Griffiths report could have freed NHS from politics

Roy Griffiths presented his highly influential report to then health secretary Norman Fowler 25 years ago. Griffiths became both noun and adjective, a shorthand for arguably the most significant NHS reform to date. "Griffiths management" replaced 1974-style consensus management, bringing with it the era of NHS chief executives and the formalisation of many separate managerial initiatives into what academics call "new public management".

The report made two main recommendations.

Under management

First, it advocated an arm's-length management board, intended to make NHS governance more like that of a public corporation at a time when some had considered the NHS, perhaps the third largest organisation in the world at the time, a major corporation without a head office or chief executive. The debate around this would come back to haunt future health secretaries.

Then health secretary Alan Milburn, appointing Nigel Crisp in October 2000 as both permanent secretary and NHS chief executive, merged the roles once more, undoing Griffiths at the central level. In part, this was to produce a simplified organisational map of the Department of Health, but the government may also have wanted to end any notion of an independent management for the NHS.

The consequences were weighty. Now there was no longer an independent permanent secretary in the old style who could speak truth to power. The permanent secretary was also chief executive, which, with no reflection on Sir Nigel, led to a conflict of roles. Ministers, including the prime minister, were arguably less aware of NHS England's mounting financial crisis in 2005-06, as a result of civil servants' and managers' need to emphasise good news. When Sir Nigel resigned, the roles of permanent secretary and chief executive were again separated, the merger being viewed as a mistake.

But the chief executive was by no means the boss of a quasi-independent NHS management board. There was less independence than in Griffiths' day. The new CEO, David Nicholson, was head of the management team reporting directly to politicians.

Power structure

Griffiths' original second recommendation was for the end of consensus management and the creation of a managerial hierarchy in the NHS, principally at regional and district levels and, following internal market reforms, at provider trust and purchaser/commissioner levels. Allied to this, Griffiths urged that doctors be brought into management.

The origins of the Griffiths report hark back to the aftermath of the NHS strikes of 1982, when then prime minister Margaret Thatcher asked Norman Fowler questions such as how many people the NHS employed. The vague answers prompted an inquiry, but early into his investigations Roy Griffiths told the health secretary it did not make sense to make recommendations about NHS manpower without tackling the overall management culture and structure of the NHS. The rest is history.

It would be wrong to paint Griffiths as a Thatcherite hatchet man. He identified some real problems and, even if he did not start with a research-based account, by the 1980s he was bringing his intellect to bear on the complexity of the NHS as a ministerial adviser. Privately, he argued against the internal market, which went live in 1991, believing it a distraction from the task of bedding in his management reforms. He was, however, an advocate of the new public management in the NHS, but in a manner that called for the NHS to be business-like rather than a business, let alone a privatised one.

Griffiths could have gone in a benign direction, with the 1992 Labour manifesto essentially calling for general management without the internal market. But in 1997 Tony Blair was unwilling to abolish the institutions of a market NHS in England, despite New Labour's complacent promises.

Changing spots

The perennial question about taking politics out of the NHS was implicitly tackled by Griffiths. It would be wrong to blame him for the inability of politicians to change their spots. A centralist structure and culture in England allows politicians to intervene at the flick of a pen. The Conservatives could not keep their hands off, burying the Griffiths report even when coming to praise it, and under Alan Milburn at the turn of the millennium central control-freakery reached its apotheosis.

The idea of taking politics out of the NHS has since surfaced with cyclical predictability.

However, politics is the lifeblood of the NHS, in a good way as well as bad. The challenge for politicians is to avoid micromanagement. But the omens are not good - two of Gordon Brown's first pronouncements as prime minister were to order a deep clean of all hospital wards and call for the restoration of matrons. Gandhi, when asked what he thought of Western civilisation, replied that it was a good idea but would never happen. A public NHS divorced from politics is perhaps likewise.

For Griffiths to work, the two main recommendations have to go together - someone has to be in charge of health agencies and command of the health service by politicians has to end. Is there any way to find a buffer though, while preserving the public nature of the NHS, when both national and local politicians meddle in different ways? New Labour backbenchers often spend much of their time berating hapless local health managers for implementing their own government's policy!

History is written by the winners. While Griffiths was well intentioned, many international commentators saw consensus management as a good model. When it worked well, it provided the basis for the sort of medical-management dialogue that the Department of Health now seeks to recreate. At its worst, it was cumbersome. But the government took a sledgehammer to crack a nut.