HC Deb 14 March 1986 vol 93 cc1316-28 9.37 am
Mr. Steve Norris (Oxford, East)

I beg to move, That this House regards the Report of the National Health Service Management Inquiry of 6th October 1983 as an invaluable guide to the efficient management of National Health Service resources; welcomes the implementation of the major recommendations of the Report and in particular the appointment of general managers at regional, district and unit level within the National Health Service; recognises that there may now be the opportunity further to improve upon what has already been achieved in the light of practical experience; further recalls that the key objective of management restructuring was identified in guidance sent to health authorities in 1984 as the improvement in standards in service to patients; and resolves to continue to examine the consequences of, and to encourage further, management innovation so as to ensure that the maximum possible amount of National Health Service resources is targeted as effectively, efficiently and sympathetically as possible on the direct care of patients. It is a great pleasure, is it not—I ask myself that rhetorically because sometimes I wonder. Having appended one's name at the instigation of one's party's Whips to the ballot for motions, one finds that one has had the immense misfortune to be successful. It is a great pleasure, Mr. Speaker, to have the opportunity to raise a subject which is of considerable interest to me and has been since I made my maiden speech in the House on it—the National Health Service and, in particular, its management.

Management in the NHS has a particular meaning. We are talking, as I think is one of the common aphorisms about the NHS, of the largest employer in western Europe and, as I understand it, excluding the Red Army, the largest employer in Europe.

I am delighted to see that my right hon. Friend the Secretary of State for Social Services has found time from his extremely busy schedule to be here in the Chamber. I thank him for his attention to this important subject. I am also grateful to see my hon. Friend the Under-Secretary in his place.

As the House will know, I was until recently vice-chairman of West Berkshire district health authority. I pay warm tribute to my colleagues of all political persuasions and backgrounds who worked with me on that authority who performed splendidly and continue to do so. They have provided me with invaluable insight into the day-to-day management of the service. It is extremely important that the House should not lose sight of the way in which the great decisions that we make here actually interact on the ground.

My interest does not stem just from my own experience on a health authority. Although my constituency is traditionally known for car-making activities, Oxford is the home of a substantial number of first-class health care services. The Radcliffe infirmary, the John Radcliffe new site, the Churchill, the Nuffield orthopaedic and the Slade, Littlemore and Warneford hospitals are all very large Health Service providers in my constituency and that of the Minister for Housing, Urban Affairs and Construction, my hon. Friend the Member for Oxford, West and Abingdon (Mr. Patten), and I hope that this debate will be equally relevant to those institutions.

Before dealing with the new Health Service management arrangements, I should say a brief word about the old arrangements. In the debate on 4 May 1984, I referred to the danger of over-simplifying the whole question of consensus management and the Griffiths proposals as alternative ideologies. I suggested then that to give the impression that consensus management was all wrong would be extremely dangerous. Seeing how the decision-making process was carried out, one had to recognise that many decisions required the cogwheel approach and recognition of the interrelatinship between disciplines and skills which was the cornerstone of the old consensus arrangement. It would have been damaging indeed to decide that the baby should be thrown out with the bath water and that the idea of gaining support for decisions across technical boundaries was necessarily wrong.

Nevertheless, I think that it is generally recognised that consensus management was, sadly, too often a recipe for inertia, with a paralysing effect on the mobilisation of resources and, worse, at the point of delivery of services and sometimes on the quality of service provided. The Government's response to that inertia was the NHS management inquiry by Sir Roy Griffiths whose report the Government accepted in principle and implemented.

It may be for the convenience of later contributors to the debate if I set out the background to my remarks by quoting circular HC(84)13 in which the Government set out the rationale for what they sought to achieve from the management reorganisation. The circular states: The Government's overriding concern is to see that the National Health Service provides the best possible service to patients within the available resources. We are seeking to ensure that the expenditure devoted to the Service"— £13 billion in England that year— does reach its target: improvement in the physical and mental health of the people and in the prevention, diagnosis and treatment of illness. We have, with health authorities, already established a programme to improve the effectiveness and efficiency of the NHS". The circular made the point that the management inquiry report endorsed the Government's view of the management's task when it said:

It cannot be said too often that the National Health Service is about delivering services to people. It is not about organising systems for their own sake … the driving force behind our advice is the concern to secure the best motivation for staff. As a caring, quality service, the NHS has to balance the interests of the patient, the community, the taxpayer and the employees. The management inquiry report went on to identify the importance of a clearly defined general management function drawing together responsibility for planning, implementation and control of performance as the key to ensuring and achieving the management drive necessary to ensure that the standard and range of care provided by the Health Service were the best possible within available resources.

Those are fine words and I believe that there is good reason to believe that we are on the way to seeing them implemented in practice.

Mr. Nigel Spearing (Newham, South)

The hon. Gentleman used the phrase "in practice". Does he intend to dwell on the principle that the people who have to take the buck for management decisions about scarce resources at ward and unit hospital level are qualified and have sufficient experience, especially in the nursing profession, without which those resources cannot be used properly? I am sure that the hon. Gentleman would not expect final decisions about the administration of the House, and taken by the House of Commons Commission, to be taken out of the hands of people with experience as Members of Parliament.

Mr. Norris

I suspect that that point will arise on a number of occasions this morning and I am sure that the hon. Gentleman will wish to expand on it if he has the opportunity to participate in the debate. I well recognise the concern about the implementation of Griffiths in that respect, and I shall be saying something about that. I know that Members on both sides will also wish to enlarge on what is clearly an area of concern which is fundamental to the reorganisation. It is, indeed, a cardinal principle of the service that any reorganisation should not be at the expense of the level of competence at the point of professional delivery of service. I accept the hon. Gentleman's comments. I intend to deal with that point, as no doubt will other hon. Members. My right hon. Friend the Secretary of State may also wish to comment on that aspect.

I wish to examine how effectively the aspirations to which I have referred have materialised. So far, certain successes have been identified but there are also certain problems. The sooner the successes are identified and built on and the sooner the problems are identified and eradicated, the better will be the service for patients. I must tell the House, and especially the hon. Member for Newham, South (Mr. Spearing), that my discussions about the success or otherwise of Griffiths with managers who are in no sense beholden to me for their answers has been extremely encouraging.

I have been surprised at the extent to which managers now in post have referred, to use their own words, to crisper management, quicker decisions, quicker local problem solving and individuals being given tasks and made responsible for carrying them out. Although group decisions—the good old consensus—still occur, especially in relation to items such as the district review, the impact of the annual budgeting exercise and priorities for services and new money where best practice exists decisions are still made after extensive consultation on both a one-to-one basis and a group basis.

We should never lose sight of the fact that there is now the opportunity for day-to-day decision making which does not involve the establishment of any great new principle and does not offend any great new norm in the service, and that those decisions are now made more quickly and more effectively. I submit that that is of the greatest benefit to the service as a whole, by which I mean the greatest possible benefit to patients.

I shall deal briefly with the concerns which have been expressed recently by the Royal College of Nursing, and by the British Medical Association and other professional bodies prior to the implementation of the Griffiths report. In all instances I treat their contributions to the debate with the utmost seriousness. The various contributions have been made with the highest standards of integrity and concern for patients. I recognise that in that sense their motives are impeccable. I hope that they will not be offended if my response is to suggest that the real picture may not be quite as they have suggested. I suggest that their views have not been wholly justified by word or in the event.

I am sure that my right hon. Friend the Minister for Health—I am grateful to him for his interest in what I am about to say—will recall his letter of 20 November 1985 to all regional health authority chairmen, in which he stated: most district management structures provide for medical and nursing membership of the district management board or similar body. Were this is not the case, I believe that it is important that alternative arrangements command the confidence and commitment of all the medical and nursing interests locally. My right hon. Friend said to health authorities, in my view rightly, that it would be wrong and misconveived of general managers at any level within the Health Service to imagine that the new notion of management accountability had overtaken all notions of the need for clinical input at the highest level. If that misconception ever existed in the minds of general managers on any scale, I believe that it has been dispelled by my right hon. Friend's intervention.

It is a misconception also to imagine that fewer units of management necessarily mean worse service or worse professional input. I understand the concern that has been expressed articulately to me by colleagues who are members of the Royal College of Nursing about the reduction in overall numbers of units in the Health Service. There is a clear danger of imposing a form of management which harks too much towards the "big is beautiful" concept, which we all, to our individual regret, came to realise was not entirely consonant with efficiency or the best quality of service. On the other hand, it would be somewhat misleading to imply that there are not occasions when the original unit structure that was set up following the last reorganisation cannot now, in the light of experience, be honed and refined to produce fewer chiefs and more Indians.

There was much with which I was not happy in the last reorganisation of the Health Service. For example, I warned that we were running the risk of removing one area of bureaucracy and replacing it with two equal local bureaucracies, with little benefit for patients at the end of the day. However, the health authority in the area that I represent was able almost to halve the number of nurse managers who previously had no hands-on contact with patients. That is something which nurses, as true professionals, welcomed. The reduction in the number of nurse managers did not result in fewer nurses being employed. Instead, more of them were able to be involved in hands-on experience, which has been of great benefit to the Health Service as a whole.

Some have expressed concern that the new arrangements will result in a diminution of professional standards and the voice of the professions. They are right to sound that warning, but my right hon. Friends the Minister for Health and the Secretary of State for Social Services, in their utterances and in the letters which they have written on the subject, have made it clear that the Department never seeks to substitute management as a concept over and above or instead of that of professional input at the highest level, and the maintenance of that high level, within the service. I have no doubt that my right hon. Friend the Secretary of State will concentrate on that when he contributes to the debate.

It would worry me if undue account were taken of, for example, the relegation of titles, whether DMO, DNS or DNO, from structures, and if it were thought that it showed that nursing or medical advice could not find its way into the new system. That would be nonsense. We are changing the way in which advice is given to those who have to make decisions, but the suggestion that it is not there—I am no apologist for my right hon. Friend and I would be the first to express my views if I felt that there were real dangers—does not reflect the true situation. I have not seen the dangers materialise to which some have referred.

To support what I say, and in preparation for this debate, I took the opportunity to have a word with Sir Raymond Hoffenberg, the distinguished president of the Royal College of Physicians. I asked him especially and specifically about the attitude of his members to the Griffiths report, they being much involved in its implementation from day to day. He said, not unnaturally, that if he were asked to express the feelings of his members, he would say that they would be of concern on a similar line to the concern which the BMA expressed before the implementation of the report, and similar to the concern which the Royal College of Nursing currently expresses.

Sir Raymond made it clear to me that he could speak only of anecdotal and unsupported evidence of problems at regional and district levels, where general management appointments have been made at ground level. That has been my experience as well. I read carefully the RCN campaign document, with which we have all been involved. The college was kind enough to talk to me about its concerns. I can find no evidence of reduced levels of professionalism or care in hospitals as a result of reducing the number of chiefs to the benefit of the Indians, but I recognise that theoretically the opportunity exists for that to happen unless adequate precautions are taken. It is one thing to argue that there has been a reduction in the level of professionalism or of care in hospitals and another to point to actual reductions.

Dr. John Marek (Wrexham)

There may have been cuts in administrative staff, but many of them have been in the clerical section. In many hospitals there is not a sufficient clerical staff to provide the service that consultants, doctors and nurses need in carrying out their jobs.

Mr. Norris

I understand the hon. Gentleman's point and I know his expertise in these matters, which I much respect. I think that he will agree with me that the difficulty in responding to his argument and the difficulty about his intervention is that it invites the consideration of specific examples. It leads to the question, "What was the arrangement for the delivery of epidemiological, medical, clinical and technical input and what are the new arrangements?" The new arrangements may be slimmer and involve fewer persons in the expression of technical advice. The advice may come from those whose titles we do not yet recognise as conventional, but that does not mean that the quality of the service has been lowered. The time to worry is when we see a difference in the provision of actual service, which must be our paramount concern. I recognise the sincerity with which the warnings have been delivered, but I do not find at this moment that they are justified.

But there is much still to be said about some of the technical disadvantages of the present arrangements. I mentioned one point in the debate in May because I felt that it was important, and I shall mention it again. I refer to the question of how we employ general managers. We use the concept of fixed term contracts. From my business experience I know that I would employ someone on a fixed term contract only if I had a specific job for him to do. For example, if I wanted to build a power station, I might employ a site manager and give him a fixed term contract. When the job came to an end, he would go elsewhere. He would understand the situation, and it would not ruin his motivation but rather enhance it, as he would want to see the job done within the time allocated. But I would not use fixed-term contracts for continuing employment, if I was interested in ensuring that morale was maintained at the highest level and that I was getting everything I could out of the best people for the job.

Four areas in which problems have arisen were identified in a very helpful article by Robin Gourlay. He is the Wessex regional personnel officer, and in July 1985, in an article in the Health and Social Service Journal, he wrote: First, consider the recruitment problem. If you were to advertise a general manager job to managers outside the NHS, offering a fixed term contract of three or five years and a salary probably well below what they consider the job worth in comparison to their own organisation, you are unlikely to attract the best recruits. Why should they threaten their own potentially successful careers with ICI, Shell, IBM or whoever, for a lower financial reward than they could expect—or maybe are already getting? Anyway, the potential amputation of a career will deter the type of manager the NHS needs. I heartily endorse that description of the disadvantage of the fixed term contract.

The sub-editors of the article rather brilliantly, for once, caught the spirit of what Robin Gourlay was trying to say in the following headline: Contract renewal could rest on personal affability. The article then continued:

Second, how can a general manager be evaluated and what truly objective basis can be used for saying whether he or she succeeded or failed? Without such a basis the question of contract renewal could rest on whether or not the authority chairman likes the general manager. That observation may be banal, but it is all the more frighteningly true for it. We will find that at the end of three or five years the personal or political relationships between the general manager and the members of the authority may sometimes weigh more heavily than it should do.

Robin Gourlay then states:

Third, the implications of Griffiths were expected to bring about changes in the NHS. Changes mean risk and cost—the risk of failure, and the cost of turbulence. Such failures and costs can count against the general manager and prejudice his reappointment as a disenchanted mafia builds up a wave of unpopularity around him. So be it, you may say—general managers are not there to court popularity. This is so, but if the potential of success is outweighed by the personal costs of failure, which general manager is going to take those risks currently demanded of the NHS? Fourth, consider the image of the NHS as an employer and its ability to retain managers of potential. Most large organisations develop their own managers … They create many incentives (of both a financial and non financial kind) to keep their managers … It is through the practice of such consideration that companies compete to attract and retain their general managers. This is not pure altruism … These companies invest a great deal in their managers and their development and to lose such investment through careless personnel policies is like publicly burning your profits. A failed general manager reflects a failed organisation. The failure of a general manager is just as much the failure of the organisation that has provided the job, as it is the lack of competence of the manager. I suspect that we use the fixed-term contract because of our inability to define, within Whitley, the termination of contracts for professional reasons other than gross misconduct. We are in the bind that if we employ people on indefinite contracts, we have the greatest difficulty in confronting them with any shortfall in performance, becaue their performance is a controversial matter and because of the practical difficulty of implementing the employment protection regulations and so on. Thus, a substantial review of Whitley is needed. I urge my right hon. Friend the Secretary of State to consider carefully the question of fixed term contracts to see what can be done to replace a mechanism that works against the interests of the service and the professionalism within it.

There is a matter of perhaps less strategic importance, but which is of great concern to individual managers. I refer to the differential pay scales between some insiders and outsiders and, perhaps worse, between insiders and insiders. One golden rule of management is that one should never pay two people different salaries for doing exactly the same job or pay someone more money for doing a lesser job than someone else. That is rule number one in any management's book. But there is another rule that appeared in the best book on management that I ever read, and I believe it should be observed in the House. It said that it was useful to have someone on the board of directors who knew where the factory was. During my business career I have noted how appropriate that aphorism is and believe that it should apply almost de rigeur in the House.

I was a member of my health authority and I know, because I was involved in its implementarion, that, horrifyingly, our district manager gets £7,000 less than his own district medical officer, after his enhancement. Yet the district manager is in charge of the district medical officer and is the primus inter pares. If that was not illogical enough—there may even be some marginal justification for it—he gets £6,000 less than Milton Keynes district general manager. I do not know that man, although I am sure that he is a splendid person, but he happens to be a former doctor. Nevertheless, the budget of the whole Milton Keynes authority is less than the budget of the largest hospital in our district, the Royal Berkshire, and makes nonsense of the idea of providing a career and salary incentive structure.

Lynn Alleway, writing in the Health and Social Service Journal, noted:

For people coming from outside, while the sky was not the limit, there were no such clearly defined restrictions. This has led to some significant anomalies. For example, the highest-paid RGM, Mike King in East Anglia, a former management consultant, is earning about £45,000 a year, £15,000 to £18,000 more than other RGMs from the NHS. Similarly there are district general managers from the private sector earning as much as £32,000—about £4,000 more than even many regional general managers with an NHS background. And yet in spite of this, salaries of £30,000 or £40,000 do not compare with deals available in the private sector. I understand that a report prepared by the Department on the whole issue of general managers' pay, containing advice from three or four regional chairmen, and from management consultants brought in from outside, has been with my right hon. Friend the Secretary of State since June 1985. I see him demurring, and no doubt he will clarify the position later. However, I am sure that professionals would welcome clarification of the position. It is important to get pay right. We are talking about producing a much more relevant career structure for professionals, and pay is a factor in that.

Incentive is equally important. I acknowledge that we probably do not have the mechanism for introducing the right type of incentive for managers beyond the incentive of seeing a job well done. We must give some priority to that. We must create what any business person knows is his first and most important task—a happy and motivated management team. I am not suggesting for one moment that there is no motivation or that there is not great dedication and expertise, but we have some way to go.

General managers' pay is negotiable, subject to upward approval, but other staff posts are appointable only within the general structure of the Whitley council agreements. That is not surprising, bearing in mind the effect that Whitley has had on the pay and conditions structure in the NHS, but it only underlines the extent to which Whitley was a reflection of the old management arrangements. It needs a radical overhaul if it is to be relevant and effective.

I warn my right hon. Friend that the nature of NHS decision-making may be working against the interests of independent manager operation. I welcome the district review procedure, the annual report procedure and the whole accountability review process, but decisions are being implemented from the Department down the ladder, and general managers are often merely the method of implementing policies that have been decided elsewhere.

Members have been affected by the management reorganisation far more than we have been prepared to recognise. The circular defines members' role as follows: Determine policies and priorities for their district within national and regional guidelines and on the advice of their officers; Review and, where necessary, challenge proposals by the district management team and to make effective arrangements for the implementation of the authority's decisions; Appoint and monitor the performance of their chief officers; As the direct employer of a large number of staff, concern themselves with their working conditions, general interests and welfare (but not pay and conditions of service, which are determined nationally). That was wholly appropriate to the old arrangements but Griffiths has changed it all. If general managers now report much more closely to chairmen, who are the only paid representatives on the authority, health authority members have a role much more akin to that of community health councils. Both are appointed bodies.

The more one examines the old role of members and how it has been changed fundamentally by Griffiths, the more their new role is revealed as being the patient's friend, the monitor of standards, the determiner of priorities and the articulator of public concerns. The role of CHC and the authority member, which has always been anomalous, ought now to be reconsidered. It is unnecessary to have two bodies charged with almost identical roles for the supervision of standards which often act against each other and against interests of the service.

I am sure that the NHS Management Board has made great achievements, especially in computing and information systems but, talking to senior NHS personnel, I discern no recognition of achievements on the ground. That comment is based not on my experience but on what I have been told by many professionals. These are early days and my right hon. Friend might be able to reassure the House but, unless the board proves its worth shortly and illustrates that it is contributing to the more effective and efficient management of the service, the sooner yet another layer of bureaucracy goes, the better I shall be pleased. We must see results soon.

It would be wrong to assume that the whole debate should centre on Griffiths. I should not be doing my right hon. Friend any service if I did not make it clear that the introduction and innovation of management budgeting, the value-for-money initiatives, the Rayner scrutinies and, contentious as it might be to say so, the competitive tendering exercises, have been of the most positive benefit to authorities in providing and unlocking funds that can be used for patient care. It is scandalous that resources are wasted on hotel and catering services when they could be spent on patient care.

As the DHSS controls the budget, it controls manpower. If caring services in the NHS are about people, what is saved on cleaning should be spent on nursing. If there is a £70,000 saving on catering and that money can buy seven community nurses, I do not want an artificial control on manpower which prevents the money from being spent in that way.

I have great admiration for what has been achieved. The introduction of management efficiency was desperately needed. As Baroness Trumpington said in another place last week:

the key objective in introducing general management to the NHS … has been to improve service to patients."—[Official Report, House of Lords, 4 March 1986; Vol. 472, c. 158.] I apologise for the length of my speech, but I am reminded of the words of one of my favourite popular songs which runs: It's my party, and I'll cry if I want to. If there is any merit in winning the ballot, it is that, for once, I do not feel quite as constrained as I might normally. I know that the Government's paramount objective has always been to improve the service to patients. The broad thrust of management reorganisation will assist to that end. I urge my right hon. Friend and his colleagues to take account of what I hope he will regard as my constructive criticisms of the performance so far, and continue his laudable and vital initiative.

10.17 am
Mrs. Renée Short (Wolverhampton, North-East)

I congratulate the hon. Member for Oxford, East (Mr. Norris) on winning the ballot and on presenting his case with such lucidity, drawing on his considerable experience of the NHS. He was a valued member of the Social Services Select Committee for some time, but then he decided to desert us. We miss him very much.

As the House knows, the Select Committee examined the Government's proposals for setting up the Griffiths management complex, and we were worried about the manpower and resource problems of the NHS, as was the Secretary of State. We reported in February 1984 after hearing evidence from all the major professional, medical and nursing organisations and others who work in the NHS. We also heard from Mr. Griffiths himself.

Nobody in his right mind can object to reasonable proposals for the better and more effective use of human and financial resources. Nobody can object to better management aimed at delivering better patient care. That must be the object of the exercise, but we felt that the Griffiths proposals were thin in detail and lacking in lucidity. We said in our report: there is an obligation on the Secretary of State to be more than commonly lucid and explicit when he comes to announce his decisions. The House must judge whether he took that good advice to heart. I have very strong views about the results so far of Griffiths and its applications.

The House will recall that there was a signal lack of enthusiasm when the Griffiths proposals were published. They were seen, rightly in some respects, as an attack on doctors and on NHS staff at all levels, but they were seen especially as sounding their death knell for nurse management, which had been introduced some years previously. Griffiths was the third attempt in 10 years to deal with NHS management, and we thought that this upheaval was taking place too soon after the recent attempts to change the management structure. NHS staff at all levels become fed up when people with no experience of their great service begin yet another attempt to meddle. The House may find it difficult to comprehend, but it is true that, originally, Griffiths had no intention of including the chief nursing officer on the supervisory board or the management board. That was changed as a result of the Select Committee report. It was a telling omission by Griffiths—a Freudian slip of mammoth proportions.

For some time the Royal College of Nursing has been worried about the failure of the innumerable layers of management to ensure effective and safe patient care. That is unfair and dangerous to patients. It is also unfair to doctors prescribing treatment to patients for whom they are responsible. Of course, it could be fatal for the unfortunate patients. Who is responsible for nursing staff at district level if there is no chief nursing officer? Who will take resposibility for nursing care when the chief nurse/adviser—as some health authorities call them—is involved only with nurse education? That is a dangerous development and the Secretary of State should take the point on board.

The Secretary of State must know that, in many areas, nurses who care for patients are expected to be subject to managers who know nothing about nursing and who cannot have a professional view of the competence of the nurses on the wards. That is another difficult problem that has arisen in many areas and it has created much hostility between nurses and managers. In some hospitals, ward sisters' posts will be abolished. We shall have the nonsense of managers being appointed, down to ward level, who know nothing about nursing. The Secretary of State must do something about this Gilbertian situation.

Does the Secretary of State have any idea of the cost of all this bureaucratic nonsense? As the hon. Gentleman said, we want to spend money on hands-on patient care, which is what the Health Service should be about. We must invest in more caring staff, not in dictators at ward, unit, district or regional level. This is a bureaucratic nightmare, and an expensive one, too.

Chairmen have an important role to play in the management of their areas. Many new chairmen have been appointed in all the regions, especially since Griffiths. In the west midlands, 10 district chairmen were recently turfed out after only one term of office and 10 new chaps were brought in. I say "chaps" advisedly, because there were no women among those who were sacked or among those who took their place. How much experience of NHS management do their replacements have? It is extraordinary to think that before people have got their feet on the ground and obtained an understanding of how the Health Service works, especially under the new management system, they are being sacked. What criteria did the regional chairman use to measure the value or otherwise of the deposed chairmen? Perhaps he thought that the chairmen were getting on too well with the managers and that he should break up that cosy relationship.

Doctors have not come out too well under the new management structure. I understand that there is only one doctor regional manager, 13 doctor managers at district level and about 20 per cent. at unit level. There must be doctors on the district management teams. The British Medical Association is keeping an eye on appointments and is asking that a consultant, a general practitioner and a community physician be appointed to each DMT. Perhaps the Minister will let us know what progress he has made with that.

Recently, the Comptroller and Auditor General drew attention to the way in which some health authorities had been saving money at the expense of health care standards. He is concerned that efficiency savings are not being put back into patient care. I am sure that the Minister wants efficiency savings to be used for that purpose, and perhaps he will respond to the Comptroller and Auditor General's comments. I understand that cost improvement schemes saved £105.2 million in 1984–85. In 1985–86, savings are estimated to be £153 million, which will represent a considerable increase. What will happen to that money? Will it be used to improve patient care?

Unless more money is invested in the National Health Service, managers will be left with the appalling dilemma of having to choose between meeting the needs of the service and reducing salaries. There is no other option. The Royal College of Nursing and the Institute of Health Service Administrators have told the right hon. Gentleman clearly about this, and the centre for Health Service management at York university has given similar advice. The Minister says that that is a major error of the report, but I challenge him to enter any large hospital and find out exactly what is happening. He need not go much further than the hospital across the river, St. Thomas's, or to Westminster hospital, to discover the difficulties that they are experiencing. In many especially sensitive areas, such as the perinatal mortality rate, he will discover a considerable contraction in service to patients and advice to mothers in hospitals and in the communities which they serve. That is extremely worrying to hospital administrators.

As one of the small minority of women in the House, I must protest at the small number of women who have been appointed to management posts in the NHS. Since 1974, more than half the graduates attending NHS management training courses have been women, and women comprise more than 70 per cent. of National Health Service employees, but not—

Mr. Laurie Pavitt (Brent, South)

Is my hon. Friend aware that the only medical specialty on which the Government have spent millions on management training is nurses, but that few of them are being appointed?

Mrs. Short

That is correct, and that is part of the difficulty to which the Royal College of Nursing drew attention. The efficient women who work in the National Health Service, even those who do not wish to take on management responsibility, feel deprived and frustrated. Since 1974 more than half the graduates attending NHS management training courses have been women, which is a significant proportion. Yet women comprise more than 77 per cent. of NHS employees. Therefore, one can legitimately ask what has happened to all those women trained at public expense. Where have they gone? Why have they not been appointed to management posts? A survey carried out by the King's Fund shows how unsatisfactory the position is. The wastage occurred among men as well, but it was three times as high among women who had taken training courses. Therefore, it is a serious waste of talent. I hope that the Minister will do something about it.

Some time ago the Secretary of State defended his health plan in a speech to chartered accountants in Brighton. Perhaps he will recall what he said. According to a newspaper report, He said it did not mean 'increased costs and more jobs for the boys."' It certainly has meant a large number of jobs for the boys, and very few jobs for the girls. The right hon. Gentleman should take that on board. He said in that speech:

We are not just giving people new titles to put on their doors and more money for doing the same jobs … The general manager will have to show that he can make the Health Service run better and can get decisions made and put in effect. The Secretary of State must admit that that honourable goal has not been achieved. The House will want to know what he intends to do to improve not only the standard of management but the breadth of talent that he proposes to take into the different levels of management to meet the considerable objections that have been made to the type of persons who have been appointed to many of the posts. A rationalisation and simplification of the several layers of management will go a long way towards meeting the real objections of the professionals working in the NHS, who feel that their expertise has not been used and taken into account.