in the end be downrated with what would in effect be demotion for their managers combined with in due course a corresponding consequent limiting of pay scales and thus much reduced promotion prospects.

ESTATE MANAGEMENT

The Inquiry report recommends that "a property function" should be established which should be directed from the top, for the commercial exploitation of the NHS "estate".

If profit were at any time to be the main consideration then the top could decide that it is more profitable to close down a 'surplus' hospital and sell it and its grounds to a developer, compared with spending money on keeping the hospital going as a functioning unit providing an essential service needed by the local community. When you look at it from the point of view of the community's needs and the very good and cost-effective service provided by the hospital then it is clear that profit cannot be the sole, or even the main, consideration.

CONDITIONS OF EMPLOYMENT

We have seen that the changes proposed for functional chief officers and managers in effect amount to demotion since the discretionary (responsibility) part of their work would be done by someone else. It follows that pay levels and ranges would in due course be limited accordingly.

Bearing in mind the Inquiry's recommendation that functional management structures should be reduced, there would also seem to be little prospect of staying in, or promotion to, higher grades of service and thus of better pay for functional managers such as doctors, nurses and technicians.

But the Personnel Director is also

"to ... identify any conditions of service which are not cost effective in management terms"

This is disturbing because it seems so vague and since it could include pensions (a waste of management's funds in the opinion of some), staffing levels determined by cost rather than needs of patients, and any wage that can be reduced further without regard to considerations other than management's, that is without regard to the needs of employees for a reasonable standard of living for themselves and their families.

ROLE OF PERSONNEL DIRECTOR

Apparently he is to assist in applying what seems to be a dissatisfying and thus disliked style of management.

He <6> is also to take over work on determining optimum nurse manpower levels in various Units so that Regional and District Chairmen can re-examine fundamentally each Unit's nursing levels. Manpower levels in staff groups other than nurses are also to be reviewed.

It is surely not the function of a Personnel Department to be responsible for Time and Motion (Work) studies or to evaluate different ways of manning a production unit or hospital ward as a preliminary to reducing staffing levels.

If a Personnel Department carried out Time and Motion studies or were responsible for such work, then this would have far-reaching consequences to relations between Personnel managers and employees. It is my opinion that any Personnel Department responsible for such activities would soon lose all credibility as regards the workforce as it would be seen to be confronting, instead of looking after, the employees.

The carrying out of such studies is clearly not part of the work of a Personnel function and the Personnel Director should not be made responsible for such work.

FUNCTION AND RESPONSIBILITY

The division of work has to be functional if organisation is to be effective. Managers have to be aware of this and need to understand functional relationships. Managers have to be skilled in working well with other people, co-operating with them and getting their co-operation in return, and need to be trained in this.

Enterprises run on non-participative or authoritarian lines are generally considerably less effective than participative enterprises. {2, 3}

COMPARISON WITH 1974 REORGANISATION

The changes of the 1974 reorganisation were comparatively mild when compared with the changes proposed by the present Inquiry's report.

The effects of the 1974 reorganisation were disruptive. The corresponding effects of the proposals in the present Inquiry's report would in my opinion be devastating.

TERMS OF REFERENCE AND INQUIRY REPORT

The UK is not only the sixth largest oil producer in the whole world but also industrialised and self-sufficient in oil so that as a country we are very much better off than say the Japanese or the Germans, the French or the Italians.

How our government spends our money is a matter of choice. But it spends much less on the nation's health than other countries. The proportion of our national product which is spent on our health is way below that of countries at roughly the same level of development. For example Canada and Sweden, France and West Germany, Italy and the Netherlands, all spend a far greater proportion of their national product on health care, spending like for like roughly 30% more than we do.

Our national health service is on the whole staffed by good experienced and caring people who selflessly make our health service work simply because they are concerned and care. The satisfaction derived from their work matters to them and we may well be paying them less than their worth because of this.

One cannot over-emphasize the importance of the changes put forward in the Inquiry's report. They amount to a fundamental and far-reaching reorganisation which, working from the top downwards, would completely alter the style of control and management in our NHS, in what is perhaps the biggest organisation and employer in the United Kingdom and one of the largest in Western Europe, on which depends the health and welfare of the whole population.

Hence one would expect fully documented conclusions and recommendations backed by comprehensive investigations and findings. The Inquiry undoubtedly spent a good deal of time seeing different people, visiting different parts of the service, must have done a lot of work over a period of eight months. But the Inquiry report does not provide details about what was done and how it was done, what facts were established and the conclusions drawn from them, so that it seems to me that what is missing from the report is much of the basis for their consequent recommendations. However, the Inquiry report states that the Inquiry was only asked for 'recommendations on management action' and not for a report.

Far-reaching decisions are to be taken affecting not just the many people working so selflessly and well throughout the NHS but the whole population, its health and thus our future. It thus seems surprising that the Inquiry report's far-reaching recommendations could be considered for implementation, and for speedy implementation at that, without a wide-ranging debate in Parliament and among the community at large on the basis of full information.

OVERALL CONCLUSIONS AND RECOMMENDATIONS

Since the Griffiths report on NHS management:

- is apparently not really about improving the quality of management or about providing a more cost-effective better service

- contains no back-up material to show what was done and how it was done and how the conclusions were derived from the findings

- contains no information about the likely cost of the proposals or indication of hoped for gains in material terms

and since its recommendations:

- appear to run counter to good management practice and could reduce the effectiveness of the NHS

- would in effect replace

- the making of District and Unit policy decisions at these local levels by local management teams

- by an apparently rigid system of direction from, and accountability to, the top

and since far reaching decisions are to be taken:

- affecting not just the many people working so selflessly throughout the NHS but the whole population, its health and thus our future

the recommendations made in the Griffiths report should be rejected.

REPORT

MEMBERS OF THE INQUIRY

The four members of the Inquiry were backed by three supporting staff and they worked at this inquiry from 3/2/83 to 6/10/83, a period of about eight months, the report being published on 25th October 1983.

What is completely missing from the Inquiry team is grass-roots representation of any kind, from all those who would be affected by the Inquiry's findings, namely from doctors, nurses, technicians, ancillary staff, NHS patients, the community at large, the Civil Service, Community Health Councils and Trade Unions.

PROPOSED ORGANISATIONAL CHANGES

What is proposed is a fundamental restructuring of the NHS organisation structure and a fundamental reorganising of duties and responsibilities, accountability and control.

A "Health Services Supervisory Board" and a full-time "NHS Management Board" are to be appointed.

The Health Services Supervisory Board is to be chaired by the Secretary of State and apparently whatever power the Secretary of State has in relation to the NHS would be exercised by the Supervisory Board which would have the same authority as the Secretary of State and the DHSS in these matters.

The NHS Management Board is to be "under the direction of the Supervisory Board and accountable to it" and is to cover all aspects of the NHS management, and all the DHSS's NHS management responsibilities, "including

Regional and District Health Authorities,
Family Practitioner Committees,
Special Health Authorities, and
Other centrally financed services"

It is to control directly:

Supply Council NHS Training Authority
Computer Policy
Health Information

and include "personnel, finance, procurement, property, scientific and high technology management and service planning".

The Inquiry's report says that their proposals "will require major changes ... in the public and parliamentary requirements of ... NHS management"

HEALTH SERVICE SUPERVISORY BOARD

This is to include

the Minister of State (Health)
the Permanent Secretary
the Chief Medical Officer
the Chairman of the NHS Management Board
two or three non-executive members with 'general management' skills and experience.

GENERAL MANAGEMENT

The term 'general management' is generally applied to the combination of knowledge and skills which underlie effective directing of the work of others for whom one is responsible, and the higher the level of a position in the organisation the greater is the general management content of the work to be done.

This applies to each level within any reporting chain, to each level within any functional group. And one of the essential ingredients of general management is the understanding of functional relationships between different groups, departments or divisions. {2}

But in the Inquiry report the term 'general management' is used in a very different sense, as if it were a function in its own right. And their terms 'general managers' and 'general management process' apparently refer to 'cross-functional co-ordinators' and 'cross-functional co-ordination', to 'administrators' and 'administration'.

So as to avoid misunderstandings and confusion arising from the way general management terms are used in the Inquiry report, I will here be using the more specific and generally familiar terms 'management' and 'executives'.

NHS MANAGEMENT BOARD

The full-time NHS Management Board is to be chaired by a manager who in effect would be the Managing Director of the NHS. He is also to "be appointed Accounting Officer for Health Service expenditure".

The NHS Management Board is intended to cover all aspects of national health service management and all the DHSS's NHS management responsibilities and it is to direct the NHS, that is "to plan implementation of the policies" decided on by the Supervisory Board, to tell the management of the NHS what is to be done, and to control 'performance'.

Considering both the Chairman (who is also Managing Director and Accounting Officer) and the Personnel Director the Inquiry report maintains that these appointments ought "to come from outside the NHS and Civil Service".

The NHS Management Board is to "review the method and process of selecting and appointing Chairmen and Members (of Regional and District Health Authorities) and advise the Supervisory Board accordingly on adjustments required".

The Managing Director is "to reduce the numbers and levels of staff involved in both decision making and implementation". Since the Inquiry recommends introducing two new levels of decision making (at the top), and at least another three new levels of decision making from Region to Unit levels, and a really large number of executives, it is functional groups such as doctors, nurses and technicians whose management structures and staffing levels are to be reduced.

REGIONAL HEALTH AUTHORITIES

Regional Chairmen are themselves appointed on a part-time and non-executive basis but are to appoint <5> at Authority level a full-time Region Executive having overall responsibility for performance in achieving the objectives set by the Authority.

Regional chairmen are to be enabled to reorganise the "management structure of the Authority", are to redefine the roles of functional managers, are to ensure that the primary reporting relationship of functional managers is to the Region Executive, and the Region Executive "would be the final decision taker for decisions normally delegated to the ... team, especially where decisions cross professional boundaries".

So the Region Executive would be the Regional Authority's chief executive.

Accountability, within responsibilities and reporting chains, is to be reviewed right down to the level of unit managers and the roles of chief officers redefined accordingly. We are told that it is the "functional management structures" which are to be reviewed and reduced.

Regional Chairmen are to be "directly involved in the appointment of District Chairmen by the Secretary of State" who would thus become more directly responsible and accountable to them.

DISTRICT HEALTH AUTHORITIES

What has just been said for Regional Authorities applies also to District Authorities:

District Chairmen are themselves appointed on a part-time and non-executive basis but are to appoint <5> at Authority level a full-time District Executive having overall responsibility for performance in achieving the objectives set by the Authority;

District chairmen are to be enabled to reorganise the "management structure of the Authority", are to redefine the roles of functional managers, are to ensure that the primary reporting relationship of functional managers is to the District Executive, and the District Executive "would be the final decision taker for decisions normally delegated to the ... team, especially where decisions cross professional boundaries".

So the District Executive would be the District Authority's chief executive.

Accountability, within responsibilities and reporting chains, is to be reviewed right down to the level of unit managers and the roles of chief officers redefined accordingly. We are told that it is the "functional management structures" which are to be reviewed and reduced.

UNITS

District Chairmen are to appoint a Unit Executive "for every Unit of management" and state their responsibilities.

The Unit Executive would be the Unit's chief executive.

Accountability, that is responsibilities and reporting chains, are to be reviewed right down to the level of unit managers and the roles of chief officers redefined accordingly. It is the "functional management structures" which are to be reviewed and reduced.

"The fact that Unit managers (administrator, nurse and clinician) are still being appointed" is seen as complicating the position. This presumably means that decisions made at present by administration, nursing and medical Unit managers are to be made by the new executives.

ROLE OF DOCTORS

At present it is consultants who make decisions about health care and thus about spending and who demand and spend resources. The Health Authorities approve the allocation of funds saying, for example, what should be spent on acute services compared with geriatrics. Control of consultants' use of funds is by the number of beds allocated to each consultant. He makes his decisions based on bed-availability and on basis of suffering, probability of death and so on, and such decisions are often made on basis of committees and meetings between consultants and concerned members of staff from different functions.

The Inquiry report, however, puts forward that in general the making of decisions should be taken out of the hands of hospital and Unit managers and be done at higher levels, saying that

Higher management should argue against hospitals and Units taking all their own day-to-day management decisions and argue for the "taking of particular decisions at a ... higher level of management" and that

"Many hospitals do not yet have budgets".

It would be a mistake to assume that the term 'higher management' refers to functional management, that is of doctors by doctors or of nurses by nurses. It apparently refers to the proposed new kind of executives who are to have overriding authority at each level over their functional colleagues and thus over doctors.

We have already seen that it is the functional (administrative, medical, nursing, technicians', ancillary) management structures which are to be reviewed and reduced, that at each level the primary reporting relationship of functional managers is to executives, that the executive is to be the final decision maker for decisions made by teams at present especially where decisions cross functional boundaries.

Budgets are a valuable aid to planning when the amounts have been agreed in the first place and when it is realised that they are an aid, and no more than an aid.

It would appear that the Inquiry report's point is about budgets, about who spends how much and on what, and it appears to be arguing that budgets should be decided at higher levels, that spending limits should be set for consultants and others by means of budgets passed down to them. For example:

Reviewing accountability "needs to be extended ... particularly to major hospitals, and it should start with a Unit performance review based on ... budgets which involve the clinicians".

In other words doctors, and particularly those in more senior positions, are apparently to be held responsible and accountable to executives for adhering to spending limits decided by others at higher levels:

"Doctors ... must accept ... management responsibility", particularly in clinical posts, and this should be recognised when "constructing the system of management budgets".

The term 'management responsibility' instead of meaning 'responsibility for managing' apparently means 'responsibility to, that is accountability to, executives'.

It seems that the management functions of doctors are to be reduced and that they are to be given tight budgets. It seems also that they are to be given rules, procedures and performance targets devised by what apparently can be non-medical managers, that is executives. For hospitals and Units, for example, the District Chairmen would be expected to ensure that

"The time at present spent by doctors in meetings, committees, etc.," is to "be reduced and employed more purposefully"

by "a fully developed management budget approach" including tight budgets

by giving them "strictly relevant management information"

and by finding a "measurement of output in terms of patient care".

It also appears that they would be set standards of performance such as number of patients to be treated every hour, or how many diagnoses are to be made per clinic, or how many operations have to be carried out at what sort of speed on what sort of patients.

Examples of possible measures are 'minutes per operation', 'consumption of essential supplies and drugs', 'patient care expressed in terms of length of stay in hospital'.

If such measures were to be evaluated primarily against cost rather than clinical need, and if 'output measurement' refers to 'operations carried out' rather than 'patients cured' and/or 'patients waiting' for the operation, then the Inquiry's proposals would have the effect of emphasising cost limitations at the expense of service needs.

When the Inquiry report states that

"Clinicians must participate fully in decisions about priorities
in the use of resources"

then this apparently means that doctors are to adhere to decisions made by executives about the use of resources which include doctors' time and work but which may be decided on basis of considerations other than medical and humane, that is on basis of 'management' objectives decided at the top:

"Output measurement, against clearly stated management objectives
and budgets, should become a major concern of management
at all levels".

The defining of measurements of output for doctors needs also to be viewed in the light of the Inquiry report's recommendation that there should be reviews of manpower levels in staff groups, and the Inquiry report's objection to the appointing of further Unit functional managers such as doctors, nurses, and so on.

The proposed executives are to set the programmes and priorities for the work of what are in effect their subordinates, in this case functional chief officers. The executive's work also includes monitoring of the professional aspects of professional work at other levels. So it seems that doctors and their functional medical line managers are at each level to be subordinate to the new 'executives' and that they are expected to fit in with the new style of management. <1>

Hence consultants could thus be placed in the position of having at times to justify or condemn more junior colleagues in discussions and arguments with non-medical executives for whom these doctors, and the consultants at the higher level, are both working.

The new executives are apparently to take over from functional managers the really interesting and responsible decision making part of their work, which would in the end amount to downrating top professional work and skill to the monotonous routine of a place on a production line without real say in directing and managing the national health service, or about the type and extent of the service to be provided, with even their own work and speed in effect outside their control, determined and laid down by someone else.

The changes proposed for functional chief officers and managers in effect amount to demotion since the discretionary (responsibility) part of their work would be done by someone else. It follows that pay levels and ranges would in due course be limited accordingly.

Bearing in mind the Inquiry's recommendation that functional management structures should be reduced, there would also seem to be little prospect of staying in, or promotion to, higher grades of service and thus of better pay for functional managers such as administrators, doctors, nurses or technicians.

ROLE OF NURSES, TECHNICIANS AND ANCILLARY STAFF

The new 'executives' are given overriding responsibilities and the Inquiry report's recommendations for the NHS functions other than doctors appear to be much the same as those for doctors. <4>

The roles of functional chief officers are to be redefined, the "functional management structures" are to be reviewed and reduced, and functional managers are to be responsible first and foremost to newly appointed executives instead of to their own functional managers.

Not only are each Unit's nursing levels to be fundamentally re-examined, but manpower levels in other staff groups are also to be reviewed. It is the Personnel Director who is intended to be responsible for determining manpower levels (This is discussed in more detail with respect to nursing and other staff in section 'Role of Personnel Director' below).

Much of what has been said in the immediately preceding section 'Role of Doctors' applies also to the other functions. Here also decision making is apparently to move to higher levels backed by tight budgets with emphasis at all levels on measuring output against "stated management objectives and budgets".

In the same way as for doctors so apparently the professional work of these other functions would in the end be downrated with what would in effect be demotion for their managers combined with in due course a corresponding consequent limiting of pay scales and thus much reduced promotion prospects.

Procedures for appointments and conditions of service are also to be reviewed and this is discussed in more detail in section 'Conditions of Employment' below.

ROLE OF OTHER FUNCTIONS

ESTATE MANAGEMENT

"A property function" is "to be established" for "the commercial exploitation of the NHS estate" "as part of the general management responsibility" and this is to be directed by the top.

"so as to give a major commercial reorientation to the handling of the NHS estate"

The Inquiry's report recommends that "a property function" should be established which should be directed from the top, for the commercial exploitation of the NHS "estate".

If profit were at any time to be the main consideration then the top could decide that it is more profitable to close down a 'surplus' hospital and sell it and its grounds to a developer, compared with spending money on keeping the hospital going as a functioning unit providing an essential service needed by the local community. When you look it from the point of view of the community's needs and the very good and cost-effective service provided by the hospital then it is clear that profit cannot be the sole, or even the main, consideration.

WORKS FUNCTION

The "Works Function" is to be "critically examined" so as to reduce the number of professional staff in it and to reduce the capital project co-ordinating meetings required "within and between the different levels in the" NHS organisation. Further,

"The Chairman of the NHS Management Board should ensure that procedures for handling major capital schemes and disposal of property are streamlined and speeded up and provide maximum devolution from the centre to the periphery".

FAMILY PRACTITIONER SERVICES

The NHS Management Board is also to cover Family Practitioner Committees and the Inquiry report states that

"everyday management, policy-making and planning, and the allocation of resources"

"should be the responsibility of the Chairman of the Management Board and his fellow Board Members."

RESPONSIBILITIES AND ACCOUNTABILITY OF MANAGERS

Managers are expected to fit in with the new style of management and to "take staff along in a positive sense", which presumably means that they are to move their staff in the direction indicated by the Inquiry's proposals.

In this they "need to accept responsibility for their staff", which is presumably intended to convey that they are to ensure conformity.

Those who do not succeed in persuading their subordinates to accept the Inquiry's proposals or who fail to ensure conformity would clearly not be performing as expected and according to the Inquiry report "the sanction of removing the inefficient performers must also be more easily available than at present".

In other words it would appear that a manager's performance is also to be judged by the extent to which he accepts the new style of management and by the extent to which he can persuade his subordinates to accept the new style of management and its objectives, the ultimate sanction for failing to perform efficiently being dismissal.

ROLE OF PERSONNEL DIRECTOR

"The Secretary of State" is to "appoint, as a member of the NHS Management Board, a Personnel Director",

"from outside the NHS and the Civil Service" ... "whose main responsibility would be to ensure that ... the new style of management we are recommending" is supported.

Apparently he is to assist in applying what seems a dissatisfying and thus disliked style of management.

Personnel Department's close support of "line management" is to be strengthened "at each level". "The most important development to be achieved is one of ... attitudes: this will be done by the line management ... ." <2>

An important qualification, if we accept the Inquiry report's recommendations, is that the Personnel Director of the NHS in charge of all this (and also its Managing Director) should have no previous experience in the NHS and in the Civil Service and thus of the type of work being done and the service being offered, its present functional organisation and existing effective teamwork between so many specialist skills.

His responsibilities also include:

"to review procedures for appointments, dismissal, grievance and appeal" and to "secure the maximum devolution of responsibility for such matters".

He is to 'review', and this presumably means to 'change', but we are not told on what basis or for what purpose except in vague terms which can be interpreted in different ways.

So does the Inquiry report's statement mean that variations are to be allowed, that there can be variations from place to place? For example can one be dismissed for persistent latecoming in one Unit but no more than reprimanded in another?

It being the function of a Personnel Department to lay down rules and procedures which apply uniformly throughout the organisation, the term 'devolution' obviously cannot mean that all managers are to appoint, discipline and dismiss and are to deal with grievances and appeals, as they see fit. So it presumably means that Personnel Department are to issue rules and procedures which apply to all and which are to be followed by all.

Procedures are agreed by top management, are a record of decisions made at the top which are binding on those below.

So 'maximum devolution' would seem to mean issuing procedures covering the widest possible field so that those below do not have to make decisions on such matters but merely apply detailed rules and procedures which are formal instructions.

His responsibilities further include

to take over and continue with the DHSS work on "determining optimum nurse manpower levels in various types of Unit ...

so that Regional and District Chairmen can re-examine fundamentally each Unit's nursing levels"

and "to secure reviews of manpower levels in other staff groups".

Manpower is the largest part of the NHS's overall cost, and nursing the largest part of that, but if the level of nursing care is to be 're-examined fundamentally' by Regional and District Chairmen then presumably the purpose of the re-examination is to reduce spending and the term 'optimum' could be interpreted as meaning 'minimum cost'.

But a 'minimum cost' level of staffing can only be acceptable if it is compatible with professional standards agreed both by the nursing profession and by groups representing patients.

Furthermore, it is surely not the function of a Personnel Department to be responsible for Time and Motion (Work) studies or to evaluate different ways of manning a production unit or hospital ward as a preliminary to reducing staffing levels.

If a Personnel Department carried out Time and Motion studies or were responsible for such work, then this would have far-reaching consequences to relations between Personnel managers and employees.

I do not think that they would regard it as their job to be responsible for such work and indeed it is my opinion that any Personnel Department responsible for such activities would soon lose all credibility as regards the workforce as it would be seen to be confronting, instead of looking after, the employees.

The carrying out of such studies is clearly not part of the work of a Personnel function and the Personnel Director should not be made responsible for such work.

CONDITIONS OF EMPLOYMENT

The Inquiry report also recommends that the main responsibilities of the Personnel Director should include the following:

"to review the remuneration system and conditions of service"

and "to ensure" ... "performance appraisal and career development" ... from the top down to the Units

to enable "chairmen to reward merit or take action on ineffective performance"

"to review procedures for appointments, dismissal, grievance and appeal"

Presumably to change conditions of employment so as to ensure that performance is appraised and that careers depend on this, all the way from the top to the Units, that is for all the managers.

If we were talking about service-orientated and participative management then this would be fine but it seems that the objectives against which merit and performance are to be assessed are likely to be mainly cost-orientated. <3>

The Personnel Director is also

"to ... identify any conditions of service which are not cost effective in management terms".

This is disturbing because it seems so vague and since it could include pensions (a waste of management's funds in the opinion of some), staffing levels determined by cost rather than needs of patients, and any wage that can be reduced further without regard to considerations other than management's, that is without regard to the needs of employees for a reasonable standard of living for themselves and their families.

ROLE OF EXECUTIVES

Officers and managers in the different functions (such as doctors, nurses, technicians, ancillary workers) instead of being responsible to their own functional managers are to be directly responsible first and foremost to the new executives who would be telling them what they have to do, both the programmes for their work and their priorities.

From officers and managers at a higher level (who are to be responsible to him) the executive would be asking only for advice while making his own decisions, but he would also be monitoring the professional aspects of the work of their subordinates at lower levels.

Executives, for example, are to monitor professional aspects of medical line management's work, are presumably to tell nurses and doctors what they are to do. So it seems that professional decisions (such as medical and nursing) are to be made by the executives.

At Regional Authority, District Authority and Unit (hospital) level, their Executive is to have

"overall responsibility for management's performance in achieving the objectives set by the Authority".

It would appear that organisation would change fundamentally. It also seems to me that the changes would facilitate markedly the obtaining of agreement to policy decisions made or proposed by the part-time chairman and to day-to-day decisions made by the executive he has appointed. The changes apparently also facilitate the implementation of decisions made by the Supervisory and Management boards. <7>

So what we now want to know is just what are the objectives which are to be set and what are the decisions which have to be made?

Making profits is not an objective in the national health service and the job of the proposed executives would thus appear to be checking up on how money is being spent, comparing expenditure with predetermined budgets. Judging by the forms of sanctions which are to be "more easily available" they are apparently also to ensure adherence to these budgets.

FUNCTION AND RESPONSIBILITY

Surgeons, nurses, accountants, administrators and others are all doing their job, planning their work and how they spend their time, assessing and controlling their performance, to an extent which depends on their level in the organisation.

Organisation depends on what the organisation aims to achieve, depends on the work to be done. When different experts need to co-operate for aims to be achieved, then organisation has to be functional. Buying and selling for profit is vastly different from cost-effectively curing the sick, preventing ill health, improving the nation's health.

To compare this with business consider a firm like Sainsburys. It is much smaller than the NHS and the success of this retailing firm appears to be based on its pricing policy, that is on buying well and selling more by undercutting the competition so as to obtain greater profits.

The NHS, however, is non-profit making. The job of its employees is the really demanding one of working together in teams coping with human emergencies.

Operations and treatment result from the application of a very high level of professional as well as functional and management skills backed by administrative support. First class dynamic teamwork, characterised by smooth effective co-operation and by an absence of detailed instructions from the top, results from the delicate web of responsibilities and relationships between functional groups working together in teams, from the high level of functional and general management skills which are being used by functional managers.

So let us explore a little the job and work of managers.

When a manager gives one of his subordinates work to do, then the subordinate is accountable to that manager, and to that manager alone, for the way in which he does it. In other words, the subordinate is responsible to the manager. {3}

The division of work has to be functional if organisation is to be effective. Managers have to be aware of this and need to understand functional relationships. Managers have to be skilled in working well with other people, co-operating with them and getting their co-operation in return, and need to be trained in this.

Enterprises run on non-participative or authoritarian lines are generally considerably less effective than participative enterprises. {2, 3}

DECIDING LOCAL POLICY

AT PRESENT

The local committees of chief officers are commonly referred to as Management Teams and such teams recommend and execute the policy approved by the Authority. The management teams are chaired by one of the management team themselves.

Units are hospitals, convalescent homes, etc. and each unit's 'management team' consists of Chief Nursing Officer, Chief Medical Officer, Administrator and possibly others.

Each functional officer at one level is responsible for functional matters to the functional officer at the next higher level, from Units up to District, and this includes administrators.

Policy is decided by agreement (consensus) and each officer has the power of veto. Just as in any other kind of well-managed organisation, if the management team at Unit level cannot agree then the matter to be decided is passed up to the management team at the District level, and if there is disagreement at that level then to the District Authority for a decision.

PROPOSED

Each Authority's part-time Chairman is to appoint <5> a new full-time 'Executive' who is to make the day-to-day decisions:

"The 'executive' ... should set ... the priorities and programmes for" the chief officers, and

"would be the final decision taker for decisions" normally taken by the management team".

This is softened a little by the suggestion that there should be agreement by the functional managers, but the term "agreement" has many meanings particularly when applied between a superior and his subordinates and more particularly so at a time of high unemployment and with readily applied sanctions.

The part-time chairmen at the various levels are

"to reduce functional management"

by functional managers so that the Executive is apparently to be in complete charge. The Executive is to have

"overall responsibility for management's performance in achieving the objectives set by the Authority".

The proposed system is apparently aimed at

"ensuring that the professional functions are effectively geared into the overall objectives and responsibilities"

of the Chairman and his Executive.

The part-time chairmen at the various levels are

to make sure that main decisions (stating which decisions) are made by the "Authority meeting" itself.

In the case of 'Authority meeting' members who might possibly raise objections to policy proposals or decisions made by the chairman, it seems that the chairman would in effect have power to direct them since he is apparently to lay down what individual members may do in relation to particular areas of interest.

This seems to indicate that organisation would change fundamentally. It also seems to me that the changes would facilitate markedly the obtaining of agreement to policy decisions made or proposed by the part-time chairman and to day-to-day decisions made by the Executive he has appointed.

It further seems to me that the changes would also facilitate the implementation of decisions made by the Supervisory and Management boards, since apparently the method and process of selecting and appointing chairmen and members of Authorities is to be reviewed by the NHS Management Board as a consequence of the way in which responsibilities are allocated between chairman, Executive, Authority meeting and individual members.

So it appears that direction from the top would take precedence over and replace local policy setting by teamwork.

CONSULTATION

It is important to take into account the views of the community when making NHS decisions at the determining levels. The presentation of users views is currently made by the Community Health Councils.

It must be remembered that the NHS provides a health service to the community (who both own the NHS and receive the service) instead of having the main business objective of making the highest possible profit for the owners.

The Inquiry report maintains that

"by any business standards the process of consultation is so labyrinthine and the rights of veto so considerable, that the result in many cases is institutionalised stagnation."

However, when the interests of people affected by a decision are taken into account, then this results in a better decision, both inside business and without.

When the Inquiry report says that the organisation they propose would "make sense of the process of consultation" then this presumably means that it would reduce the process of consultation.

When the Inquiry report states that:

"We have concentrated ... on ensuring that management plays an active, not merely a reactive, role in relation to patients and the community, ..."

then this apparently means that management (that is executives) are to provide patients and the community with what management and higher authority think is good for them, that higher authority should apparently decide what is to be done for patients and community instead of reacting to their needs. That is instead of trying to ensure by a process of consultation and participation at all levels that management allows for and provides the kind of effective treatment and service needed by patients and the community, whose needs are expressed by and through the Community Health Councils, Joint Staff Consultative Committees and community organisations.

ORGANISATIONAL EFFECTIVENESS

It seems that the Inquiry report's recommendations would reduce functional management, consultation and teamwork in the NHS, would move decision making to the top and interpose another five levels of management into the reporting chain.

This does not appear to make sense from a management point of view and it is possible for the Inquiry report's recommendations to have the effect of creating a more authoritarian organisation with a tougher style of management.

In my opinion the Inquiry report's proposals as a whole would have the effect of considerably reducing the effectiveness of the NHS.

COMPARISON WITH 1974 REORGANISATION

The 1974 reorganisation of the NHS was a move towards greater centralisation. In other words, towards increased direction from the top and towards a more authoritarian management style and structure. Health Authority members, for example, are regarded as collectively accountable to the Secretary of State and the executive and supervisory function of the Regional Health Authorities increased.

There is no mistaking how those who worked in the service reacted. The consultants were the first to express their dissatisfaction and for the first time were services to patients disrupted by 'industrial' action clearly indicating the predictable reaction of those who worked in the health service against the loss of job satisfaction and against the erosion of working conditions {5}:

In 1975 some hospital consultants brought pressure to bear upon their employers so as to obtain extra duty payments by refusing to man emergency and accident units. In 1976 it was junior hospital doctors who, by restricting their working week to 40 hours, seriously disrupted many hospitals and thus broke with the tradition of putting the patient's welfare first. This kind of attitude was condemned by many when during the winter of 1978/79 the much lower paid manually working employees in the health service, then being among the lowest paid in the country as a whole, went on strike and in this way inconvenienced patients and delayed treatment and the operating programme.

In addition the effectiveness of the NHS organisation had been deteriorating since it was reorganised and four years after the reorganisation its deteriorating effectiveness was common knowledge. It was largely those who worked in the service who pointed out {2} that:

- A deluge of instructions, guidance and advice came from the centre, often without appreciation of the practical implications.

- The national health service had travelled a long way along the road to declining standards and that

- morale in the service was low. Disputes and stoppages had increased alarmingly during the previous two or three years. Internal conflict and confrontation increased in severity and disputes became more bitter.

- There was increasing support for more decision making, and control of resources, by authorities nearest to the point where services are provided for the patient.

- There was increasing demand for all regional and area authorities to learn better ways of organising.

The changes of the 1974 reorganisation were comparatively mild when compared with the changes proposed by the present Inquiry's report.

The effects of the 1974 reorganisation were disruptive. The corresponding effects of the proposals in the present Inquiry's report would in my opinion be devastating.

NOTES AND REFERENCES

NOTES

REFERENCES

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