Twenty-five years ago Roy Griffiths famously said: ‘If Florence Nightingale were carrying her lamp through the NHS today she would be searching for the people in charge.’ When he set out his subsequent plan to overhaul management, staff feared it would be the end of the health service - Peter Davies looks at what happened next
A bland 300-word statement in the House of Commons on 4 June 1984 announced “the government’s decisions on carrying forward the recommendations of the NHS management inquiry”. The government had accepted supermarket boss Roy Griffiths’ suggestion to introduce general managers, said social services secretary Norman (now Lord) Fowler. The measure was to launch a cultural revolution and 25 years of continuous change.
You could say, ‘I’m in charge’. Instead of saying, ‘I wonder, doctor, what you think of so-and-so?’
Mr Griffiths, deputy chair and managing director of Sainsbury’s, famously said in his report: “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.”
Today, Lord Fowler says: “You could not have done the internal market without general management. It was absolutely crucial that you changed the management structures. Once you did that you could go on to other things. But unless you did that, there was no way of delivering.”
Regional health authorities had four months to appoint their own general managers, then embark on district health authority appointments. Districts had until the end of 1985 to find unit general managers. The Department of Health began recruiting a national general manager. Mr Griffiths said this should be someone “almost certainly” from outside the NHS and civil service, with experience of effecting change in a large organisation.
Turmoil rapidly ensued. Doctors and nurses feared their professions would lose influence after the dissolution of the consensus management teams that had run the NHS until then. The Royal College of Nursing mounted a campaign to resist general managers, led by Ray Rowden, its then national management officer.
“There was a lot of upset. I was doing meetings around the country with 300 nurses turning up,” he says.
Other staff suspected the move was in preparation for cuts and privatisation. Speculation was rife that the top job would go to some ruthless and charismatic captain of industry such as Michael Edwardes, then heading British Leyland. Administrators jockeyed for the new posts - theoretically open to any profession - and jealously watched for signs of the government covertly recruiting a quota of business executives. Suspicions intensified when one or two prominent regional administrators found they were no longer required.
“There were some very unfair appointments,” says Ken Jarrold, who became district general manager of Gloucester health authority. “Some very distinguished people didn’t get jobs because of political interference.”
Ministers have always denied this.
“We wanted managers from inside the service as well. We did not want it to be seen as a private sector takeover. We had to take people with us,” says Lord Fowler. “It was depressing how a whole range of people reacted against general management. That we had got as far as we had in the history of the NHS without it seems to me extraordinary. It’s glaringly obvious, looking back on it. So called consensus management was not working.”
Not all agree, although no one now argues that general management should be replaced. Christine Hancock, a nurse manager who became district general manager at Waltham Forest HA and later the Royal College of Nursing’s general secretary, says: “I do not think consensus management was a failure, and I do not think Roy Griffiths thought that.”
While she acknowledges that where team members used it to veto decisions it was “disastrous”, she emphasises it could also encourage teams to solve problems by reconciling different perspectives. For Mr Jarrold consensus management only worked “where you had very able people who could make it work”.
Yet NHS Confederation policy director, Nigel Edwards believes consensus management has been “demonised” and can be made effective.
“It is the model in a lot of other healthcare systems that work quite well,” he says. But the NHS’s version - with the administrator, medical officer, nursing officer and treasurer, all of whom had the power of veto, having to agree to a decision - was “not helpful”.
At its worst, consensus management was referred to as “lowest common denominator” decision making.
Andrew Wall, who became district general manager at Bath HA, dismisses consensus management as a “myth”, arguing that the administrator was first among equals and “general management was necessary to make this explicit”.
“You could say, ‘I’m in charge’. Instead of saying, ‘I wonder, doctor, what you think of so-and-so?’ you could say, ‘I think we should do this. Get on with it’. I enjoyed it. You could do important things,” says Mr Wall, though he does recall how anxious staff were. “I had about 100 meetings to introduce the idea. The most tricky area was the nurses.”
Focusing accountability on a single individual represented a “dramatic and sudden change” that affected relationships, says Mr Jarrold. “It’s difficult now to appreciate how radical that was. It made an immediate difference. People felt something new and not very welcome was emerging.”
Clinical staff especially balked at their perceived subordination to what they dubbed “supermarket style management”. Nurses bemoaned their loss of influence “at the top table” and complained that too few of them were winning the new posts. Only half those nurses who were successful were up to the job, in Ms Hancock’s estimation.
“Not many of the best nurses became general managers,” she says.
Nurses who did faced the novelty of being in charge of doctors. Ms Hancock had been Waltham Forest’s nursing director earlier in her career and says most medical staff there welcomed her return as “someone who understood them and clinical issues”. But she adds: “One old style consultant was heard to say, ‘She used to be our matron, now she’s come back as our boss’.”
Eventually organisations revised the initial management structures that had excluded nurses.
“So to a degree the RCN campaign was successful,” says Mr Rowden, who became a general manager in 1986 after hearing a speech by health minister Kenneth Clarke. “He said, ‘Stop whingeing - anyone can go into general management.’ In three years there were more than 100 nurses in unit and district general manager posts.”
Griffiths had envisaged a major role for doctors in general management, particularly at unit level. One of the first was (now Sir) Cyril Chantler, currently chair of the King’s Fund and UCL Partners but then a consultant at Guy’s Hospital and its first unit general manager.
Crucially, Guy’s pioneered the devolution of responsibility for clinical budgets to clinicians.
“All you have to do to involve doctors in management is give them responsibility and authority and hold them to account. That goes on all around the world,” says Sir Cyril, who laments that doctors and managers now feel so divided. “It never occurred to me we would end up with doctors sitting on one side.”
But with the advent of the internal market in the early 1990s, chief executives became legally responsible for balancing the books.
“They grew nervous and immediately began to suck back to the centre all the financial responsibility.” Sir Cyril believes this was a major factor in frustrating Griffiths’ vision of doctors in management.
“In 1992, Roy Griffiths said: ‘I have a genuine horror that managers in the various professions will go down parallel routes barely touching each other and with very different objectives’. In many instances that is exactly what’s happened. It is ironic and sad that should be the case.”
In fact general management’s biggest weakness is widely perceived to be the way it alienated staff from managers. Mr Wall blames governments using “barely contained threats” to make managers conform, often to unpopular policies. Others see a trend for management to intrude into clinical issues while overlooking basics - such as cleanliness - that the old administration held paramount.
Griffiths, ever mindful of the “customer”, would be horrified by this, Ms Hancock points out.
Unison head of health Karen Jennings identifies a “climate of machismo” after 1984 - most notable before 1997, less so in an era of better trade union relations and annual staff surveys. It introduced “management babble” into the NHS, and saw itself as “hard-nosed, lean and mean”.
District general managers at the time spotted the trend too.
“Some people could not believe their luck,” says Mr Jarrold, recalling the “pernicious arrogance” of those who flaunted big cars and lavish offices. “If you did not understand the NHS’s central values, blood did rush to your head and you damaged the reputation of management. It was never widespread, but there were always some - and still are today.”
Yet no one suggests the NHS should abandon general management, nor even that any viable alternative exists. It has enabled the NHS to attract high calibre chief executives, rationalise management structures and sharpen accountability for how it uses taxpayers’ billions.
“Management is much more an advocate of the patient and public voice than clinicians, because managers play a neutral role in services. They are not a vested professional interest,” says King’s Fund director of leadership development Karen Lynas. “The NHS is better now at responding to what the public want, and a lot of that is to do with general management.”
But successful management tends to be an invisible “backroom function”, unlike the high profile enjoyed by clinical practice, she says. So general management still has to convince the public of its importance. In another 25 years, perhaps.
The Griffiths report
Roy Griffiths published the report of his “NHS management inquiry” in October 1983. His four-strong team had taken only six months to reach its conclusions after consulting widely, but inviting no formal evidence. All were from outside the NHS, although one chaired a regional health authority. Its low key presentation and flimsy format belied its impact.
“Griffiths stands the test of time as the single most important document on NHS management ever produced,” says Ken Jarrold. It signals themes that still reverberate in the NHS 25 years later. Roy Griffiths died in 1994.
“[Health authorities should] involve the clinicians more closely in the management process, consistent with clinical freedom for clinical practice. Clinicians must participate fully in decisions about priorities in the use of resources.”
“[Boards should] ascertain how well the service is being delivered at local level by obtaining the experience and perceptions of patients and the community.”
“[The NHS] still lacks any real continuous evaluation of its performance.”
“The NHS is so structured as to resemble a ‘mobile’: designed to move with any breath of air, but which in fact never changes its position and gives no clear indication of direction.”
“It is not for the centre to engage in the day to day management of the NHS.”
“The NHS is in no condition to take another restructuring, and much more can be achieved by making the existing organisation work in practice.”
Room at the top
Six months after implementing general management in the NHS, the Department of Health finally recruited a general manager to head the service. Many expected a high profile household name. However, Victor Paige, deputy chair of the National Freight Corporation, did not quite fit the bill.
Like many others with careers outside the NHS, Mr Paige struggled to establish himself. He resigned after 18 months, complaining of interference from politicians and civil servants.
“He did not have the authority to be what you might call a chief executive,” says then health secretary Lord Fowler.
“I became persuaded in the end that the way round this was to have an NHS commission that would answer to the DH but be one step away from it.”
The outsiders tale: ‘I was called the Axeman’
Efforts to recruit general managers from outside the NHS had mixed success. Salaries were too modest to attract many from business, but recently retired officers from the armed forces - enjoying generous pensions - found the posts offered an attractive second career. Few survived to the end of their three year contracts, having underestimated the job’s complexity and doctors’ power. A more successful outsider was Lorne Williamson. He joined from industry, first as district general manager of Brent health authority and then of Tower Hamlets. He says coming from a family of doctors helped.
“I remember my first interview. I was asked how I would deal with an awkward consultant. I said my father was an awkward consultant and therefore I have experience. The lay people thought that was excellent and the medics thought, ‘he’s one of us’.”
He was quick to grasp the importance of getting on with the “power broker medics” who could block change. “I was told it was impossible to deal with inefficient or lazy doctors directly. If I took on a doctor directly, that would be the end. We did get rid of several, but not by the direct method.”
The general managers who joined from the forces “could not handle mixed messages”, Mr Williamson says, whereas his career had equipped him for them.
“In industry, being the managing director of a subsidiary company, we had tension with head office telling us to do one thing and the practicalities telling us to do something else.”
What he calls “the people’s republic of Brent” was an “overtly political” health authority that voted on every issue and where “almost everyone” was against the government. Employees felt little loyalty to their hospital - unlike today, he says.
“Managing in a goldfish bowl” gave him a high profile. “I still have in my loo a leaving present, which was a collage of headlines I attracted. I was called the axeman. I was seen as an agent of change.”
Yet Mr Williamson believes his lack of NHS experience was an advantage. “I was not expected to do things the same way as other people. I got away with a lot. My long term strategic plan was two sides of A4. The average was an inch thick.”
He left Brent when it was merged with Paddington HA, was briefly a locum general manager in North Hertfordshire, which he described as “just too dull”, then joined Tower Hamlets in a hunt for more “headlines, confrontations and victories”. Faced with another reorganisation, he left the NHS in 1992, although he is now a governor of Cambridge University Hospitals foundation trust.
“It was a great experience and I have great admiration for the NHS. Management is much more professional now, but it is hidebound by regulation and fear of risk.”