§ The Secretary of State for Social Services (Mr. Norman Fowler)
I should like to intervene at this stage of the debate. As I explained to my hon. Friend the Member for Oxford, East (Mr. Norris), I shall not be able to stay for the whole debate, but my hon. Friend the Parliamentary Under-Secretary of State will be here throughout. As he has responded to four debates during the past 13 hours, we thought that he might as well stay for this one.
I congratulate my hon. Friend the Member for Oxford, East on giving us the opportunity to debate the management of the National Health Service. At the beginning of his speech, he made some remarks about putting his name in the ballot, but, whatever may have been the pressure brought on him to do so, it is entirely from his own choice that we are debating the Griffiths report today. I congratulate him not only on his speech but on the way in which he has emphasised the fundamental importance of the issue.
I agreed with what my hon. Friend said about consensus in management. Although the new changes mark an end to the old system of the consensus teams, they do not mark an end to consensus in management. General managers are not autocrats; they cannot be. They must build on the present consensus team approach.
I also agreed with what my hon. Friend said about the signs concerning the new management process. Like him, I believe that the signs are encouraging, not discouraging. My hon. Friend referred to the permanent pay structure for general managers. I accept that such matters will have to be settled shortly, and I think that we shall be able to satisfy my hon. Friend on that point.
I agreed with a number—not all—of the points made by the distinguished Chairman of the Select Committee on Social Services, the hon. Member for Wolverhampton, North-East (Mrs. Short). No one would be more pleased than me if we could get more women managers into the Health Service. That is a good policy aim. I should also like to see the development of management training throughout the Health Service.
Basically, the debate is about seeking to get the NHS to work better. Over the coming year, the Health Service's budget will be about £18.7 billion, an increase of 24 per cent. in real terms since 1978–79, but it is vital that those resources are used to best effect, by which I mean that we should give the best possible service to the public. The starting point of any policy must be to seek to provide the best possible service to the public. It is not a matter of controversy between hon. Members that, in seeking that goal, we must aim to achieve as effective management in the Health Service as possible.
That is the same challenge faced by any service or company, but with perhaps this difference. The challenge of management in the Health Service is probably greater than that in any other service and possibly any other industry. The Health Service employs about 800,000 full-time staff. By any standards, that makes it an enormous service, the biggest employer in the country, and probably the biggest employer in western Europe. We should be under no illusion about the problems that are implied in 1330 the management of a service of that size, for if good management is essential in small and medium-sized companies, it is doubly important in a giant service such as this. Again, I hope that that is not a matter of controversy between both sides of the House.
At the same time, we must recognise one other feature of the Health Service—indeed, of any health service in any country. Demand for services is céonstantly rising. The fact that the number of elderly and very elderly people is increasing and likely to go on increasing provides inevitable demands on a service where a high proportion—about 40 per cent.—of the costs is accounted for by services for the elderly, while medical advance—the development of new treatments—also makes new demands from the public.
For example, in 1978 there were about 20,000 hip replacements. Today the figure is up to 30,000. Let us look at the history of other medical advances. In 1970, only 1,830 people were treated for kidney failure. Today that figure is over 11,000. In 1977, 2,800 patients had coronary artery bypass surgery. Today that figure is over 9,400.
My point is that it is inherent that medical advance itself produces new demands from the public, which any health service must seek to meet. Therefore, there is a management problem for the Health Service in trying to meet a virtually limitless demand and at the same time trying to improve the quality of the services that are also available.
In meeting that challenge, we have one inestimable advantage, which is the skill and dedication of the staff of the Health Service—not only the doctors and nurses on the wards, but the staff who ensure, for example, that the appointments system does not break down, and the ancillary staff who provide the services that are necessary for any hospital to function properly. I pay tribute to all the staff working in the Health Service, who seek to give a high standard of service to patients day in, day out, and sometimes in circumstances that are far from ideal. That is where the strength of the Health Service lies—in the skills and hard work of its staff.
My concern is not the dedication of the staff, but how this asset is managed. The evidence of the past has not always been enouraging. Let me give one example, which is very much in the recollection of the House, of how the old system of management was clearly, sadly and tragically defective. In the outbreak of food poisoning at the Stanley Royd hospital in Wakefield in 1984, which was prior to the new management changes, 19 people died and 450 patients and staff were infected.
The report clearly revealed a number of basic management difficulties. We now know that grossly unhygienic and unsatisfactory practices were allowed to flourish in the kitchens at Stanley Royd. For example, a drain in the kitchen was found to be blocked by cutlery which had not been removed. There can be no excuse for that. It was a failure of supervision and management. Once the outbreak had occurred the staff on the wards—the nurses and junior doctors—acquitted themselves with real distinction. I pay tribute to them. However, I have to say that some of the managers did not take a sufficiently active role in handling the outbreak. In particular, the report of the inquiry said that it regarded it as unacceptable that some managers considered it their function to monitor 1331 and to attend meetings rather than to go out and see what was happening. That was the old system being described. The Committee said it was
one major explanation of why nurses from outside Stanley Royd were not brought in, a decision which was taken without firsthand examination of the situation by those taking the decision".It is clear that the regional health authority did not have a clear and positive view of its management and leadership role within the region. I think that both sides of the House should be concerned about that. A capital scheme for the improvement of the kitchens at Stanley Royd had been in operation for over four years, with very little progress to show for it. The business simply drifted on with no firm management to ensure that decisions were taken and action progressed.
I go over that ground not to point the finger at individuals, but to remind the House of what the tragedy tells us about the management system which prevailed at that time. It was a system in which authorities and senior staff were not always clear about their roles and responsibilities, in which there was often a lack of leadership and in which individual reponsibility was submerged. No one was responsible and no one was accountable. Such a position would not be tolerated in any well run company. There is no reason—and again I hope that this is not a matter for controversy—why it should exist in the National Health Service. It was because of concerns about the management of the National Health Service that in 1983 I asked Sir Roy Griffiths and his colleagues to give us their advice. Building on the programme that the Government had already established to improve the efficiency and effectiveness of the Health Service, the Griffiths report recommended new and important measures which hold the key to improved management.
§ Mr. Jeremy Corbyn (Islington, North)
May I intervene before the Secretary of State gets to the substance of the Griffiths report? I do not in any way want to underestimate the terrible tragedy of the Stanley Royd hospital and the appalling suffering which occurred as a result. Obviously, there is common ground on that point. However, will the Secretary of State, in his strictures on that tragedy, also consider, by way of getting the record straight, the large number of serious contract failures which have occurred where private cleaning companies and private enterprise have been involved in the National Health Service? There are a large number of them, and I hope that he will recognise that.
§ Mr. Fowler
I am not sure that there are a large number of them. However, if the hon. Gentleman is asking whether we have the same standards for inside and outside contracting, the answer must be absolutely yes. There is no question of seeking or allowing a lower standard from outside. My point about Stanley Royd was not concerned with any particular method in the sense of the difference between inside and outside contracting. I was saying that it is quite clear that management and supervision had broken down in the hospital. It was not just at kitchen or hospital level, but throughout the whole structure of management.
We are now well advanced in the implementation of the Griffiths report. I think that it is only too easy for the basic message to be obscured or misrepresented. Let me explain what we are aiming to do in introducing the recommended changes. As the report said, the National Health Service 1332 is about delivering services to people. It is not about organising systems for their own sake; it is about securing the best deal for patients and the community within available resources, the best value for the taxpayer and the best motivation for staff.
The fundamental importance of the public and patient provides a starting point for all our work. Our aim is to strengthen and improve the service to the public. It is not in the interests of the patient that the NHS should be run ineffectively. Our thrust is to strengthen management and give it a clearer sense of purpose and the means to achieve that purpose.
§ Mr. Fowler
Please let me continue for a while.
The Griffiths report also identified the need for general management in the NHS. Its absence meant that there was basically no clearly identifiable officer in charge at regional, district or hospital level. I regard that as a basic defect. There was no driving force seeking and accepting personal responsibility for getting plans carried out. The establishment of general management means that at long last there is an answer to the question of who is in charge.
An essential part of the general manager's position is that he should accept personal responsibility for getting things done. Clearly—and I accept what my hon. Friend the Member for Oxford, East and the hon. Member for Wolverhampton, North-East said—the general manager cannot be a one-man band. Personal responsibility must also be placed on the other staff within the management structure, so an important part of the reshaping of management is the clear definition of the tasks that each person must carry out and the placing of personal responsibility on the individual for carrying them out.
Equally essential are arrangements for holding individuals and authorities accountable for what they do. Before the Griffiths report we had begun the process of sharpening up accountability within the service by introducing reviews of regions by Ministers to monitor performance against agreed objectives. That process has now been developed and extended further.
§ Dr. Miller
Are we going far enough in this respect? Have we not fallen into the same difficulty as we fell into some time ago in our manufacturing industry where people thought that the only thing to do was to manage and to administer, but we did not have enough engineers who understood the processes to do the administering and managing? Are we not in danger of perpetrating that on the National Health Service? The whole sphere of medicine is not as it was when I graduated. It has become an extremely complicated matter. There are technological and scientific advances, the purpose and operation of which must be understood by the people who are doing the managing. Should we not be going further and having people doing the managing who understand the processes?
§ Mr. Fowler
To some extent, I agree with the hon. Gentleman. I think that we are at the start of the process. Many of the general managers who have been appointed have come from within the Health Service. Clearly, some administrators have become general managers, but also there have been many doctors and nurses. A minority have come from outside. It is an important minority because it brings fresh perception and management skills to the Health Service. To make the parallel that the hon. 1333 Gentleman is making, I think that over the coming years we will need to develop the management skills within the Health Service. We shall have to put more emphasis upon management education and training. To develop good management is not against the interests of the Health Service. It must be in the interests of the Health Service. If I can get no other point accepted, I hope that the House will accept that one.
§ Dr. Marek
As of 21 January 1986, two of the 14 regional managers and 41 of the 191 district general managers appointed came from outside the NHS —a large number. We are worried that, if the nursing staff has to report, the only person to whom a sister on night duty could turn would be someone with a degree in business administration. Will the right hon. Gentleman comment on that problem?
§ Mr. Fowler
I think that the hon. Gentleman will accept that, whatever the background of a particular manager, the line for providing professional advice will still continue. That must happen.
The majority of general managers have come from within the Health Service. Of the 676 managers at all levels—regional, district and unit—more than 100 are doctors, 400 are from administration, more than 55 are nurses and 81 are from outside. I am glad that 81 people have come from outside because I believe that is an important aspect of management improvement. It is wrong simply to believe that all the management skills of the Health Service now exist in the Health Service. We want to achieve a reasonable balance. In some ways, I should like more nurses to be appointed, especially at unit level, although more nurses have been appointed at unit level than at any other level. Whatever else has happened, there has been a reasonable range. There has not been a mere redrawing, renaming or relabelling exercise, as we have sometimes had in the past.
Of course I accept that there has been some concern—it has already been expressed in the debate—about the impact of these changes in management on professional staff, especially nurses. I understand that, at a time of change, people are apprehensive about how it will affect them. We shall listen carefully to what is said in the debate.
I shall seek to put straight at least some of the points on record. The Government have the highest regard for nurses and for their contribution to the Health Service. We are employing more nurses than ever before. I believe that changes, such as the introduction of the Nurses and Midwives Pay Review Body, have been widely welcomed by the profession. I wholly agree that nurses should play a full part in the management of the Health Service, both as managers and as professional advisers to general managers and health authorities.
In all, 55 nurses have obtained general manager posts, mostly at unit level. However, a much larger number of nurses are widening their management experience as a result of the changes now occurring. Many senior nurses now combine their professional role with a wider task, such as that of personnel director or director of patient services. The introduction of general management is giving staff of all backgrounds opportunities to show what they can do.
1334 On the provision of nursing advice to district health authorities, I have insisted that every authority should continue to designate one nurse as its principal nursing adviser, that that nurse must be at an appropriately senior level, and that, in that role, he or she must have guaranteed access to the authority. Part of that responsibility will continue to be the monitoring of professional standards of nursing care throughout that authorité. The titles by which that nurse is designated vary across the country. Some of the posts may no longer be called chief nursing officer, but every district level authority has its own chief nursing adviser. As I mentioned earlier, some of the chief nursing advisers undertake an additional management role. We have told authorities to ensure that the professional advisory function is the main responsibility and that the chief nurse has adequate support to discharge it.
As far as units are concerned, it is important to be clear about the position from which we are moving. Previously, the director of nursing services answered both professionally and managerially to the district nursing officer. Clearly, with the introduction of general managers at unit level, that arrangement cannot and, indeed, should not continue, and the line of responsibility should go to the manager of the unit. The manager has the responsibility for getting things done, but he leads a multidisciplinary team and he must, of course, respect the professional competence of each professional in the team.
Our approach to management structures has differed from the one adopted in the early 1970s when the Government sought to impose patterns and a blueprint throughout the United Kingdom. Our approach to management structures has been to allow health authorities the flexibility and freedom they need to make arrangements that best suit local circumstances. That is a deliberate policy. It is a sensible policy because we want to avoid centrally imposed bureaucratic structures. Districts and, even more so, units vary enormously across the country. District health authorities are best placed to devise the right solutions for them. We have insisted that, in doing so, they should consult professional staff interests at every turn.
My hon. Friend the Member for Oxford, East raised with me the role of the NHS Management Board. That is not an additional layer of bureaucracy. Griffiths recommended that within the Department and within the existing statutory structure there should be a management board. That means that Ministers remain responsible for policy but now have the support of a board inside the Department which is dedicated full time to better management of the health authorities' services.
The board, therefore, brings the Department's role in management of health authorities into clearer focus. Its aim is to cut down unnecessary intervention from the centre. I assume that we all want that. Its aim is also to bring new skills to bear on those tasks which must be led from the centre—such as personnel, financial management, procurement, estate management and information technology—to give leadership to the health authorities by bringing together people from the private sector, the Department and the NHS itself—they are all represented on the board—and to get better services and better value for money from the health authorities by regular monitoring and review of their performance against those objectives.
§ Mr. Pavitt
Has not that job description borne out the point made by the hon. Member for Oxford, East (Mr. Norris), that another tier of management has been inserted? There are various sections within the NHS—for example, personnel. Instead of those sections having direct access to the Secretary of State, another tier will intervene.
§ Mr. Fowler
That is a fundamental misconception of how the DHSS is organised. There is a focus now where there was not one previously. The functions remain very much the same but they are focused and the Management Board will report to the Secretary of State. That means more effective management instead of the rather ad hoc system by which, I concede, we did things in the past. The board is introducing greater professionalism into the running of the Health Service at departmental level. It would be extremely curious if, having asked health authorities to do that, the DHSS were not prepared to do it as well.
I believe that we have made significant progress towards improving National Health Service management. I accept that there is still a great deal left to be done because I believe that we are, in many ways, at the beginning of this process. I think that a contribution has been made through the appointment of general managers, the extension of the accountability review system down to hospital level, and the institution of the new system of performance reviews. In the end, what the House and the public want to see are results—results in terms of better services for patients and better value for money.
Clearly, it will be some time before the full benefit can be delivered from all the changes that we have made and are currently making. I would claim that the results are already coming through. This year, we are treating more patients than ever before.
At the same time the National Health Service manpower is being properly controlled. In direct response to the point raised by my hon. Friend the Member for Oxford, East, the proportion of front-line staff, especially doctors and nurses, is increasing. That, again, is one of the things which should be achieved from a manpower policy.
This year we expect to achieve improvements in efficiency which will release something like £120 million for use in the service. Moreover, I have just approved the health authorities' plans for the coming financial year. As part of our arrangements for management in the Health Service, we now require health authorities to draw up short-term programmes every year. Those programmes set out their plans for developing services in the coming year. I have now approved the plans for 1986–87. Those plans show that health authorities are planning a significant expansion in services. They will treat more patients, make more advanced forms of treatment available, and continue the progress already being made towards caring for people in the community. The plans build on the progress that has been made in recent years.
Since 1978–79, an extra 17.5 per cent. in real terms has already been provided for hospital and community health services. In the coming year an extra £650 million—6.7 per cent.—is being provided against forecast general inflation of 4.5 per cent.
It is also significant that the steps that we have taken to improve management are now beginning to pay off in this respect. Health authorities are planning to generate cash savings of £150 million in the coming year through 1336 a wide variety of value-for-money measures. Those measures include energy conservation, better management of supplies, and competitive tendering for support services. All of that £150 million will be retained by health authorities.
Health authorities will also be making better use of manpower. In the next year, overall numbers are unlikely to change much, but again there will be an increase in staff working directly with patients. Most of those staff, to stress the point made by my hon. Friend the Member for Oxford, East, will be nurses.
The progress being made in developing the services can perhaps best be illustrated in three ways. First, total capital spending will be over £900 million in the coming year compared with £365 million in 1978–79. Next year's figures include an estimated £130 million of receipts from the sales of land and property which the health authorities will be able to retain.
Secondly, we shall continue the move towards community care for the mentally handicapped and other groups of patients. That means, for example, that in the northern region, by July 1986 only four children will still be in mental handicap hospitals, and in South-East Thames region, no children will be in such hospitals by March 1987. That is entirely good news and should be welcomed on both sides of the House.
Thirdly, all regions are also planning important developments in their acute services. They expect the total number of patients treated to rise significantly over the next 12 months and to make progress in the provision of priority services. For example, coronary artery surgery and renal dialysis will be expanded, there will be more hip and joint replacement operations, and a children's bone marrow transplant unit will open in Bristol.
Whatever differences there may be in the House about Health Service policy, one fact remains. The aim must be to use resources to their maximum effect. The Health Service is about providing the best possible services for patients and good management is about achieving that aim. It is not some alien concept. It is a common sense policy aimed at providing the best possible service for patients, and as such it deserves the support of the House.
§ 11.4 am
§ Mr. Michael Meadowcroft (Leeds, West)
Like other hon. Members, I congratulate the hon. Member for Oxford, East (Mr. Norris) on his choice of subject today. I am not sure whether his description of the pressures put upon him to enter the ballot are quite accurate, knowing the hon. Gentleman's propensity for tongue in cheek. Nevertheless, I am glad that he did enter the ballot, and chose this subject.
The hon. Member for Oxford, East, is one of the best Conservative Members at walking the tightrope. At times during his speech he wobbled too far towards the Government, but with a few variations of pace towards the end of his speech, he almost reached the opposite pillar. We welcome that as well.
I also enjoyed being part of the Select Committee on Social Services with the hon. Member for Oxford, East, and the hon. Member for Wolverhampton, North-East (Mrs. Renée Short), who spoke earlier, when we produced the report on Griffiths. I still think that the conclusions and recommendations of the report stand up to examination in the light of the experience so far.
1337 It would be possible to summarise the present position with Griffiths as a report conceived in hope, born in doubt, and nurtured with some worry. The representations that all of us have had today will demonstrate that. The hon. Member for Oxford, East quoted a popular song at the end of his speech. There is another popular song which I think that the Government sometimes employ too much, and that is "Wishing will make it so". I sometimes think that the Government embarked on their proposals with that song in mind. I will refrain from giving hon. Members the refrain.
Today's representations are important, as they tend to come mainly from the nursing sector, and the particular focus of the debate has been on the problems faced by nurses. However, if we concentrate solely on that matter, we would ignore some of the more general aspects of management and the control and accountability which are more fundamental to this topic.
Nevertheless, the facts are that, so far, very few nurses have been appointed. Indeed, it is not surprising that the proportion of nurses appointed as one goes down the scale from region, to district, to unit, will be greater. It is also not surprising, alas, in this male-dominated world of ours, that the proportion of men appointed at the nursing level is higher than the proportion of men within the nursing profession. That is a commentary on the present position.
The feeling in the nursing profession is summarised in a letter to me from an official of the Royal College of Nursing in the city of Leeds in my constituency. In that letter I received a copy of the Seacroft and Killingbeck hospital unit general manager's proposals, which say:As you can see, there is no one between the Charge Nurse and the U.G.M. other than Consultants, so that money could be allocated to medical propositions while the staff closest to the patients have no line of complaint.That is the fear in the nursing profession. I am sure that the Secretary of State would say that there are lines of complaint which may not necessarily be within the nursing profession, but it may be too narrow a view to suggest that; or the Secretary of State may say that the designated nurse adviser is the person to go to.
It is the feeling that is important, because so often when one deals with a large organisation and personal services appearance is as important as reality. Unless people feel that they are part and parcel of the system, they are unlikely to accept the mechanics of that system. The feeling is that no one understands the problems that nurses already have. Therefore, there is a depth of feeling that what is happening is dangerously wrong at the point at which the service is delivered to the patient.
Another great concern of the nursing profession is about what they regard as the hasty amalgamation of units. I accept what the hon. Member for Oxford, East said, that to amalgamate is not necessarily bad, and that there are occasions, with changing circumstances and perceptions of care, when to amalgamate into larger units may be better. On the other hand, the opposite is equally true: to amalgamate for the sake of it may not improve things at all. The figures show a drop in amalgamations of almost a third, from 850 to 600. That is alarming.
That means that there will be a lot more split sites and more shared equipment. We all know the worst example of that—someone who thought that he could share a defibrillator between separated units. That piece of 1338 equipment was peculiarly required in an emergency. I suspect that changes on that scale occur in every organisation, whatever the Government may wish to say to the contrary. The problem with nurses is that they are the most vulnerable and open to exploitation by management systems. During the NHS strike, the nurses kept the service going, stood up to the pressures on them, and were most open to exploitation from outside.
I hope that the Minister will take on board the feelings of those within the nursing profession, and not simply counter them by saying, "The structure is there and the people are in place to cope with the need," but will somehow inspire confidence in the proposals so that nurses feel part and parcel of the structure.
The two most important matters with which Griffiths was said to deal were how one made a decision when there were disagreements about which policy should be followed, and how to ensure speedy action. Every system must have a way of sorting out disagreements, and not all systems will prove to have speedy action. Sometimes we look for speedy action rather than seek to understand what the action should be. There is no point in speedy action for its own sake. The electorate, for example, wants less talk and more action. Throughout the decades, our policies in housing with excessive action without proper discussion about what we wanted were disastrously wrong. Speedy action of itself is not necessarily a criterion to follow.
I stress that these are not exclusively management problems. To try to contain them in a box marked "management" is dangerous and contrary to the sort of service that we wish to develop. The management of such delicate and important services, for example, involves accountability and decisions about resource allocation which cannot be contained within a unit, district or region. Those decisions are taken, bearing in mind the power to raise the funds as well as to spend them. It is essentially a political problem within the NHS, and every political problem requires a political solution. Problems of politics cannot be resolved mechanically. The danger is that we separate the problem and say that it is a management problem, which I do not believe to be true.
If there was a proper political solution to the structure of the NHS, management decisions would follow much more easily. The separation of responsibility between the Government and the NHS, and local government and social services has demonstrated that there is far less linkage between the different services and separate authorities than there should be. We have joint consultative arrangements and many other structures which detract from the perception of management being an entirely separate body. That type of political problem causes great difficulty.
§ Mr. Pavitt
Is the hon. Gentleman advocating that reorganisation number four should take the whole NHS into local government, as is the case with education?
§ Mr. Meadowcroft
I shall come to that. I am not in the business merely of providing problems.
The root of the problem from the Government's point of view is their obsession not merely with management but with control. They adhere to the fallacy that central administration from London to the regions, districts and units is somehow efficient of itself. I do not believe for one moment that that is true. The problems of scale are immense and contrary to the efficiency of a service and the 1339 sensitivity with which it is administered. I am pleased that the motion carefully talks about efficiency, effectiveness and sympathetic management. Those three characteristics must go together. The desire for central control is dangerous if one seeks sympathetic management.
The Government are obsessed with uniformity, and think that if there are to be general managers in one area there must be general managers everywhere. The hon. Member for Oxford, East said that the problem with the renewal of a fixed contract depends on whether one's face fits and whether one is popular. The same is true of the chairman of the health authority, and that these are important and powerful considerations in deciding whether to reappoint him. I do not believe that that is so. The hon. Gentleman drew attention to the changing role of authority members, and I am glad that at present he is not being too distracted. It is important to consider the implications and knock-on effects of changes in management.
Similarly, what happens with district authority chairmen is important to the whole structure because it affects the way in which the chain is implemented all the way down. In my region three of the district health authority chairs have unfortunately not been reappointed.
§ Mr. Meadowcroft
The same problem was dealt with in The Guardian yesterday. The chairman of the west Lambeth health authority, who resigned, was quoted as saying:I was told by two senior Conservatives that Central Office was vetting all candidates in London and the South-east for the chairmanship of health authorities because they wanted a smooth ride during the run-up to the general election.That is not conducive to sympathetic management. If a chairman is worried about whether he will be reappointed, how on earth can he deal properly with staff management? The position is intolerable, and is focused particularly on management. In Yorkshire, for example, the person chosen by the other chairs to be the district representative has now been set aside. It means that if one says unpopular things, one's future may be in doubt. That is dangerous.
I do not think that the problem involves either general management or consensus, as if the two were mutually exclusive. Any general manager who does not have a large measure of consensus is doomed to fail, and any consensus arrangement which does not have a way of resolving disagreements with some efficiency is also doomed to fail. It is extremely artificial to pretend that the two are mutually exclusive.
Similarly, the question of defining efficiency is artificial. Some people may define a system as efficient, if it is run on military principles. Indeed, some people from the military have been appointed. Stories are told with amusement and mild horror about the way in which some ex-military general managers sit down with something like a chess board and try to move the pieces about without understanding the consequences. The hon. Gentleman said that it was useful to have a director who knew where the factory was, but I always understood that the managing director knew where the factory was. If the general manager is not in tune and aware of where everything is and of the different pressures within the system, no amount of efficient management in the Government's terms will solve the problem.
The heart of the problem is that, if one separates the power to tax from the power to spend, one will always 1340 have problems. Strangely enough, one of the key documents about politics in the NHS was produced by the right hon. Member for South Down (Mr. Powell), following his experience as Minister of Health. Two short quotations from "Medicine and Politics" are relevant. The right hon. Gentleman said:the constitutional principle (is) that the proceeds of taxation must be expended by those who are responsible to the representatives of the taxpayers.He said of the boards that are appointed by the Government:They are, directly or indirectly, the Minister's appointees. They must obey his instructions. They have no independent authority derived from any other source, such as a local electorate, which could put them in direct relationship with the public. They have, for practical purposes, no independent sources of revenue, but spend what the Minister allocates to them.That is the difference.
The right hon. Gentleman also compared the NHS unfavourably with local government social services, and spotted the point that the latter are locally accountable for the service and must stand up in a public forum and defend their decisions because they both raise and spend the money. Once that is separated, as is the case with health authorities, no amount of obsession with Griffiths and efficient management will get us out of the problem.
If we are to deal with the problems of accountability and uniformity, different general experiments must be adapted to different methods. The Select Committee recommended that there should be some experimentation before we launch the report's recommendations everywhere, and to see what advantages there are. Why is there uniformity in the regions rather than variation? Why can we not have experiments within the district health authorities with local government? The district health authorities are now conterminous with local county boundaries. Uniformity is not displayed in every other service.
When we were debating the fluoridation of water, we discovered that, for example, in Scotland water is not controlled by appointed water boards but is part of the regional councils. If it can be done elsewhere, why can it not be done in the Health Service? There do not have to be general managers everywhere.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. Ray Whitney)
I am listening carefully to what the hon. Member is saying and I am trying to understand the recommendations he is seeking to put forward. He is suggesting that the power to tax and the power to spend ideally should not be separated. He is complaining that we are seeking—I do not accept it—to control from the centre. Is the hon. Gentleman suggesting that there should be a local tax paid to some sort of local health authority? Does he wish to devolve local taxation and break up the Health Service into separate entities?
§ Mr. Meadowcroft
The Minister stopped me in my purple passage. I do not want to see regional assemblies. I want to see regional authorities with the power to tax and the power to control services which are clearly regional.
We already have regional government in Britain. In Leeds, there is a massive tower block, City house, which contains the civil servants who are the regional government for Yorkshire and Humberside. They are controlled from London, but I want the control to be in 1341 Yorkshire and Humberside. There is no intrinsic reason why one cannot have regional government in Britain with the power to tax exactly where the power of spending is centred. That gets around the problem of control and the problem of uniformity.
The democratically elected, accountable authorities will be able to decide what they want. Management in a truly elected forum would have the immense advantage of multi-purpose authority, not confined solely to the National Health Service, however large, but linked to other personal social services, one that has links with other nursing services within the local authority. That would thus enable us to have management which, in the words of the hon. Member for Oxford, East, is effective, efficient and sympathetic. That is what I wish to achieve, but I suspect that it will not be achieved by simply isolating the management in the way the Government have done.
§ Mr. Roger Sims (Chislehurst)
I believe that the Griffiths report and its adoption are landmarks in the National Health Service. Like any other organisation, the NHS cannot stand still, and it must develop.
The NHS is big business, both in the sense of the number of employees and in the sense of its budget. I am sure that Griffiths was right when he said that the NHS needed management structures and techniques. The NHS is not big business in the sense that it is a profit-making concern, such as Marks and Spencer, a petroleum company or, indeed, the grocery company from which Mr. Griffiths came. However, the NHS is certainly comparable with those organisations in size and complexity. It therefore needs management.
The National Health Service is basically a health service or, perhaps more accurately, an illness, disease and injury service. It provides medical and nursing care, but it also provides catering, laundering, cleaning and general administration services, and one has to consider also the financial aspects of its work. Each hospital can be said to be a community in itself.
Any organisation of such complexity needs management. This House, a complex organisation, has a board of management. The National Health Service is larger than many industrial and commercial concerns, but it is not different in its needs. The NHS covers many disciplines. As in commerce and industry, management can be drawn from a wide range of disciplines. In commerce and industry some engineers make good managers, but some do not. The same applies to accountants, marketing men and so on. Surely it is sensible in the NHS that managers should be drawn from a wide range of disciplines—doctors, nurses, pathologists, treasurers and administrators.
We must realise that not only are we introducing a new philosophy to a wide range of people—many of whom are rugged individuals —but we are introducing new ideas to people who will be fundamentally affected by their implementation. The prospects of people in the National Health Service are at stake in the way in which Griffiths is implemented. Naturally people are concerned about whether to apply for management posts, or to accept that they will find themselves answering to managers with whom it will be congenial to work.
1342 What is surprising is not that there have been some grumbles and problems in implementing the Griffiths report, but that they have been so few. It was inevitable that there would be problems and misunderstanding.
Nurses, or, to be more precise, the Royal College of Nursing—I do not know how representative the college is on this issue—has been waging a campaign which appears to show that when the managers have been appointed at various levels, nurses have not been appointed. That is what the RCN is complaining about. When one begins to ask questions, one discovers that relatively few nurses have actually applied for management positions. In fact, in a number of instances nurses have been appointed to management positions. Although the RCN claims that there is a problem, it admits that it is perhaps only in certain areas and that it is not a national issue.
I do not dispute that nurses can be good managers, but it seems unnecessary to assume that every manager should be a nurse. As I understand it, even though nurses may not hold a management position, they are represented on management groups. Nurses have written to me in support of the campaign. I have asked them specifically whether they can give any instances where nurses are not able to make an adequate contribution to management decisions. If they had been able to furnish me with such details, I would have been happy to present them to the Minister. I can only say that I am still waiting for that information.
I do not say that the RCN campaign is without justification, but I think that its campaign has been grossly overplayed. I contrast the RCN with the British Medical Association, with which I have from time to time crossed swords. The BMA has not always been satisfied on the issue of management. It believes, quite understandably, that doctors should have an input in management decisions. However, it insists that the management structures are correct.
Each district management board, writes the BMA,or the equivalent body which has succeeded the District Management Team, should include three doctors: a hospital consultant, a general practitioner and a community physician. Proposed structures which were wrong have been challenged by the BMA. Over 50 structures were initially unacceptable; most have been modified and the BMA continues to ensure that the remainder are satisfactory. Similar monitoring is being carried out at unit level.That is a sensible way in which to proceed.
It is far too soon for us to pass judgment on Griffiths. As my right hon. Friend the Secretary of State said, we are only at the beginning of the process, but it is useful for us to watch developments carefully. It is one thing to monitor developments, and another to interfere. The Government, having introduced the Griffiths recommendations, must let the health authorities get on with it. Naturally, my right hon. Friend will want to give guidance on how it should be done, but, having given that guidance, it should be left at that. I speak with some feeling because my local health authority of Bromley took the lead in contracting out for various services, but then found itself in dispute with the Department when it started to do things in its own way.
The Secretary of State has overall responsibility for the NHS, but I urge him to leave district health authorities to get on with the job, to organise themselves and to make appointments in accordance with local needs and conditions and with minimal interference. Meanwhile, it is valuable that the House has the opportunity to discuss 1343 these matters, and it is indebted to my hon. Friend the Member for Oxford, East (Mr. Norris) for giving us that opportunity.
§ Mr. Willie W. Hamilton (Fife, Central)
I congratulate the hon. Member for Oxford, East (Mr. Norris) on initiating this debate. He obviously speaks with much authority and experience in these matters, and I detected in his well-informed speech considerable reserve about the Government's proposals in this context. No Labour Member would complain about that.
We have been told that the Secretary of State has other appointments and has had to leave, and we understand that. However, I object, as I have done on previous occasions, to his selective use of facts to persuade the country as whole as to the improvement of the quality and extent of Health Service provision over the past five or six years. The hon. Member widened the debate to make party political points, and I too want to widen the debate to make my riposte.
I objected very much to Secretary of State's reference to the "skill and dedication" of all staff. That point is made repeatedly, but it does not butter any parsnips with the people who are on the receiving end. The low pay, among vast sections of employees in the Health Service, is well known. Indeed, when the Prime Minister talks about the incidence of income tax, she refers to a nurse on £140 a week having at least 30 per cent. of that deducted in tax. She cites the nurse as a low-paid employee, so it is no good talking about the skill and dedication of these people unless one is prepared to link that with adequate pay.
§ Mr. Hamilton
I shall give way later on, because I now want to give some specific examples.
The fine words used by the Secretary of State are far removed from what we see happening all round the country—crumbling hospitals, peeling paint, inadequate maintenance, closing wards and hospitals—all these things are happening, and everybody knows it. The specific point of the debate is the Griffiths report. The House knows that I am sponsored as a Member by the Confederation of Health Service Employees. [Interruption.] The Minister need not say "Ah" as if that is a great revelation. I reveal it whenever I speak in such a debate.
COHSE warned about the dangers of the Griffiths propositions about two years ago, but not until the Royal College of Nursing began its campaign did the Ministry see fit to send a circular letter to hon. Members, dated 21 January 1986. That letter was designed, if not to rubbish, at least to defuse and downgrade the nursing unions' campaign against the ways in which the Griffiths report recommendations were being implemented.
That letter was for Members to circulate in case they got representations from the RCN. If the hon. Member for Chislehurst (Mr. Sims) got a copy, no doubt he sent it to the unions. He would have been wise not do so because that letter sought to show, through the usual jargon, that the whole purpose of the exercise was to give patients a better service. Always, when the Government interfere and meddle with the Health Service, in one way or another, they end with a certain expression—it is all designed "to give the patients a better service".
1344 The second aim was to give the patients an increased voice in and influence on the standard and services in our hospitals. We have heard not a murmur about the second claim in the debate so far, and it is difficult to see how Griffiths and its implementation would achieve that aim, even supposing that it achieved the first. I dispute that it would achieve the first either. However, the implications of the letter seem to be that the RCN and COHSE do not want to give patients those things, or that the machinery that exists does not enable them to do so. That is absurd, insulting and inaccurate.
The way in which the Griffiths proposals are working has the nurses —particularly the nurses, but also the doctors—angry and unhappy, to use no stronger language. The implementation is further forward in England and Wales than it is in Scotland. As a Scottish Member, it was with some trepidation that I decided to speak in the debate because, although Griffiths did not refer to Scotland, the Secretary of State for Scotland made it clear at the outset that he would follow the general propositions outlined by Griffiths for management. Therefore, Scotland is to some extent lagging behind England in the implementation of the proposals.
I shall now examine why unhappiness and anxiety exist among the nurses and the doctors. It is not because the nurses have any selfish self-interest. I suspect that, to some extent, the doctors are motivated by that, but the idea that the nurses are peddling their self-interest is too laughable even to contemplate. They are worried and anxious because they suspect—I put it no higher than that—that their role is being eroded and downgraded, and the management of health care is being put into other hands.
I referred to the proposition that the Confederation of Health Service Employees, my sponsoring union, put forward in November 1983. It predicted then that nurses would be squeezed out of NHS management and that the voice of nurses would be ignored as the Government installed hand-picked managers to carry out the Government's plans. The so-called new and thrusting, super-efficient, cost-conscious managers have already brought about a situation in which it is envisaged that there will be no nursing managers above ward sister grade and that directors of nursing education will be responsible to somebody in the personnel department.
Most of the top jobs have already gone either to existing NHS administrators or to outside business men who have been baited with salaries of up to £45,000 a year. As has repeatedly been stated in the debate, only a small proportion of those jobs have gone to doctors, nurses or medical officers. The figures were given in the Health and Social Services Journal of 12 September 1985 and they were quoted by the hon. Member for Oxford, East.
The claim has been made repeatedly that there are singularly few women, if any, among them. I do not know whether the hon. Member for Oxford, East has the exact figures of how many women applied, but the fact that they do not apply shows that there is something wrong, somewhere, with the system. The promised good mix of experience from the private sector and the public sector has not been realised. Although the Secretary of State for Social Services claimed that such a mix has occurred, it is minimal. Over 80 per cent. of the top jobs have gone to existing top NHS staff, and four fifths of that total have gone to administrators.
Interestingly enough, nearly six out of every 100 jobs have gone to ex-military personnel. The health authorities 1345 cannot attract good quality men from private business because of the salary levels offered. The hon. Member for Oxford, East said that one of the reasons why some men will not come into the NHS is that the health authorities cannot match the salaries that they are already getting in private industry. But the military man, the Royal Air Force man, the Army man of 50 who comes out of the services with a good pension presents no pay problem. He already has a moonlighting job. No, it is not a moonlighting job, but he has another income. Therefore, he can afford to take the relatively low salary that the health authorities can offer.
No problems are involved, either, in transferring such people's pensions from the private to the public sector. However, even if the health authorities have followed the correct procedures, a meddling Minister has vetoed some appointments for reasons that have not always been made clear. In the meantime, many health authorities have abolished the post of director of nursing as well as the post of chief nursing officer. This means that nurses will no longer manage nursing and that they will be excluded from decision making.
I wish to say a few words about Scotland. I make no complaint about the absence this morning of a Scottish Minister, because I gave no warning that I intended to speak in this debate. However, it is worth putting it on record that very few Scots believe the Tory claim that the National Health Service is safe in their hands. The vast majority of Scots are deeply suspicious of any proposed reorganisation by the Government, whether in the Health Service, local government or any other sphere.
The Government's claim that the aims of the Griffiths proposals are better care for patients and more participation by them in decision taking gives rise to hoots of derisive disbelief in Scotland. Nobody denies that public money must be spent efficiently and with adequate accountability at all levels. There will be consensus about that both in this House and outside Parliament. The National Health Service cannot be excluded from the exercise of the disciplines and restraints that ensure that those aims are achieved. However, it is interesting—the Scots have commented on this—that the propositions relating to National Health Service management came from Mr. Griffiths, who is the deputy chairman and managing director of a big supermarket, Sainsburys.
The reaction of the Scottish TUC is typical of the rest of the country: that we simply cannot look at the turnover of patients in hospitals in the same way as we look at the turnover of tins of baked beans in a supermarket like Sainsburys. Nurses cannot be treated, either, as though they were of as little account as shop assistants in Sainsburys or Marks and Spencer, although that seems to be happening. The National Health Service is not a supermarket. It is concerned with providing the best possible service to patients. That cannot always be measured in money terms. It cannot always be shown in a profit and loss account. It never is and it never can be. It is not concerned with those things.
The National Health Service as a whole is a complex web of interacting disciplines, skills and interests. The present structure might sound conservative, but it allows those different interests to be represented and heard. It is absurd to pretend that one can select a general manager at each level and expect him gladly and willingly to be 1346 accepted by doctors, nurses, technicians, administrators and ancillary workers. That is the meaning of consensus. So many complex interests are at work that this can be organised only on the basis of consensus. To appoint a general manager at each and every level makes the achievement of consensus, in my view, that much more difficult.
A few weeks ago—for the first time, to my knowledge—the Scottish area of the British Medical Association invited Labour Members of Parliament to a working dinner at Tavistock square at which they voiced their grave misgivings about these matters. There was an element of special pleading, but they made the important point that the people who know best how the National Health Service works, what makes it tick and how to achieve maximum consensus and co-operation are the people at the sharp end—those who know it from the inside. The view was expressed, which we accepted, that when they are in position the general managers of Scottish health boards will have, among their other responsibilities, an overall responsibility for strategic objectives and allocating resources. In discharging those functions those general managers will be accountable to the Scottish Home and Health Department in Edinburgh and not to the local health boards.
Since the appointments are also within the effective control of the Government, it means, in effect, that the control of the Health Service will effectively be transferred to the Government as, increasingly, local government has been transferred to the Government. That, along with the various other reconstructions of the Health Service over the past decade, make it understandable that morale at all levels in the Health Service is at its lowest since the inception of the Health Service. Can anyone wonder, at a time when young City slickers can obtain salaries of £100,000-plus and conscientious skilled hospital workers are paid in peanuts?
I return to the claim made by the Secretary of State about the skill and dedication of the workers in the Health Service. A trained hospital cardiographer, after 34 years at the same hospital, earns a basic salary of £98.63 a week. That is at the top of the scale, after 10 years of service. Going through the range of ancillary workers' pay—I see that my hon. Friend the Member for Islington, North (Mr. Corbyn) had an Adjournment debate earlier this morning on the same matter—we find basic wage rates as little as £67 a week before stoppages. A dental technician starts at £5,636 a year—£108 a week gross. Medical laboratory scientific staff start at £115 a week, or thereabouts. A medical secretary receives £89 a week. A general staff nurse—the linchpin of the ward, highly trained and hard working—receives basic pay of £115 a week gross. It costs the Secretary of State not a penny to compliment them on their skill and dedication. It is the pay scales that count.
I quote in conclusion the 14th report of the Committee of Public Accounts on the control of nursing manpower. On page ix, paragraph 22 says:We were particularly concerned about the high rate of loss to the NHS of both qualified nurses and those under training. In addition to the obvious loss of the value for money, the prospect of a future shortage of nurses, both qualified and in training, is a most serious matter of direct importance to patients.That is very different from the picture painted by the Secretary of State today.
Paragraph 15 of the report says: 1347the current shortages in the mentally ill and mentally handicapped areas … have occurred despite overall increases in numbers, and that some hospitals are finding it difficult to maintain standards.That is the reality of the situation today and, much as we want increased efficiency and more steps taken to ensure that we receive value for money at all stages—that applies in every department throughout the economy; there is nothing novel about that—I am of the view, which I think is shared by many people throughout Britain, not least in Scotland, that those ends will not be achieved by the Government's proposals.
§ Mrs. Edwina Currie (Derbyshire, South)
May I add my congratulations to those of my hon. Friends to my hon. Friend the Member for Oxford. East (Mr. Norris) not only on winning the ballot but on seeking to introduce a subject of such considerable importance of which he has such expertise? My hon. Friend has come a long way since we were at school together in Liverpool. These days he is very much the sort of person from whom one would buy a used car. Indeed, I hope to do so soon.
It has been mentioned that my hon. Friend served on the Select Committee on Social Services, but I believe that his expertise on the Health Service comes from his long membership of a health authority. Indeed, I think that he is still vice-chairman of the health authority on which he has served with much distinction for a number of years. In that, I imagine that he would regard himself as lucky. I always feel sorry that I had to give up being chairman of my health authority, as it was an office of profit, in order to come to the House, and I have often missed it.
I should like to nail another argument that we have heard today. The hon. Member for Leeds, West (Mr. Meadowcroft) has now left the Chamber, leaving the alliance Benches in their true glory— completely unrepresented—but that is nothing new. The hon. Gentleman talked about uniformity, but I did not quite understand his argument. He rightly said that as the health authorities spend taxpayers' money, those who run them should be responsible to the Minister. To me, that is an argument for uniformity throughout the country. The hon. Gentleman then went on to say that uniformity was a bad thing and that we should have regional boards, which is what I thought we had already. That was an argument against uniformity. The hon. Gentleman cannot have it both ways, although perhaps as a member of the alliance party—or parties—that is what he wants.
The hon. Member for Fife, Central (Mr. Hamilton) referred to low-paid staff, especially nurses. If he is as concerned as he says—and as I am sure he is—he should jump on to two other important bandwagons. The first, on which many of us are trying to ride, seeks to reduce the amount of tax and national insurance contributions that low-paid people have to pay so that they can take home what they earn. I believe that the hon. Gentleman's figures related to take-home pay. He should be aware that those people earn a little more than that and we should like them to have that money.
The other bandwagon seeks to improve the family income supplement and family credit system. It does no credit to the hon. Member for Islington, North (Mr. Corbyn) that he has consistently voted against those proposals in the Standing Committee on the Social Security Bill. The proposals are intended not only to bring 1348 in a more generous family support scheme for low-paid people in work who have families, but to ensure that the money is paid in their pay packets far more quickly than at present. I welcome that scheme, and I believe that it will be of the greatest help to low-paid staff.
The hon. Member for Fife, Central speaks for the Confederation of Health Service Employees. I put it to him that hospital cleaners will never be well paid, but they do essential work and we should join together to ensure that they at least take home 100 per cent. of the money that they earn.
§ Mrs. Currie
There is no point in paying them more if it simply disappears in tax.
It has been argued that Britain spends less than many other countries on its health services. I have looked at the OECD figures for percentages of GDP which were published recently. Those figures go back to 1960, but I have gone back to 1955. The percentage spent by the United Kingdom is certainly lower than that spent in other countries—about 6.2 per cent. compared with 10.8 per cent. in the United States, 9.3 per cent. in France, and so on. But even in the earliest years of the National Health Service that was so. The United Kingdom has always been behind the United States, Germany, France, Canada, Australia, Austria, Italy, and so on. Moreover, as those countries have become richer, the gap has widened. If there was ever an indictment of Britain's relative economic decline in the 1950s, 1960s and 1970s, it is that those countries have been spending a relatively greater proportion of an absolutely larger amount on health care. Nevertheless, the United Kingdom has steadily devoted a larger percentage of GDP to health care. The figure was 3.9 per cent. in 1960; it is now 6.2 per cent.; and I am delighted to report that under the first Tory Government of the 1980s the gap between this country and the OECD average has at last begun to close.
Presumably, we are talking about public expenditure on health. I imagine that the hon. Member for Wrexham (Dr. Marek) will seek to make this point in speaking for the Opposition, so I will unmake it before he starts. In fact, the United Kingdom shows up a great deal better in this respect because many countries devote a high proportion of private funds—personal, trade union and company funds—to health. Health staff in those countries, therefore, include billing, credit and invoicing staff and others who do not devote their time to the care of patients. When that is taken into account, some nine OECD countries devote a lower percentage of GDP than the United Kingdom to health care. In some cases, the percentage is far worse. Some of the countries that come out worse than the United Kingdom on this ground are eminently respectable and health-conscious nations, such as Australia, New Zealand, Finland, Japan and the United States.
Of the 10.8 per cent. of all resources devoted to health care in the United States in 1983, only 4.5 per cent. came from public resources. In Japan, 6.7 per cent. of all resources went to health care, with 5 per cent. coming from public funds. In the United Kingdom, 5.5 per cent. of the resources devoted to health care come from public funds, so we are not doing too badly. Indeed, we are doing a great deal better than some much wealthier nations.
I shall pick up some of the comments made—
§ Dr. M. S. Miller
On a point of order, Mr. Deputy Speaker. Will you rule on the difference between the copious use of notes and direct reading from a brief?
§ Mr. Deputy Speaker (Sir Paul Dean)
The hon. Member for Derbyshire, South (Mrs. Currie) is making use of notes, and that is in order.
§ Mrs. Currie
I am most surprised by the intervention of the hon. Member for East Kilbride (Dr. Miller), who knows so much about health care. I am sure that he is well aware that it is exceedingly dangerous to quote figures without having the figures in front of one. I am extremely careful to get figures right.
Many of the criticisms of the Griffiths report are well founded, and it has never been pretended that the report has all the answers. It is worth saying that not all general managers are in post. I think that my right hon. and hon. Friends in the DHSS have estimated that not all general managers will be in post until May or June. We cannot expect to have all the results of the implementation of the Griffiths report at this stage. We have been reorganising the Health Service since 1981, and those of us who were involved in that process in 1981 will recall the hours, days and months that were spent interviewing applicants for the posts that had been created. We spent many hours discussing structures, followed by further hours rediscussing the new structures. We consulted all the various interests. I remember going through six rounds of interviews for the district medical officer position. It was one of the positions that had not been filled during the 1970s. When I had authority, I knew exactly what I wanted. However, it was necessary, because the DMO was to be employed by the NHS, to pass through all the ring fences that the trade unions had forced on the NHS and which those in charge of the service had been foolish enough to accept instead of having open competition. However, we ended up with the chap we wanted.
Under the Griffiths report the whole business has started all over again. Officers have been reinterviewed, and in many instances they have been paid £2,000 or £3,000 more for undertaking exactly the same job. I cannot see that we have benefited to such an enormous extent from reorganisation after reorganisation. This is the fifth successive year of economic growth and of reorganising the Health Service.
§ Dr. Marek
I must ask the hon. Lady who brought about the various reorganisations. I am glad that she takes the view that the Griffiths report does not have all the answers. On 20 November 1985 the Minister for Health wrote a letter to the chairmen of regional health authorities, part of which stated:I do not wish to give the impression that this is a widespread problem or"—this is the important part—that we would favour any derogation from the fundamentals of the Griffiths approach.If the hon. Lady thinks that the Griffiths report does not have all the answers, perhaps she should talk to the Minister for Health.
§ Mrs. Currie
I am sure that the hon. Gentleman will agree with me that my right hon. and hon. Friends in the DHSS are capable of answering that sort of question themselves. My views on the Griffiths report are on record in the debate on the report which took place some time ago. I said then that I doubted whether it had all the 1350 answers. It would be foolish to say that one reorganisation can produce all the answers. The reorganisation was introduced by a Government who have tried extremely hard to get things right in the Health Service and who have devoted more resources to it than any other previous Government. If that has led to any particular feelings on my part, it is a fear of reorganisation, and that fear has carried over to some of last suggestions which have been made in the dark hours of the night about education vouchers. We should beware of political panaceas. Reorganisations postpone the resolution of problems that do not go away. They make the resolution of problems harder as they divert resources and effort.
I had lunch recently with a splendid gentleman who took my place as the chairman of the Midlands health authority. I was delighted to hear that he still faces the same problems, which I felt reinforced my judgment of them, but I was sad to hear that they had not been resolved.
One of my suspicions about reorganisation and some of the arguments that have been advanced during the debate is that we tend to regard better management as an objective. Some of the comments of my right hon. Friend the Secretary of State tended towards that. There is a tendency to see better management as an objective, but it is a means to an end, not an end in itself. The objective is better health care. But, as always in such debates, we seem to be concentrating on input instead of output, or the results. Good management is merely the method by which we achieve those results. The evidence of good management is the more efficient use of resources for better health. I think that we are seeing that now. My right hon. Friend the Secretary of State quoted all the figures for more treatment, more patients, and so on. The fact that people are living longer and that 95 per cent. of our people have enough confidence always to use the NHS is proof of its success.
I shall give some figures to illustrate the efficiency of the NHS and of its management. They come from page 72 of The Economist of 8 June 1985. I hope that the hon. Member for East Kilbride will not mind if I refer, occasionally, to my papers. They show the comparative cost of transplants in the United Kingdom and the United States of America, which is, by any standard, the wealthiest country in the world and spends the most on health care. In the United Kingdom a heart transplant costs about one third of the price in the United States. A heart and lung transplant—one of the most advanced forms of surgery—also costs about one third of the price in America. The same is true of liver transplants. A pancreatic transplant is about half the cost of a similar transplant in America, as is a kidney transplant. Moreover, a bone marrow transplant probably costs five times more in America than in the United Kingdom. Thus, although the United States is devoting many more resources to health care, we achieve better health care out of the money that we are able to spend. The results speak for themselves.
I turn to the campaign run by the Royal College of Nursing and to some of the disgraceful remarks made by nurse administrators and senior nursing trade unionists about the Griffiths report and its implementation.
An advertisement in New Society of 24 January 1986 shows a picture of Florence Nightingale and a picture of a modern nurse. It says:The nurse on the left"—splendid Miss Nightingale from Derby— 1351established British nursing standards. The nurse on the right is being forced to compromise them … because, whilst we agree that administrators can run hospitals, we don't believe that they can run nursing. More and more Health Authorities are appointing executives: at the same time, they are depriving nurses of any meaningful management role.There is nothing to prevent nurses from applying for such posts. But they do not do so, because they like nursing, being on the wards, and being involved in patient care. They look at the general management job and realise that they like what they are doing. For much the same reason, all the capable ladies in the real world, the councillors, magistrates, head mistresses, and so on, look at the House of Commons and decide that they do not want to go there. One sometimes wonders who is right.
There is nothing whatever to prevent nurses from applying. In recent weeks, the nursing press has been full of horror stories, such as the story that 70 or 100 applications were received for general management posts, although only one had come from a nurse. Too seldom do nurses make any real effort to become good managers, even of nurses. I know of horror stories concerning senior nurse managers during the 1981 reorganisation. I asked one such person what the turnover of trained nurses was in his hospital. He did not know. When I sent him to find out, he came back with a scribbled bit of paper. But he should have been asking that sort of question, he should have had the information to hand, and he should have been acting on it. It was not right that someone should have had to come in and probe like that. But too seldom do nurses make the effort to make good managers and too seldom do they have any real knowledge of what other skills and professions can do. In other words, they suffer from exactly the same problems of ignorance of other professions as they criticise in others.
The Health Service needs the best managers that it can lay its hands on, and I do not much care which discipline they come from. That being so, some general managers will not be nurses. I am surprised that the RCN cannot find anything better to do than knock its colleagues. If it really wants to go back to the days of Florence Nightingale, it is talking about going back to the days of nurses working 100 hours a week, scrubbing ward floors on their knees and having to resign when they got married. I am not sure that I would want that.
One of our aims with Griffiths was to bring in outsiders. If there has been any failure, that is the one that we have to admit because, as reported in a written answer of 5 February 1986, we managed to find all of 35 outsiders out of 423 unit general managers. That is fewer than the nurses. Many are not industrial people, but have come in from the service.
I found an article by an industrialist called Lorne Williamson, who, for his sins, is the district general manager for the Brent health authority. I hope that he is enjoying it in Brent. I am sure that the hon. Member for Brent, South (Mr. Pavitt) will be acquainted with him. It is interesting to read his criticisms of the Health Service. He commented on the public scrutiny with which they work. That strikes everybody who enters the NHS. One cannot do a thing without everybody taking an exceedingly keen interest and criticising absolutely everything. He said:I feel like I am managing in a goldfish bowl.That will not go away, and it will not attract industrial managers.
1352 Mr. Williamson's second criticism is of the lack of agreed objectives. He speaks of the enormous verbiage of the NHS and mourns the absence of monthly quantitative measures of performance. That reflects the fact that there are not any real objectives. He comments on the literacy and articulateness of senior staff and their relative innumeracy. We may have a problem there. I suspect that he is right.
The third criticism was that the absence of any kind of incentive for performance is striking. He wrote that, as a result,delays seldom have cost penalties and frequently bring positive benefits!We have to devise a system for giving incentives for good management. We tried to do it in local government, but I suspect that we have halted that recently. If we are to encourage good management, we have to take such criticism. Mr. Williamson does not mention the biggest pressure of all on the NHS and its administrators—the fact that there is always a budget limit but that expectations are infinite. The public are never satisfied and they never will be. It takes a very special type of person to work under those circumstances.
I am extremely fortunate to have had a close association with the NHS for many years. I have met and worked with NHS managers from all sorts of backgrounds and of the highest calibre. We are very lucky to have them. They are honest, hard-working and committed. We should be very proud that the NHS is safe with them.
§ Mr. Laurie Pavitt (Brent, South)
As a good House of Commons man I am always sad to hear a mere knockabout politics speech such as that made by the hon. Member for Derbyshire, South (Mrs. Currie) after hearing a thoughtful opening speech. Although our views differ across the Chamber, there was at least a genuine debate until the hon. Lady spoke. I am afraid that she does herself no good by bandying about figures, most of which I can refute, especially those concerning Germany and France. She mentioned one of the finest constituencies in the country—mine.
The House will know that I am not unacquainted with health matters. I am not unfamiliar with serving in what used to be called the district health authority. The hon. Lady made comparisons with my area, but we are fighting vigorously to prevent the closure of another 100-bed hospital. A 94-bed hospital has already been closed and two others have been reduced to one third of their original capacity. The Parliamentary Under-Secretary of State knows that I approve of the policy affecting the mentally ill and Shenley, but I urge the hon. Lady to do as much homework for her speeches as the hon. Member for Oxford, East (Mr. Norris) did for his.
§ Dr. M. S. Miller
Instead of making the comments that she did about the Health Service, the hon. Member for Derbyshire, South (Mrs. Currie) should have attacked the Government for making cuts in the service. Will my hon. Friend expand on some of the figures that she gave? She mentioned the cost of surgical operations and procedures here as compared with those in the United States. However, she did not say that in the United States the cost is borne entirely by the patients, whereas it is not in Britain. The difference becomes enormous. It is not just two or three times more expensive, but sometimes a choice between going bankrupt and not having the operation.
§ Mr. Pavitt
My hon. and qualified Friend makes an important point, and I wish that I had time to deal with it. The hon. Lady gave the figures for renal dialysis, renal transplant and heart bypass operations. Every year, I am privileged to be invited to lecture to medical faculties in universities in the United States, for which my fares are paid and I receive a fee. My hon. Friend is right. In America, some patients cannot obtain necessary operations because they have been priced out of the market. That is another problem that we must watch. I know that the Under-Secretary of State will be worried about the growth of litigation in the United States, where before one signs a form for an operation one must ensure that the doctor has enough money to pay for insurance cover in case he receives a bill for $500,000 after a failed operation. As usual, I am digressing from the main theme of the debate. I apologise for that, but it was an interesting point.
I criticise the entire Griffiths report. The hon. Member for Oxford, East and the Secretary of State recognised in words—the hon. Member for Oxford, East recognised it in more than words—that management in the National Health Service is a different ball game. But although the Secretary of State recognised that in his words, he has not recognised it in his implementation of policy. For those of us who read the Griffiths report line by line, there is no doubt that he was talking about a separate, individual, management skill—an expertise in commodities, equipment and units of production.
My hon. Friend the Member for Fife, Central (Mr. Hamilton) said that Health Service provision is about caring people who are in service, and about caring for patients. Any experience in that area is much superior to book learning, certificates or Institute of Management expertise. That is at the heart of the campaign being conducted by the Royal College of Nursing in protest against the downgrading and demotion of their traditional experience. They have had 100 years of practical experience since Florence Nightingale, although not personally, created St. Thomas's hospital. The disastrous consequences to nurses and patients of the Griffiths report lie more in the Government's interpretation and implementation than in anything it contains. The report did not recommend the wholesale restructuring of the NHS at local level, or the downgrading of nurses' professional responsibility, yet that is what is happening.
What is especially sad to those of us who have a strong affection for our Health Service is that nursing morale is at is lowest ebb for 40 years. That is because each reorganisation knocks to pieces all security for senior nurses. The House saw the disaster of 1974, the brainchild of the present Secretary of State for Education and Science. There was turmoil when senior nurses had to reapply and find new positions in the new structure. That took place as from 1 April 1974. It was so appalling that when the Conservative Government returned to office in 1979 they had to do something about it, so the then Secretary of State for Social Services, the right hon. Member for Wanstead and Woodford (Mr. Jenkin), had a mark 2 reorganisation. He had to clear up the mess that had been made. However, once again the jobs of senior nurses were put in jeopardy. We eliminated the area health authorities and created 191 district authorities. Many nurses in senior grades spent two years not knowing whether they had a job, and having to reapply for jobs. Again, that affeced the morale in our nursing service.
1354 I claim that the Griffiths report is the No. 3 massive reorganisation. It is not just about management. It is reorganising the National Health Service for the third time. In the past year I have had discussions with colleagues in health authorities and, of course, with nurses, and I find that nurses with 20 or more years' experience—qualified state registered nurses, such as the daughter of my hon. Friend the Member for Fife, Central and my daughter, who trained at Guy's at the same time—do not know whether, after 20 years' service, their job is still the same with the same responsibilities, or whether it has any future at all.
Therefore, I claim that the Government have implemented Griffiths in the most ham-fisted way. I also claim that the Tory Government are a suitable case for treatment for their own congenital disease, which causes each Minister for Health to reorganise as a substitute for dealing with the real problems of health provision. I repeat the cry of anguish by Petronius Arbiter 2,000 years ago:We trained hard, but it seemed that every time we were beginning to form into teams we would be reorganised.I was to learn later in life that we tend to meet any new situation by reorganising; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation.I am afraid that those words of 2,000 years ago are true today when we look at the Griffiths report.
One of the immediate consequences is that the input into policy of skilled trained nursing has been dismantled. Organisation of the new structures is geared more to the administrative convenience of the administrators than towards patient care, despite the Secretary of State's protest this morning. Nurses have been demoted. They have positions of secondary responsibility in their own area. Now they will be mere advisers.
I quote from the Secretary of State's letter to the Royal College of Nursing:In practice so far as nursing is concerned we would expect authorities that will need a nuring adviser at a senior management level whose main responsibility is the provision and quality of nursing advice to the authority. The officer may of course carry out other duties in support of the general manager.That is patronising in the extreme; soft soap that seeks to ease the tragic consequences for our Health Service. What an upheaval.
Nursing is now in the middle of an earthquake. In another place, on Tuesday 4 March, Baroness Trumpington, the Under-Secretary of State for Health and Social Security, said that the number of nursing units in the NHS in England is expected to decrease from 850 to 600. That is a 25 per cent. decrease, to happen in months. How does the Secretary of State think that the nursing service can withstand such shocks with equanimity? The Royal College of Nursing is seeking to advise us on those matters. I wrote to the Minister, arising from his letter to me, on 14 February and I am still awaiting a reply.
The Minister will deny that this is a major reorganisation of the Health Service. I claim that it is. Because of the importance of the hospital service, we sometimes forget that the Cinderellas of primary care—the district nurses, health visitors and school nurses—are also being profoundly affected by the way in which this report is being implemented. Shirley Goodwin, who is one of the experts, in my opinion, on the issue of domiciliary nursing care, says:There are a number of negative effects upon the service when community units disappear. One major cause for concern is that if the nursing management structure is split among several units, 1355 the level at which community nursing services are led by a manager with the necessary community qualifications and expertise is forced down. In some areas, the most senior managers within a unit will he graded as Senior Nurses and will report to a general manager, not a Director of Nursing Services.It is not difficult to appreciate that busy immediate managers (the nursing officers or Senior Nurses) will have neither the time, the expertise nor the perspective to provide professional leadership".That is an important point, because within the team work which takes place in the NHS, nurses have provided professional leadership over the decades. Shirley Goodwin goes on:
Without a Director of Nursing Services, these tasks will either remain undone or will be undertaken by a unit (or lower tier of) general manager who knows nothing of nursing generally, let alone of the specific services provided by district nurses, health visitors and school nurses.I shall quote again from Shirley Goodwin because I believe that she has done so much for this subject. The House and the public are inclined to pay lip service to primary care. We concentrate, inevitably, because of the large amount of resources it takes up, on the hospital service. Shirley Goodwin says:It is easy to see what will happen to community nursing in an authority where, for example, it forms only one part of a unit which also contains a large hospital. The unit general manager can hardly fail to find himself responding as a priority to the more dramatic and urgent needs of a district general hospital where paediatric or intensive care beds might be threatened. We all know that running today's health service is a case of constantly robbing Peter to pay Paul. But where Peter is represented by acute services vociferously championed by shroud-waving consultants, how successful can the general manager be in keeping Paul's needs firmly to the front of his mind"?I think that Shirley Goodwin could qualify for a debate with the hon. Member for Derbyshire, South. I would put my money, I am afraid, on Shirley Goodwin.
The post of chief nursing officer has been retained in only 11 of the 191 district health authorities. That post has no power and no participation in decision-making; it is merely advisory. Another catastrophe is the change down. That has already been mentioned by other hon. Members and I shall not go too far into it. There is a change to an adviser educator in 49 district health authorities. The Royal College of Nursing is right to fear for the future of student nurses.
In case the House thinks that I am a spokesman for the Royal College of Nursing, may I say that I am a member of the National Union of Public Employees, although I am not sponsored by that body. Where nursing is concerned, there is no difference between my hon. Friend the Member for Fife, Central talking for the Confederation of Health Service Employees and me talking as a member of NUPE or for the Royal College. We are talking about the basic problem faced by nurses of all kinds, whatever organisation they belong to.
A new piece of management jargon is the hybrid posts. I always think of the hon. Member for Tiverton (Mr. Maxwell-Hyslop) when I hear anything about hybrid posts. However, there are hybrid posts in 63 of the district health authorities. If anybody cared to look at nursing structures, I think that they would realise that the hybrid post must be one of the most confusing things which have ever been permitted to exist.
If Ministers had any real understanding of the NHS or a genuine involvement in its basic principles or the caring philosophy, the harsher effects of the two previous Tory reorganisations could have been avoided. Instead, in implementing Griffiths, they have magnified the effects. 1356 Ministers come to the Dispatch Box ad nauseam with platitudes giving the impression that nurses are in favour of the Griffiths recommendations in general and oppose only small details.
As I said in my letter to the Minister, we must admit that the Royal College of Nursing is not a Government basher. It is not concerned with its own status and with the number of posts. It is concerned with morale throughout the nursing services, which have been eroded.
If the Under-Secretary of State had any sense of the mounting grievance among nurses, his first action on Monday morning would be to get down to a round-table discussion with the organisation of nurses concerned and ascertain whether, even at this late stage, something could be done. The Griffiths report has been implemented, causing much anguish to individual employees, The harsh effects have been magnified. Because of the way in which the Government have acted, they should return to the drawing board.
I join the congratulations extended to the hon. Member for Oxford, East. He made a gentle, thoughtful speech. He was loyal to his party but his speech contained enough good points to lead the Under-Secretary of State to think again.
Last night, when I was crossing swords, as usual, with the Under-Secretary of State, I told him that I would send him copies of all my correspondence. I knew that, although the big guns fire first, all the pieces had to be picked up by junior Ministers. I was not disappointed today. I realised, after the hon. Member for Oxford, East explained how he chose this subject, why on a Friday, for the first time in centuries, we saw the Secretary of State in his place. I did not expect him to last long and so the Under-Secretary of State takes his place. In these as in other matters I shall keep the hon. Gentleman fully informed. I know that he, in turn, will twist the arm of the Minister for Health to obtain answers to letters sent more than a month ago. I have not yet received replies to my letters.
§ Mr. Colin Moynihan (Lewisham, East)
I always enjoy participating in debates when the hon. Member for Brent, South (Mr. Pavitt) speaks. I regret that I do not share a platform with him in the United States and share his fee. I hope that I share with the hon. Gentleman and all hon. Members who speak in this debate the knowledge that we are talking not only about management structure and incentives but about how we can maximise the provision of health care to those in need. That is what the whole exercise should be about. I agree that it is a mistake to rule out the element of consensus from management. It is important in the Health Service to have a strong element of consensus management among those involved in the provision of services.
For line management to be effective in any business, it requires management tools to do the job properly. The first and most important of those tools is the availability of data and information to enable management in the Health Service to effect an efficient service. I am concerned that, in trying to use resources to their maximum effect, we have not travelled anywhere near far enough down the road towards accurate clinical budgeting, all the way through from unit budgeting to budgeting for consultants. We must consider this important point in the development of an effective NHS management service.
1357 The new structure requires that managers recognise that professionals find it difficult to be managed. Not only in the House but in the NHS, sensitive handling by new managers in post is needed to persuade professionals to be accountable to new structures.
I shall concentrate on financial provisions. If one wants to achieve a change in the provision of out-of-hospital based services of community care, it is very difficult to ask management to implement that in a long-term policy on a year-by-year financial basis with year-by-year financial accounting. We must be very careful, therefore, about the issue of the rates and the speed of change that we expect from year-by-year financial accounting against what are careful and long-term projections of, for example, community health care provision.
As I mentioned, I want to concentrate on the most essential tool for any management system which is to be effective. That is the financial plan and how performance can be assessed against reasonable targets. The problem is that the financial criteria used by regions for the distribution of resources to those who manage the districts are often not the right and best form of distribution of resources. I particularly consider London's case in that context.
The most important issue faced by NHS bosses should be the financial system under which the managers work. Allocation of sub-regional RAWP has a detrimental affect on unit management performance at present. I have nothing against a national RAWP concept and the way that that works, although my minor reservations on that are for another place and another time. I would like to concentrate on my major reservation about sub-regional RAWP as it affects management.
§ Mr. Corbyn
Would the hon. Gentleman not accept, if he is dissatisfied with sub-regional RAWP, which I am, particularly in the way that it affects London, that that is of itself an inevitable consequence of the national RAWP formula, which sucks money away from urban centres such as London into the more rural sectors? While I share his criticisms of sub-regional RAWP, the hon. Gentleman will have to oppose RAWP as a whole in order to protect services in the inner urban areas.
§ Mr. Moynihan
I accept that there are problems and I have reservations about the national RAWP formula. My major concern about the management effects of sub-regional RAWP is that there are far greater cross-boundary flows between districts than there are between regions. I want to concentrate on that point, as my argument today will centre on the fact that major cross-boundary flows make it difficult—however efficient the management of a hospital such as St. Thomas's might be —to implement an effective policy for that hospital without running foul of financial targets. I hope that the hon. Member for Islington, North (Mr. Corbyn) will allow me to concentrate on that aspect.
§ Mrs. Currie
Does my hon. Friend recognise that the changes brought about by RAWP are helping inner London health authorities? My constituents in Derby no longer have to travel down to London for health care treatment because they can now get that in the midlands through the allocation of resources at home.
§ Mr. Moynihan
I only wish that in practice that was borne out by the numbers of people still coming into London. There is, however, still massive demand from outside London to come to London teaching hospitals. One of the major problems—rightly so—is the clinical freedom allowed to doctors to refer patients to consultants. Doctors who have a close affiliation with or training background in a London teaching hospital still refer large numbers of people to London to be treated. Financially, that acts against people living in those districts.
On the performance indicators given by the DHSS, virtually all the London teaching hospitals perform very well. Yet it is still a fact that they are massively over target. The traditional argument is that the net flow by specialty is done on national average costing by specialties. That has always been thought to be the problem, as it was regarded as insufficient. For example, in St. Thomas's hospital that is not so. There is renal medicine and surgery in that hospital which is a high cost specialty and also a regional specialty. The regional health authority makes a general allowance at full cost reimbursement for what the hospital considers to be the cost.
That is not the answer. Management is still faced with being told by the region that it is grossly over target, with the implied criticisms of inefficiency and extravagance. That is simply not borne out by national criteria. The real reason why it is so difficult to manage is that the regions say to a district, "We shall fund you for your population and give you a net credit or debit according to your inflows or outflows. We see that you have a large inflow component and a large outflow component, but our target can leave you only with a small residual component for the residents inside your district". That is fine nationally, where the cross-flow is small, but not locally where it is great. In effect, the region is saying that it is in the interests of management to treat as few patients as possible from inside its district, and, at full national costing, to treat as many people as possible from outside the district, and to have as few people as possible being treated outside the district. That is the way to reduce the cost of medical provision to those living within the district. The best thing to do financially to improve performance against target is to increase the number of day patients and out-patients coming from within the district, and to supplement that with as many people as possible from outside the district staying overnight.
If every hospital did that, NHS funding could not work on either a regional or national level. Ironically, a hospital can perform worse against target if it treats someone from its own district, because it recoups only about 42 per cent. of the cost of treating somebody from outside the district. Therefore, there is a positive incentive to draw people in for treatment from outside the district. Even if a hospital is brilliantly efficient, and treats many more people from inside the district, it can perform worse against target. I am extremely concerned that urgent attention is given by the regions under the present structure to ensure that that problem is tackled.
Other factors need to be considered by regional health authorities in allocating their district resource. The first point deals with hospitalisation rates, rather than the pure population point. It is well known that only those on the tip of the clinical iceberg are treated, and that there is a great deal of sub-mode sickness in the community. Roemer's law, developed in America, recognises the fact 1359 that if one builds a hospital, it will be filled. Hospitalisation rates vary enormously. In Boston, for example, there is twice the provision of hospital facilities that there is in New Haven. Although there are huge inequalities in provision, nobody is up in arms. Even in Chichester, taking into account age, sex and standard mortality rates, there is half the demand for hospitalisation that there is in Wandsworth. The provision of a large number of hospitals in a district of London leads people to want to use them, so the demand for the services in inner London is greater.
Given that background, it is no good a region saying, "We shall take a national average of population and as there is over-demand for hospital resources in your district, you must do something about it". RAWP fights to correct Roemer's law, but hope that we shall move away from the population-based RAWP formula within a region to recognise some of the criteria that I have mentioned, including hospitalisation rates.
There is a historical quirk involved in the present important problems of St. Thomas's and the West Lambeth health authority. St. Thomas's lies at the tip of a triangular district. St. George's hospital is much more convenient than St. Thomas's for many of the local people. Seventy per cent. of the cases come from outside the district, and that means that two thirds of the local population choose to go elsewhere for treatment. It is difficult for management to intervene when management has no control, rightly so, over the doctor's decision as to where he is going to refer his patient for consultant and hospital provision.
Against the background of RAWP and the targets, it is difficult for some people to avoid the conclusion that it is not the efficiency of St. Thomas's hospital which is in question but the nature of the financial provision under the existing system. It gives the hospital the appearance of being inefficient. It gives the management the appearance of being profligate by virtue of being well above target.
I hope these points have been taken into account during the review of RAWP. The critical issue of the particular districts where there is a large proportion of inflow and outflow patient care can be considered in the light of the points I have made.
In conclusion, I wish to reflect on the substantive issues which have been raised today. The implementation of the Griffiths report is an important first step in improving management. I strongly welcome it. I also believe that the quality of management from outside and inside the Health Service is very high. We should not under-estimate the quality of the management that has come through from inside the Health Service. The next step for improved management is the need for better clinical and unit budgeting down to the individual consultant level. This would provide an important benefit to the quality of management and the quality of health care provision. I firmly believe this can be achieved only by an overhaul of the criteria used by the regional health authorities in allocating limited resources to their districts. That will enable us to have the good management we need for the most important service we provide the community—the National Health Service.
§ Mr. Jeremy Corbyn (Islington, North)
I welcome this debate on the structure of management in the National Health Service because I think that it is a subject that is 1360 not discussed sufficiently. I believe that the effect of the Griffiths proposals is not fully understood by many people outside the NHS.
I was studying the NHS annual report for 1985 earlier in the debate, and I noticed that in the introduction to the section on management it says:The NHS needs an effective system of general management to ensure the best possible service for patients and value for taxpayers' money.The report goes on to say how last year's report discussed the recommendations of the Griffiths inquiry, and states that many general managers have been appointed. That is perfectly true. Where I part company from the Griffiths proposals for the reorganisation of the Health Service is over the effect of the reorganisation on the Health Service. I object to it because it undermines the principle of a publicly accountable, democratically run Health Service.
I do not pretend that the pre-Griffiths system of management was especially accountable or a democratic form of management. It had many faults and inadequacies, but the way to treat those inadequacies and faults is not to bring in experts from every other industry and ask them to treat the Health Service as one would treat a supermarket chain, a biscuit manufacturer or a motor manufacturer. One must look at the effectiveness of the Health Service in relation to the health of the people whom it is supposed to serve.
I strongly object to some of the management measurement techniques that are used in the Health Service. Instead of examining the overall health of a particular community or district, there seems to be an obsession with the throughput of patients in a National Health Service hospital. The Minister is fond of claiming that more patients are being treated than ever before within the National Health Service. That may be true, hut what those figures do not show is the number of those patients who are readmissions to hospital because they were released too soon and had to be readmitted for treatment. That is portrayed as an improvement in health care, when in fact it is a deterioration and something that causes great suffering to many people.
§ Dr. Marek
Would my hon. Friend care to comment on the point that we should measure, not the number of people who have been ill and who have been cured of their illness, but the number of people who would have been ill if it had not been for the NHS, and therefore did not have to go to hospital in the first place?
§ Mr. Corbyn
My hon. Friend is correct. We must look at the overall health of the nation, and that is not the priority of the Griffiths proposals or of the system of general management. The Griffiths report is obsessed with the management of existing health units rather than with examining the health of the nation as a whole.
I remember, on a visit to Nicaragua three years ago, a rather wry comment being made by the Minister for Health there when I complimented her on the development of its new health centres and hospitals that it was trying to build. She asked what it was like in my area, and I had to tell her the tale of woe of closures and cuts in hospitals and hospital facilities in the borough of Islington over the past 15 to 20 years. She said, "But Mr. Corbyn, you must be very pleased that in Britain the National Health Service has so improved the health of the people of your country that you no longer need so many hospitals." Unfortunately, I 1361 had to tell her that they were being closed because of financial management, and not because of the health of the people in my community. That is still the case today.
On establishment in 1948, after much debate within the Labour party, the Labour movement and the group of people who sought to establish the Health Service, a decision was taken to go for a National Health Service, with essentially national control. While I admire Nye Bevan very much, I wish that in everything that he did to establish the National Health Service, and the undoubted success that it was, there had been a much more local input to the running of it, because this would have played an important part.
I say that because the present system of national structure and national funding effectively means that the Chancellor of the Exchequer, through the Cabinet, decides on the overall levels of spending on the Health Service, just as he decides on other services. That decision is communicated to the Secretary of State for Social Services. The decision goes out to the regional health authorities, and when the RAWP formula comes into operation those decisions are handed down to the district health authorities. In effect, it means that the spending patterns of each health authority throughout the country are decided at national level.
In areas of declining health expenditure, because of the way that the RAWP formula operates, the powers that health authorities have are unclear. In my own borough of Islington, for example, until recently we had a significantly declining population—that I recognise, although the corner has now been turned and the population is stable, if not increasing. Nevertheless, we have been told that for the rest of the decade we can expect cuts in real terms in health spending in the borough of Islington, to the tune of around 15 per cent. in real terms. Within that, there has been a centralisation of health facilities at the Whittington hospital, which has exacerbated the decline and closure of outside health facilities such as the Royal Northern hospital and some of the health centres.
§ Mr. Pavitt
Do not my hon. Friend and I have the same problem? We both have inner city areas that are vastly different from other parts of the constituency where there is a demand, where RAWP should not apply. In my area, despite urban aid, we are having to cut resources for Brent to send them to Bedfordshire and Hertfordshire.
§ Mr. Corbyn
That is a valid point, and it is similar to the experience of my area. I have no quarrel with the people of Hertfordshire, Bedfordshire, Essex or anywhere else. I want them to enjoy good health facilities, just as we wish to enjoy them. We resent being told that we are in competition with the people of Southend to get a decent hospital because we are in the North East Thames health authority. It is a ludicrous way to go about decision making. It creates false conflicts when in reality the conflict should be between the poorest people in the inner city areas and central Government who are denying to them money for decent health services in their communities.
If we look at the overall position in London, we notice that, because of the way in which the four Thames health regions are delineated, there is an outflow of resources from the inner London area to the so-called growth areas 1362 in the home counties. I do not want that to continue. I want there to be at least stabilisation and an end to the desperate and miserable process of cuts and closures that is the lot of the inner London health authorities.
That brings me to the point that I want to make about the role of elected members and the role of democracy within the National Health Service. The area health authorities; were set up in 1974. It was decided that there should be a mixture of appointments and automatic membership of area health authorities; some members were appointed by local authorities, while others represented trade union and professional interests.
The problem with that system was that although people were appointed to represent an interest as a whole—for four years I was the trade union appointed member of an area health authority—they had to operate within the terms of reference of the area health authority. They had to operate within an overall level of health expenditure, and they had to carry out the decisions that were handed down to them from a national level. This led to a reduction in the ability to innovate at local health authority level. It led to great difficulties when a local health authority wanted to increase the amount of money that it spent, for example, on Well Woman clinics or local health centres, or when it wanted to decentralise health services at local level. It is difficult to do that if a local health authority is told by higher management that so much money is being allocated to it to spend on a particular aspect of local health service provision.
When we look at the way in which the Griffiths proposals are being implemented. We have to ask whether it is sensible to appoint to a body which is funded with public money and which is designed to ensure the health of the nation a series of business experts in private enterprise who in many cases have no experience of running health services and who are obsessed with cash flow figures rather than with the health of the people whom they are supposed to represent.
If general managers from outside the National Health Service are appointed to fill the top jobs—people who have no record of involvement in the National Health Service—we shall find that the prospects for further privatisation of the National Health Service are enhanced, because their mentality is to privatise services, cut jobs and achieve short-term savings within the National Health Service. Technical savings within the NHS budget may be made, but in reality those savings are picked up by people losing their jobs, or by social security and unemployment pay when people lose their jobs in the National Health Service, or by badly cleaned hospitals. That is a common tale when privatisation of cleaning services has taken place.
§ Mr. Pavitt
The privatisation of a laundry service by means of a short-term, three-year contract may result in an immediate saving, but the National Health Service will be unable to provide that service again. In three years' time a hospital could be held up to blackmail. The National Health Service will be unable to provide the service again because the laundry facility at that hospital has disappeared. The longer-term provision is no longer available.
§ Mr. Corbyn
My hon. Friend has hit the nail absolutely on the head. If a hospital laundry service is deemed by some slick—suited individual from a biscuit 1363 company to be inefficient and overpriced, it is privatised. Its capital equipment is sold off or closed down. The hospital then has to depend upon a private laundry service. Even if, within a year, that private laundry service is deemed to be inefficient and expensive—as it often is—and the health authority wishes to return to the use of direct labour, it cannot get either the necessary capital allocation from the region or a national agreement to rebuild the laundry and the publicly owned infrastructure that has been so wantonly destroyed. The Griffiths proposals lead on to that position.
We must look at the membership of health authorities and the appointments system. Is it right that the health authority in an area such as mine should have someone appointed to the chair who cannot be said by any stretch of the imagination to represent the political will of the people of my borough? Our chairman does not, and there are many such cases.
Can it be right that health authorities should have entirely appointed members who, when they go against the wishes of the Secretary of State as they did in the constituency of my hon. Friend the Member for Brent, South (Mr. Pavitt), are sacked for their trouble? They were dismissed from office because they refused to carry out the cuts and closures which were determined by the Secretary of State. It is for those reasons that the time has come to look at the fundamental democracy of the NHS.
That means two things. First, it means recognising the close relationship that should and must exist between the NHS and local government. Local government, particularly in social services and environmental health matters, is concerned with the health of the people of the community. The NHS is also concerned with the health of the people in its area, but increasingly the NHS is seen as the national sickness service, whereas the local authority is trying to do the curative part through community care, social services back up, and so on. I wonder whether it is time to look at a much closer relationship between social service departments and the NHS. Increasingly, there is an overlap.
If community care policies mean anything, they mean a much closer relationship between the social service departments and the National Health Service. I remember vividly the discussions that took place between health authorities and local government. Some discussions are fruitful and productive, but often they are not. Often it is a matter of finding out who is prepared to foot the bill for what and trying to get rid of that, chiefly because they have clearly constrained budgets. The time has come to look at that.
The time has also come to consider the relationship of appointed and elected members of the health authority. If members are appointed or elected to an authority, but are controlled within the terms of reference of that authority by national decision making, that obviously undermines the effectiveness of any kind of local democracy and accountability for what is going on in the Health Service.
I want to see our Health Service expand and become more responsive to the health care needs of the people. I want to see the end of the concept of a national sickness service, and a move to the concept of a National Health Service. That will not be achieved by appointing general managers from outside the Health Service to run the service. It is not achieved by the sort of centralised dictation that is going on at present. Let us see the maintenance of national minimum standards, and with that 1364 the ability of local authorities to develop their services much more widely into preventive medicine, Well Woman clinics and health education—all those areas which are so important but which are not being achieved at present.
It is not on to have two principles in operation within the Health Service—on the one hand the principle that we have health care irrespective of the ability to pay and irrespective of the needs of the people who are seeking health care, and on the other the concept of making money out of people's ill health or through private medicine in Britain. I want to see a National Health Service that is truly that.
That brings me to the obvious question of how all that will be paid for if there is an open-ended ticket. The issue must be faced of the amount of money that is being spent on the NHS. Moreover, we must face the issue of the amount of money lost through ill health and people in hospital queues and on waiting lists; and the inefficiency of having an unhealthy population when we could have a much more healthy one.
Britain spends less on the NHS than any other equivalent western European country, despite the most dramatic propaganda campaign by the Government. People outside realise perfectly well that in real terms Health Service spending is going down. They see hospitals being closed, increasing queues for operations and the creation of images. We talk about creative accountancy, but this is creative publicity in the NHS.
Far from being safe in the hands of the Government, the National Health Service is in grave danger in their hands. The NHS is faced with cuts, closures, the centralisation of power and the gross exploitation of the lowest paid health workers. Perhaps the Minister will now answer a question which he was unable to answer in the Adjournment debate on this subject. When agreement is reached on pay for nurses, ancillary staff or Whitley professional technical "B" grades, will the Government underwrite and honour the agreement and not pass it back to local health authorities so that any pay increases have to be paid for by cuts in services, as now happens?
§ 1.5 pm
§ Dr. John Marek (Wrexham)
This has been an interesting debate. All hon. Members have tried to be reasonable, with only occasional outbreaks of slapstick politics and selective statistics. I am grateful to the hon. Member for Oxford, East (Mr. Norris) for raising this topic and for making a speech which caused every one of us to think carefully.
I even thank the Secretary of State for most of his speech, although not all of it, as he again trotted out the 24 per cent. figure as the increase in NHS spending in real terms since 1979. As I have said before, that does not represent the real situation. The Secretary of State takes a good starting year for his calculation, and then fails to take account of demographic changes with the increased health care needed by an older population, or the fact that the retail prices index for medicine and medical equipment rises much faster than any general household index. He also fails to mention that operations considered risky and unproven five or six years ago are now commonplace and are performed without any trouble at all. If the population increased by 1 million or 2 million, we would have to spend more on food. Similarly, as medical techniques expand, we have to spend more money to give life to people who five years ago might have died.
1365 The Secretary of State also said nothing about the evils of unemployment and the proven connection between ill health and unemployment, especially long-term unemployment. If more people suffer ill health as a result of unemployment, more money must be spent on the NHS. I do not challenge the 24 per cent. increase in itself, but it must be put into perspective as it turns out in reality to be far less than a casual glance might suggest.
The Secretary of State said that more nurses were employed, but he did not say that they worked fewer hours. Year by year, the Government indulge in that kind of selectivity to try to pretend to the public that more money is being spent, more people are being employed and everything in the garden must therefore be lovely. That is not true. The real interpretation is that limits have been placed on nursing manpower for the first time. Furthermore, nurses have had their working hours cut, and rightly so.
The Secretary of State read out a list of figures fairly quickly and I was unable to take a note of them all. If I have it correctly, he said that £650 million extra would be spent next year on the Health Service on the basis of inflation running at 4.8 per cent. I do not know exactly what the right hon. Gentleman's figures referred to, but if extra spending on the NHS is to be £650 million, it will not be an increase of 4.8 per cent. and it will not match the rate of inflation. As I have said, I did not hear the right hon. Gentleman accurately in that part of his speech.
The Secretary of State explained that the NHS would receive £130 million from the sale of land. I am sure that that will include the sale of nurses' homes, which is one of the factors that will have an effect on the supply of nurses in the London area. Nurses will not be able to afford to buy their own houses or flats in the London area, and it is necessary that we provide adequate housing for them. Apart from the matters to which I have referred, the first part of the right hon. Gentleman's speech showed that he was trying to address himself to the problems of implementing the Griffiths report and whether the Government have it right. The general impression of my right hon. and hon. Friends is that not everything is right.
I am glad to know that some Conservative Members have certain reservations about the implementation of the Griffiths report, but it seems that by and large they think that it is all right. Conservative Members who are present for the debate are those who care and think about the NHS. Unfortunately, many Conservative Members do not, and they are not present. None of us can be in the Chamber all the time, and that includes myself, but a member of the public who reads the Hansard report of the debate will have an impression of Conservatives that is unrepresentative of the Tory party at large and its attitude to the Griffiths report. I hope that any member of the public who reads the report will get a reasonably accurate impression of the thinking on the Opposition Benches on the report.
I wish to address myself to two main points, and I shall do so at some length. The first one is directed to nursing and the campaign that the Royal College of Nursing is pursuing that is designed to make some changes to the way in which the Griffiths report is being implemented. The college had no cause for fear when the report was written because in September 1983 Sir Roy Griffiths, the managing director of Sainsburys, in paragraph 15 stated: 1366A General Manager should be identified from within the existing team or elsewhere according to the Chairman's view of the local requirement.The important line reads:This is not intended to weaken the professional responsibilities of other Chief Officers, especially in relation to decision taking on matters within their own spheres of responsibility.The reference to "other Chief Officers" must mean chief nursing officers.
I did not particularly like the Griffiths report when it was published. Like my hon. Friend the Member for Islington, North (Mr. Corbyn), I do not like the idea of bringing into unit management individuals who might have been bank managers or those with some sort of business expertise who know nothing about the NHS. There is no harm in having consultants coming into the NHS, but management of it should be undertaken by those who know what the service is about.
§ Mr. Pavitt
Does my hon. Friend recall that when the supremo of the management of the DHSS, Mr. Victor Paige, was appointed, he was given a salary of £90,000 a year? He said that he did not know very much about the DHSS but he was a good learner. I am a good learner, too. If anyone wants to give me £90,000 a year to manage the Health Service, I should be delighted.
§ Dr. Marek
My hon. Friend has made my point for me. It is with sadness that I agree with him. I am sure that such a person is of no benefit to the NHS. He probably had no interest in it until £90,000 was dangled before his eyes. Unfortunately, such appointments do the NHS a disservice and represent a loss to the taxpayer.
Originally the Griffiths report was such that the nursing profession did not worry about there being any restructuring responsibility within the NHS that would leave it and its management professionals at a disadvantage. Indeed, in the Daily Telegraph of 18 November 1983 Sir Roy was quoted as saying:The proposals don't threaten nurses at all. The nurses are doing a good job and the changes that are being talked about aren't designed to affect them, except beneficially.There is the rub. Sir Roy may think that what has happened is beneficial, but every Opposition Member would disagree.
Ministers tend to focus debates on the Griffiths report on how many nurses have been appointed as general managers. But that is not necessarily an important factor. The significant point is what has happened to the nursing voice, to professional accountability and to supervision in the structures that now exist. After all, precious few nurses have been appointed to managerial positions within the NHS. Indeed, the Secretary of State gave the figures earlier.
I am grateful to the Royal College of Nursing for having provided the following information. It sampled 150 district health authorities in England. As at 10 March, 27 of them—18 per cent. —had no chief nursing officer. That should be of great concern to every hon. Member. It means that almost one in five of those health authorities has no chief nursing officer. Thus, there is no nurse member of the management team at district level, and responsibility for giving professional advice to the health authority has been delegated to a director of nursing service from one of the units, perhaps the director of nursing education or sometimes the chairman of the Professional Advisory Committee. That means that the management of the NHS is at a serious disadvantage.
1367 In a letter dated 16 November 1984 to the general manager of the Royal College of Nursing, Trevor Clay, the Secretary of State said:
In practice so far as nursing is concerned we would expect that the authorities will need a nursing adviser at senior management level whose main responsibility is the provision of nursing advice to the authority.One might have a director of nursing service, but it would be difficult for him just to concentrate on nursing within the district, because he would have other duties. There is a risk that any advice given will not put the emphasis on nursing so much as on areas of more concern to that director.
Of the 150 district health authorities studied by the RCN, it was found that 11–7 per cent.—had only an advisory chief nursing officer post. The individual had a purely advisory role and was not a member of the district management team, so there was no direct line management responsibility for nursing. Such advisory officers might have official access to the district health authority, but they are excluded from participation in day-to-day management, which would give them a real influence in decisions. In such circumstances, access to the district health authority would simply become a system of appeal against decisions that have already been made, perhaps contrary to the wishes of the nursing profession. The RCN strongly objects to that.
The RCN found that 49–33 per cent. —of the sample of district health authorities had an adviser/educator—a person responsible for nursing education, but not a chief nursing officer responsible for nursing as a whole. That causes fragmentation of the service. One of the strengths of the NHS is that it has avoided fragmentation. We used to have the matron who ran everything. More recently, chief nursing officers have been responsible for nurses, their training and education.
There were hybrid posts in other district health authorities where nurse education was relegated to an administrative function. Nurse education is slowly becoming a personnel function. Education is being fragmented down to lower units in some areas. Student nurse intakes are a significant manpower variable and there is widespread anxiety that manpower considerations will begin to take precedence over education and training. Managers from outside the service tend to regard their functions in terms of what is on the bottom line. With the best will in the world, patients tend to become statistics and staff tend to become employees with a payroll number. The training and education of nurses, for example, is not considered to produce any advantages on the bottom line, but it has to be undertaken. There is, therefore, a tendency for it to be given a lower priority. That must prove detrimental to the service.
It appears that many student nurses are experiencing difficulties. The English National Board for Nursing, Midwifery and Health Visiting, the statutory body for the supervision of nursing education in England, has recently had to issue a letter to district health authorities expressing concern that management arrangements mean that recognition of the school of nursing will be put in jeopardy. The Government are selling nurses' homes and not paying nurses adequately. In an earlier debate, my hon. Friend the Member for Islington, North said that nurses have not had a real terms wage increase since 1975. It therefore comes as no surprise to learn from a London newspaper recently that a leading teaching hospital is so 1368 desperate for nurses that it is offering cash prizes for recruits. Perhaps that is symptomatic of business management, but it should not have anything to do with NHS management. There must be better ways in which to organise recruitment. We know why they must go to such lengths. Hammersmith hospital in Shepherds Bush is a specialist hospital. The nurses have to train longer, and they suffer pecuniary disadvantage.
In the sample of 150 district health authorities, 6342 per cent. — had hybrid posts. The incumbents of those posts are responsible for nursing and for other matters. Sometimes the title of the post is quality assurance manager. There is no problem if the responsibility is close to nursing, such as the supervision of the meals service in wards or the cleaning of wards. However, some of the officers who hold hybrid posts may be responsible for nursing and the ambulance service. The health authority of which the hon. Member for Oxford, East was vice-chairman has proposed such a hybrid post, with the officer being responsible for nursing and for the ambulance service. That cannot be good management. No manager can have two such disjointed functions and give of him or herself sufficiently to manage both functions well.
All district management structures must be approved by the DHSS. All the posts that I have mentioned have already been approved, despite Ministers' assurances and the contents of the Secretary of State's letter of 16 November 1984. The Griffiths report originally led nurses to believe that there would be no problems with their conditions of work and promotion prospects. However, the position is rapidly becoming different. Many managers have no nursing experience or they have other commitments, or the chief nursing officer is not sufficiently high up the line management ladder in the new Griffiths system to carry any weight or be able properly to consider any problem. The Opposition believe that such a system cannot be allowed to continue. Something must be done about it.
My second main point relates to the changes that are taking place in the number of units, largely without the public being aware of them. This is a serious matter. I thought that what are called the Cinderella services in the NHS would be properly looked after and funded because they would have independent management and an independent source of finance. In many ways, the Cinderella services are as important as the high profile acute services that are available in hospitals. Unfortunately, one of the most serious and least reported effects of the management reviews is that we have an amalgamation of units that were previously under separate management. It is common again for the elderly, the mentally handicapped and the mentally ill to come under one unit, with loss of management priority and identity. In many cases, those services are amalgamated with the community unit—although it should remain separate—which has also suffered disadvantage during succeeding years. The blame for this goes from one Government to another, right back to the inception of the NHS.
Some years ago, there was hope that all these other services and provisions would have some management priority and identity. Unfortunately, that is not so now. There has been much amalgamation. If the amalgamation goes on, especially so that those units are combined with units providing acute services in hospitals, that will be bad for the Cinderella services of the NHS. They are in no 1369 position to withstand consultants' demands, when they rightly fight for the provision of acute services in hospitals. Things go badly for the Cinderella services because they are not in the public eye. There is little public awareness of them. Unless one is a recipient of those services or takes the trouble to be aware of them, it is not easy to know that they are provided.
The public throughout the county of Clwyd have been campaigning for two body scanners for about two years, raising money here and there. I have been to innumerable functions where money has been raised for those scanners. Whether that should happen, and whether essential equipment should have to be provided by voluntary donations, is another matter which I shall not go into now. Public concentration and awareness is focused on equipment for use in the hospital and, willy-nilly, Cinderella services are left in the background.
Many of the new amalgamated units are large and often widely dispersed. Administrative and financial convenience appear to have taken priority over patient and client group orientation. Theoretically, good management would not find it difficult to give attention to the Cinderella services. However, experience in the Health Service has demonstrated that the sheer pressure from such wide, large and diverse responsibilities can overcome even the best manager. I cannot believe that the patient-client groups, such as the elderly and the mentally ill and the community service, should be lumped together with the hospitals in one unit, hospitals providing acute care and having the powerful pressure groups behind them.
Management at unit level is perhaps the most important because it is at the interface with the patients. There are proposals that some units can be managed without a director of nursing services, even at that level. I shall be extremely worried if that happens. For example, a nurse who has a problem could go and see the sister on duty, but if the sister on duty cannot resolve the problem—an emergency or something that the sister would wish to consult about—it is possible that the next line of management above the sister will be an ex-bank manager or an ex-advertising agent. Surely that cannot be good for the NHS. I hope that no district or regional health authority will allow anything like that to happen.
The new form of management means that managers down the line will become beholden to their superiors for their budgets. The problem will increase if cash sums are available for each section of the service. The cash sums will be divided up and allocated to managers below the management team. They might be reduced in years to come, certainly under this Government. "Reduced" is perhaps not the right word to use. The sums will be increased, but not sufficiently to take account of the indices that I enumerated earlier. There will be a shortage of funds. If line management is worried whether it will have sufficient funds, it will be beholden to its superiors. I cannot believe that that will be beneficial to the Health Service.
It is better to have complete freedom of discussion. People should be able to speak their minds. If there is a problem in a unit or section of a hospital or in any service, the manager should be able to say what the problem is and how urgent it is and make a bid for an alleviation of the problem. I am not convinced that the Griffiths report and that form of management will provide for that. Perhaps 1370 more importantly, I think that it will inhibit the freedom of people to speak out on professional matters, not just in terms of work and conditions, but on professional issues such as nursing or medical matters. I cannot see how one can get round managers being beholden to their superiors, unless one brings consultation, co-operation and democracy in some form—I use those words loosely—back into the National Health Service. That would mean accepting that the basis of the Griffiths report is flawed in that respect, and a different solution would have to be found.
The Griffiths report could have been implemented in consultation with the staff, it could have been implemented at a slower rate, we could have had the report a little longer and we could have been given some reasons for some of the proposals in the report. It was not well done. I hope that the Government will not disagree too strongly with that. It is still not right. I urge the Governent to take seriously the views of members of health authorities up and down the country, particularly the views of the staff within the NHS. They are largely critical of certain aspects of the Griffiths report. It can do no harm to look at that criticism to see whether there can be some meeting of minds and an acceptable compromise between the two sides. We need more democracy and more management by consultation.
The Government might disagree, but I believe that they are primarily obsessed with saving money and spending as little public money as possible in order to please the masters in the Treasury and the First Lord of the Treasury. If the Government will not work for more democracy and consultation because it means spending more money, it is a task which the next Labour Government will have to undertake. The next Labour Government will do it by consulting the Royal College of Nursing, the Health Visitors Association and the professional bodies first. After consultation, we would have to put right the mess we have got into with the Griffiths report.
§ Mr. Nigel Spearing (Newham, South)
The House should be grateful to the hon. Member for Oxford, East (Mr. Norris) for initiating this important debate. So often, debates on some of the most fundamental issues in our society attract relatively few hon. Members, but that does not detract from their value, because everything that is said is in the Official Report.
As hon. Members know, I was able to intervene briefly in the opening speech of the hon. Member for Oxford, East, but unfortunately, because of a constituency engagement to open a sheltered housing scheme—which is full of consensus and co-operation, I should add—I was unable to hear the speech of my hon. Friend the Member for Brent, South (Mr. Pavitt) or those of other hon. Gentlemen.
I hope to identify a few issues which bear strongly on the management of our Health Service, and two in particular. I begin by trying to identify those matters within the Griffiths' proposals and general philosophy which I think will carry general agreement and those where there has been, and will continue to be, strong disagreement. Unless we identify those issues, the debate will be unfruitful.
The hon. Member for Oxford, East mentioned, quite properly, the morale and importance of the managing team. He dwelt at some length—I make no complaint 1371 of this—on whether there should be a period of appointment against performance—one of the great management tools.
I do not think that we have yet made a fundamental distinction between different types of management. Sir Roy Griffiths came from a well-known chain of retail grocers, Messrs. Sainsbury. We have been adjured by the Government many times to take advice from business men —Marks and Spencer, Boots and perhaps even British Leyland have featured largely among those businesses from which we should seek advice. I suggest to Conservative Members, especially the Prime Minister, that there is a fundamental distinction in management between those providing services on a willing seller/willing buyer basis, and those providing services to the community, especially in health, housing, education and the caring professions. The simple point, which is so often overlooked, is that Messrs. Sainsbury, Boots, Marks and Spencer and even British Leyland have no obligation to provide what the customer wants. Of course, if they do not, they may go out of business. Each package displayed by Marks and Spencer is one that the company finds it convenient to provide. If a customer does not find what he wants on the shelf, he goes elsewhere.
§ Mr. Spearing
I am grateful to the hon. Gentleman for agreeing with me. However, he may have forgotten that, whereas there may be 10,000 grades of product available from Messrs. Sainsbury, Boots or Marks and Spencer, every client of the Health Service is, at every point in his progress towards full health and strength, a unique case. One cannot put live human meat on the shelf, freeze it or move it in refrigerated vans, and operate é la Sainsbury. Every person requires a certain measure of treatment and human care. The condition of patients, especially acute patients, can change rapidly. I suggest to those concerned with management expertise—I issue the challenge as an amateur—that they are dealing with a totally different type of management in the NHS.
My next point follows what the hon. Member for Oxford, East said in his interesting remarks. It relates to the matter on which I challenged him on principle and to which he did not return precisely, although other hon. Members may have done so. It concerns management experience in relation to decision making. Of course, this is an exercise in stopping buck passing and in the necessity of buck taking. Someone, somewhere has to take a decision, and that person may draw on the advice of others, engender co-operation or try to decide on the basis of consensus. A decision made by Mr. Speaker is his responsibility. A decision made by a manager on the allocation of resources is his responsibility. The same is true of a ward sister deciding how to allocate resources and of a doctor making a difficult clinical decision on the allocation of his resources.
The buck stops somewhere. It may well be that the NHS needed greater emphasis to be placed on line management and on sharpening responsibility, especially in regard to the allocation and use of scarce resources. There is no question about that. That point unites us across the Floor and across parties. —[Interruption.] I welcome any intervention which shows that the Under-Secretary of State agrees with me.
As I said to the hon. Member for Oxford, East, hon. Members would not for one moment tolerate a House of 1372 Commons Commission which was not governed by Members of Parliament, former Members of Parliament or servants of this place and, therefore, servants of the public. I believe that one of the great weaknesses of British management, and the great weakness in our society, is that too many people who have the privilege and responsibility for making decisions have not had sufficient, adequate experience on the ground floor which would give them important insights into what occurs in practice.
I have bitter experience of that over 12 or 13 years in the teaching profession, and I have no doubt that nursing is much the same and may, indeed, be more fraught. As we all know, particularly in unit management, whether it be in a hospital or in a ward in a hospital, one is under pressure on numerous occasions. Unless one has experienced such pressures, how can one take decisions for others in line management?
The hon. Member for Oxford, East referred to the morale of the management team. I believe that even more important is the morale of what he might call the operatives, the rank and file, the non-commissioned people. They are the people who know.
In all the things that I have read about the Griffiths report—and I have had complaints about that report from nurses who I know personally and from people in my constituency—that distinction is not being made. In fact, I doubt whether that distinction is understood. In the reorganisation which is going on apace in the Health Service, within the management structure people are being appointed— and I trust that the Minister will put me right in his reply, although he admitted this to me in a letter—and it is possible for people without nursing qualifications or experience to be in a position of line management and taking decisions about nursing and medical matters. Medical practitioners would not tolerate that for an instant, and nor would hon. Members
The situation is even worse. As I understand it, the implementation of the Griffiths recommendations means that people will have to apply for their own jobs. Instead of Griffiths coming along and instituting a form of management appreciation—which may be necessary, because there is no reason why traditional SRN training should include managment skills in respect of complicated scientific apparatus—and adding that to the original job, a member of staff will have to reapply for his own job. Unless somone can show management competence, for which he was not trained or recruited, and for which he presumably has only limited ability, he is liable to be dismissed.
We know that dismissals have taken place, because Baroness Cox, in a debate in another place last Tuesday, said so. I cannot quote the noble Baroness directly; I will have to paraphrase her words. She said that many senior nurses had after many years of professional service been asked to go. In fact, one senior nurse in a London health authority was actually dismissed and sent on eight months' gardening leave.
What would happen in organisations connected with the retail trade or the motor car industry if such procedures were adopted? A business may be able to sustain that using the principle pour enourager les autres. I suggest that the impact on nurses in post at present and those in training is serious, as they know that the people to whom they have been responsible, whom they may respect professionally, who have given years of devoted service and who are highly skilled, are either deciding to take early retirement 1373 —as they are—or are liable to dismissal. I put it to the Minister that when Griffths was introduced nobody thought that that was possible. Indeed, all the assurances were to the contrary. The possibility of that happening is causing well-justified concern among the whole nursing profession. I challenge the hon. Member for Oxford, East to deny that.
Baroness Cox is well known for her views. She is not a lady who will criticise the powers that be immediately or readily, but I understand that she said in the debate that it would be difficult to find any nurse who believed that the Health Service was now safe in the hands of the Prime Minister or the Government. The one may be equal or less equal to the other. She is a highly respected professional noble Lady in the other place, and she has not yet been contradicted. If that degree of alarm, perhaps unjustified, has entered into the heart of one of our greatest professions, what the hell do the Government think they are doing? I apologise to the House for an unparliamentary expression. If one is in a position of uncertainty and does not know what will happen in future, while day after day one gives of oneself and then one's boss says that life is hell.
The story does not end there. Yesterday I received an answer from the Minister's twin. Nurses are being evicted from nurses homes. A circular went out to district health authorities telling them that they must be prepared to sell their medical accommodation on principle. I understand that the proposal met with a great deal of argument, and the Government changed their mind and said that it was a matter for local decision.
An answer that I received on 12 March shows that in Chester the Government are planning to reduce our 435 current units to 272 by 1 January 1988. That is a reduction of 163, or one third. The reduction is to be of the same proportion in Warrington and Liverpool. The Government plan to reduce the number of nursing accommodation units in Liverpool by 300. That is almost unbelievable, in view of what we know about that city, and in terms of what we know about the Health Service, especially as there is no guarantee that second or third-year student nurses will get accommodation.
§ Mr. Pavitt
May I remind my hon. Friend that the Minister for Health asked 14 regional health authorities to submit complete lists of accommodation that would be available for sale? Further, in a recent answer to a question the Minister said that he would not put the list in the Library or tell us which places he would endorse for sale until such time as the decision had been made.
§ Mr. Spearing
That confirms what I am saying. I hope that my hon. Friend will speak in the debate, especially about co-operation in the neighbourhood. As this is an important subject, I make no apology for continuing my speech.
The way in which the Government have approached the matter shows only too amply their complete ignorance of the psychological havoc that they are creating in our hospitals. Management is not only about people. It is about services—the "hotel" services, to which the hon. Member for Oxford, East referred—and about hardware and medical science.
Not too long ago, when I was in one of the leading teaching hospitals visiting a patient, I found out that a few 1374 days previously the staff had had to revert to using paper sheets because the supply mechanism had broken down. In three year's time no doubt the new manager will have to show what he is made of if he is to be reappointed. This is what they are reduced to. I was also told about some of the throwaway medical equipment—I think they are called flungs—which is used for giving blood transfusions. The quality of the flungs has been reduced to save money.
Faced with that situation, with, as I have said, the sword of Damocles hanging over one's head because of the likelihood of being evicted from accommodation which one thought would always be there, what will be the result? What will be the effect on those who are thinking of taking up the profession? What will people in the profession say about their prospects? The people in the higher reaches of the profession appear to be arbitrarily barred from management, yet they are the people who are most needed for the job.
The noble Baroness Cox asked the noble Baroness Trumpington a specific question in the debate in another place on 4 March. I shall paraphrase her question. She asked whether the Minister would issue a circular to the district health authorities asking them to ensure that when they make appointments to the post of manager of nursing, not only is the manager part of the team—some of them are not and I have asked a question about that—but that the district authorities will make sure that the qualifications and experience of the people appointed are within the nursing profession. Baroness Trumpington said that it was a matter for local management. In other words, the Government will not intervene.
The Minister said:My noble Friend Lady Cox concluded her speech with four specific questions. I have covered a number of these points, but let me now address them one by one. The question of nursing management is covered in, we expect, the structure of general management and nurse management in each unit to take account of the need for proper supervision of the work in wards and departments. This is a matter which really must be left to local decisions, taking account of the views of local professional interests."—[Official Report, House of Lords, 4 March 1986; Vol. 472, c. 161.]I suggest to the House that it is improper to leave such a matter for local decision when the Government have already said that they will allow people without the necessary professional experience or qualifications to take these managerial roles.
When an army fights in battle, it must have confidence in the general staff. If it is aware that the general staff have never fought in the trenches, what confidence can the army place in their decision making? I thought that we had learnt that about 70 years ago. It appears that the Government have not learnt it yet.
I refer to the question of professional conduct, not only of nurses, but of medical practitioners. I raise this under the motion on the efficiency of the National Health Service. Later today the Minister will object to a Bill on this subject. The Bill relates to the inadequate powers of the General Medical Council, despite its responsibility under the Merrison report, which said:Parliament acts in this context for the public".It is for Parliament to decide the nature of a contract and the way it is to be executed. The contract is between the public and the profession.
The Minister has sent me a letter in which he says that the president of the council—this is the first time that that gentleman has put an objection in writing—objects 1375 to the Bill because it maintains that the additional power that is proposed would not be helpful because it might lead to a tendency to substitute the lesser for the more serious findings of the GMC.
§ Mr. Spearing
The efficiency of our Health Service is part of the debate. I am not surprised that the Minister objects to his letter being read out.
§ Mr. Whitney
I am glad that the hon. Member has had a good day in his constituency. However, I draw to the attention of the House the fact that the letter refers to general practitioners, as the hon. Gentleman is aware, and this debate is on the National Health Service and the Griffiths report.
§ Mr. Spearing
We are certainly discussing the National Health Service. The letter concerns not just general practitioners but medical practitioners. I apologise to the House. The service that they give, and the confidence that we can give to them and to their professional body, which Parliament set up as a self-regulatory body, is part of the motion, which deals with the efficiency and competence of the NHS. We are talking about confidence. Confidence in a democratic country is the petrol of politics, and without confidence there can be no proper democracy. I see the Minister smile.
§ Mr. Spearing
I do not think that this is a cliché at all.
The Bill that I wish to introduce fills a gap in the way that we can deal with these matters of professional conduct.
§ Mr. Deputy-Speaker (Mr. Ernest Armstrong)
Order. The hon. Gentleman cannot refer to the Bill in detail, but he can refer to it generally.
§ Mr. Spearing
I shall do it in a sentence. I understand what you have said, Mr. Deputy Speaker, and the Minister does as well—that is why he is not very happy at the moment. Unfortunately, the current legislation dealing with these matters, the Medical Act 1983, does not provide powers for the General Medical Council to deal with conduct that it finds unacceptable. There is no sanction, nor remedy even, of conditional registration, and my Bill would provide the council with optional powers. If the public wish to have confidence in the way that the General Medical Council goes about its business of providing services to the Health Service, it is not for the Minister to say that the Bill must be blocked.
I conclude on a happier note, but one that challenges the Government. I have been talking about confidence in the Health Service. The Prime Minister claimed that the country could have confidence in her management of the Health Service. Our debate today shows, for the reasons that I have suggested, that those who are at the sharp end in the wards, the ancillary services and the nursing profession have no confidence in the way in which Government are dealing with the Griffiths report. They believe this because those who have experience and professional knowledge of these matters are not put in the right positions and are not an adequate part of the teams that make the decisions, and will not necessarily be required by the commissioned managers under whom they seek to serve.
§ 2.3 pm
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. Ray Whitney)
I am grateful to have this opportunity to contribute to the important debate introduced by my hon. Friend the Member for Oxford, East (Mr. Norris), in whose election I was able to play a very small part some years ago. I shall not repeat the congratulations any further, nor shall I respond to my hon. Friend's point, because my right hon. Friend the Secretary of State did so, as he did to the hon. Member for Wolverhampton, North-East (Mrs. Short).
A number of important points have been made more than once, and in particular I pick up the points made by the hon. Member representing the alliance, the hon. Member for Leeds, West (Mr. Meadowcroft), who said that he had to leave at midday, but was hoping to return. Unlike some who returned, the hon. Member has still not been able to join us. He gave an interesting performance, typical of the contributions that we have learned to know—I nearly said love—from both the Liberals and the Social Democrats. We listened carefully to the "on the one hand but then on the other" approach which is always a feature of alliance contributions. I agree with the hon. Member for Leeds, West that it is not a question of either general management or consensus. That is an artificial dichotomy. The Government are not saying, "On the one hand," and, "On the other hand." What is at issue is not an autocratic, general management versus a happy, Soviet-type democracy. A balance has to be struck. We are striving to achieve that balance.
Having complained, as usual, about the existing system, the hon. Member for Leeds, West then referred to his own solution. If the hon. Gentleman is, as I understand him to be, the Liberal party spokesman on health matters, this has been a very important morning. Far from the National Health Service being safe in the hands of the Liberal party, it transpires that the Liberal party intends to break up the National Health Service.
The hon. Gentleman said that the power to tax should not be separated from the power to spend, because that always creates problems. The hon. Gentleman's solution, therefore, is to create regional taxation and regional expenditure. The National Health Service disappears and regional health services appear. I do not know what that would mean for the national facilities that are provided in London. There is also the rate equalisation problem to be grappled with. We know all too painfully about that in terms of rate support grant. The London region would be able to fund its activities by means of taxes on its vast riches, but that would result in the deprived regions being provided with grossly inferior health services. That is an interesting concept. I shall follow its development by the Liberal party with great interest.
I agree with what my hon. Friend the Member for Chislehurst (Mr. Sims) said about the nurses. He said that, although he has asked nurses to explain the problems and difficulties that have been referred to in the Royal College of Nursing campaign, he is still waiting for their replies. That is my experience, too, despite having prodded them again and again. On Monday morning I had the privilege of appearing on a television programme with Mr. Trevor Clay, general secretary to the Royal College of Nursing. I asked him to tell me about the problems, because we are anxious to resolve them. I was told that the Royal College of Nursing is still working on it and that it hopes to find 1377 a few examples one of these days. That is not only my experience; it is the experience of most of my hon. Friends. I agree with my hon. Friend's injunction that the Government ought not to interfere unless it is necessary. The devolution of as much responsibility as possible is a fundamental part of the Government's approach.
The contribution of the hon. Member for Fife, Central (Mr. Hamilton) was not surprising. His interest in the Confederation of Health Service Employees is well known. We were told about hospitals that are crumbling, about hospitals that have been closed and about the rest of the panoply of woe that is a feature of the Pavlovian reaction of all Opposition Members. However, that has to be reconciled with the increase in capital spending while this Government have been in office, from £365 million a year to £900 million next year.
We were also told that the Government are being very hard about pay. We have a proud record on nurses' pay. Mr. Trevor Clay was good enough to admit on Monday morning during that television programme that last year's pay settlement was "a reasonable settlement." Basic pay rates for nurses have increased by 30 per cent. more than the rate of inflation since this Government took office. The number of nurses has increased by 11.9 per cent. and the working week of nurses has been reduced from 40 to 37.5 hours.
§ Mr. Whitney
I apologise to the hon. Member for not giving way.
The hon. Member for Wrexham (Dr. Marek) believes that the reduction in the working week for nurses is to be deplored. However, I do not think that many nurses would agree with him.
We have instituted the pay review body. We would love to do much more but, given the limitations of national finances, it is not possible to write blank cheques. We all know from the experience of the previous Labour Government where the writing of blank cheques brings the national finances. We can take considerable satisfaction from our record on pay, while recognising that we would continue to wish to do more within the limits of good sense and good housekeeping.
The hon. Member for Fife, Central talked about the tax burden. Let him consider what the hon. Member for Islington, North (Mr. Corbyn) said in the Adjournment debate at 8 am. After nine hours sitting here my memory is not what it was, but if I remember correctly the hon. Gentleman gave the example of a hospital worker with a gross pay of £130 and a take-home pay of about £80, with £43 in deductions. The damage to that is caused by the tax. If we fell into the trap, into which Labour Members would like to lead us, of continually increasing Government spending, not only on the NHS but on all sectors—the £24 billion spending spree that Labour Members are promising the country—what would that do to the taxes of the nurses and ancillary workers? That point was well made by my hon. Friend the Member for Derbyshire, South (Mrs. Currie).
The hon. Member for Brent, South (Mr. Pavitt) talked about the problems of the hybrid post. We recognise the point that he was making but we also understand and accept that there are now new and different posts, not nursing posts. They widen the scope and area of 1378 responsibility. If a nurse were appointed to such a post, we would expect her to be adequately supported and the nursing role to take precedence over any competing priorities. But instead of looking on the bright side, some of the Opposition look on the gloomy side. The Griffiths proposals imply and represent not a contraction of nursing opportunities but an expansion. We now have 55 nurses who have moved by their own choice into general management. My right hon. Friend has said more than once, and it is our firm policy, that the more nurses who wish to take up management posts the better. But, as my hon. Friend the Member for Derbyshire, South said, many of them are happy to stick to their particular job.
My hon. Friend the Member for Lewisham, East (Mr. Moynihan) voiced his concern about RAWP. I draw his attention to the answer of my right hon. Friend on 17 December 1985 in column 156 of the Official Report. That implies a review of that important point and I hope that that will allay some of my hon. Friend's concern.
The hon. Member for Islington, North, in his second appearance of the day, seemed to want to tear up RAWP altogether. I hope that he will be able to persuade those of his hon. Friends who represent areas where the funding for the Health Service is a fraction of the funding in Islington, North that they will be happy when abandoning the RAWP policy which has been a feature of Governments of both complexions.
The second proposition that the hon. Gentleman seemed to offer the House was to go one better, in a Dutch auction in reverse that we had from the hon. Member for Leeds, West. He was after the regional break-up of the health authority to which I have referred. But it appears that the hon. Member for Islington, North wants a local health service. He wants it to be the equivalent of the social services departments. My hon. Friends will readily appreciate the kind of funding row that that would create.
In our earlier exchanges, the hon. Member for Wrexham was disposed to refer more than once to my explanation of the increases in real resources for the Health Service as "claptrap". On this occasion, however, I congratulate the hon. Gentleman and welcome him to the fold as he now accepts the figure given by my right hon. Friend the Secretary of State of 24 per cent., including next year's increase. Clearly I had under-estimated the increase. I agree with the hon. Member for Wrexham that we would like even more. I agree that there are technical advances and clinical adventures as well as greater demands from the elderly, but where is the limit? We have increased the funding by 24 per cent.
Where would the Opposition draw the line? According to Aneurin Bevan, the language of Socialism is the language of priorities. The Government speak that language and we reckon that the funds that we have given are what the country can afford. If the Opposition think that they can afford more, they must consider the pressure of taxation, especially on the low paid.
The hon. Member for Wrexham referred to the sale of nurses' homes. This is part of the drive to ensure that resources in the NHS are well used for the benefit of patients. It is a question of patients first, not management for its own sake. The patients are the first and absolute priority. As part of that approach, we must consider the real estate held by the NHS. The Health Service is one of the biggest landlords in the country and there may be no good reason for that to be so. It has been estimated that the estate includes about 100,000 flats, bedsitters and 1379 houses, 20 per cent. of which were unoccupied at the time of the study. Less than 50 per cent. of trainee nurses and less than 10 per cent. of graduate nurses were in that accommodation. The policy decision was therefore taken that much of that property should be disposed of and health authorities are being asked to proceed with that. In the future, we shall not expect health authorities to provide accommodation for staff other than for professional training or in particular local circumstances.
§ Mr. Whitney
I will not give way, as the hon. Gentleman spoke for a long time.
There are two benefits from that policy. First, it will produce great resources—we do not yet know how great—for the NHS. Secondly, it will provide resources to refurbish and improve the standard of the remaining accommodation for the benefit of nurses and others in the Health Service. Nurses and others living in those properties, many of which are off site, will be given the opportunity to buy them at discounts as favourable as those for local authority properties. Moreover, no one will be required to move elsewhere until the end of 1987.
§ Mr. Whitney
No, it is selling property that is neither used nor needed, to put the resources back into the Health Service.
The general theme of the debate has been one of concern and I am sorry that much of what has been said by the Opposition may have exacerbated that concern. I am convinced that the concern which has been expressed is greatly exaggerated and not justified. In my travels around the country I have found a much greater understanding of what the Griffiths report is all about. There is certainly a clearer understanding than that which has been suggested during the debate.
We are not interested in management for management's sake. There must be management for the patients' sake, and it must embrace nurses and all the other professional disciplines as part of the team. As we all recognise, and 1380 as the Stanley Royd inquiry demonstrated, the previous management system was flawed, to put it mildly. We have introduced a better system, which depends on the co-operation of all who come within it. We recognise that everyone concerned has a valuable contribution to make, not least the nurses. The nurses' position is assured by all the procedures which my right hon. Friend the Secretary of State set out in his contribution to the debate and I urge all nurses to understand that we are conscious of their concerns. I understand that all the chairmen and general managers of the authorities are concerned as well.
I believe that the debate will have helped to focus these worries and I am sure that the Health Service will respond. I look forward to continuing and developing fruitful co-operation within the Health Service, especially with that most important element, the nurses.
§ Mr. Norris
With the leave of the House, Mr. Deputy Speaker. I had a good run at the start of the debate and I do not want to delay the House, as I know that it wishes to move on to other business. Through you, Mr. Deputy Speaker, I extend my gratitude to hon. Members on both sides of the House for a most stimulating debate on what I am glad has been seen as a most important subject.
§ Question put and agreed to.
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 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.