Consensus management is emerging as a model for primary care groups. This dangerous trend must be stopped.
The New NHS proposals for PCGs and primary care trusts are descriptive in nature, in contrast to the prescriptive approach of previous reforms. This leaves much for debate, discussion and decision. Unfortunately, too much discussion is beginning to evolve around structures, instead of the organisations' purpose. GPs participating in setting up PCGs are contributing their knowledge of structures from general practice. This is built around partners working together, or not, as the case may be. An 'in-charge' structure is largely alien to primary care.
The danger is that PCGs will be set up on the consensus management model, which they could take into primary care trusts. This must not be allowed to happen. It is disturbing that it is even being considered, but people who do not remember
the dark days of consensus management are advising GPs.
Memories are short. Multidisciplinary teams to manage the NHS resulted from the reforms of the early 1970s. The guidance said: 'The teams will be consensus bodies: that
is, decisions will need the agreement of each of the team members. They will share joint responsibility for preparing plans, making delegated planning and operational decisions, and monitoring performance against plans.'1
The idea was that a doctor, nurse, accountant and administrator would make joint decisions, and collectively be held accountable for them. But decisions were often made to the lowest common denominator, were delayed, and then lacked ownership. The service was not managed, much less led.
This is not to say that management is not about consensus. Rather, it is about gaining consensus, to get the troops behind decisions that result from analysis, choice and implementation. The problem with consensus management lay in the absence of someone in charge, who did not necessarily need to be the administrator.
This was solved by Roy Griffiths' management inquiry bringing about general management, which drew together in one person responsibility for planning, implementation and control of performance.2
General management has succeeded. Even clinicians acknowledge this, though when they want to have a dig at management - forgetting they are managers themselves - they refer to the 'administrators'. It brought a new cadre of managers to the NHS, who could focus on organisational purpose, marshal resources, take decisions and corrective action if things went wrong. These managers evolved into chief executives in the last reforms, and, as leaders of organisations, had to take the tough decisions. Accountability has largely worked through the board-of-directors framework, though the extent of a board's real control over a chief executive is debatable. Where this has been an issue, the fall-out has resulted in the chief executive and/or chair heading off into the sunset.
As organisational control moved along from administrators to managers to leaders, customers became sidelined. The backlash was therefore emerging from patient groups and GP fundholders before the white paper, and now it is coming from GPs collectively.
'In-charge' structures do not sit well with partnerships. This applies not just to primary care, but to lawyers, architects, dentists, accountants and management consultants. It is a professional thing - first among equals. But it results in organisational inertia, inflexibility, lack of direction and lost opportunities. That is why larger professional firms have moved to a hierarchical structure.
Setting up PCGs presents fundamental challenges to GPs - consensus or 'in charge'. One sure way to stifle the organisations at birth is to go to the extremes. The answer is both - 'in charge' with consensus. Leadership is about getting people behind decisions, so it is logical to adopt a participative management approach that not only gets staff on board, but gets managers on board clinical agendas as well. Too often the aim is the former.
The way ahead for PCGs, primary care trusts - and in Scotland, local healthcare co-operatives - is to combine general management and a board. The key components would be the board, chair and general manager.
The board would be representative of all GPs but also other stakeholders; this would mean a larger board, so an executive committee might be required within the board itself.
The chair would be non-executive, part-time, and a GP. It is too early to expect GPs to allow a non-GP to fill this post, but it may come. The criterion for appointment would be that the candidate was someone with authority. This does not mean a dictator but someone with an iron fist in a velvet glove.
The general manager would be full-time, and the job size would depend on the size of the PCG or primary care trusts and the extent of management infrastructure. This would be the 'in-charge' person, who would ensure that the principles of general management were applied.
Nothing gets done without people in charge. Equally, people in charge must have the organisation's support. The 'in-charge' framework outlined combines decision-making with accountability. The re-emergence of consensus management should be knocked on the head. This would allow stakeholders to focus on the real issue - the organisation's purpose.
1 Department of Health and Social Security. Management Arrangements for the Reorganised National Health Service. London: HMSO, 1972.
2 Griffiths R. NHS Management Inquiry.
6 October, 1983.
Next week: Let function determine the structure of PCG boards, argues Jonathan Shapiro.