HL Deb 25 October 1983 vol 444 cc166-73

5.14 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Glenarthur)

My Lords, with the leave of the House I will now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Social Services. The Statement is as follows:

"With permission, Mr. Speaker, I would like to make a Statement on the publication of the advice given to me by the National Health Service Management Inquiry. As the House will recall I set up an inquiry into the management of the health service under the chairmanship of Mr. Roy Griffiths, the Deputy Chairman and Managing Director of Sainsbury's, in February of this year. I asked him to review current initiatives to improve the efficiency of the health service in England and to advise on the management action needed to secure the best value for money and the best possible service to patients. I have today placed in the Vote Office copies of the report which I have now received from the inquiry team.

"The inquiry team endorses the main initiatives that the Government have already taken to make health authorities accountable for the performance of the services they provide. However, they say an enormous programme of management action is still needed. The inquiry team found that at all levels in the National Health Service there is a lack of a clearly defined general management function. Responsibility is too rarely placed on one person. Although they would like to harness the best of the consensus management approach, they found that at present consensus management can lead to lowest common denominator decisions, and long delays in the management process. Another effect is that the process of devolution of responsibility is ineffective.

"Accordingly the inquiry team propose a series of changes aimed at making the existing organisation work better in practice rather than aiming at yet another restructuring of the service.

"Inside the Department of Health the team propose that I should set up and chair a new Health Services Supervisory Board. The board would have some external members and directly accountable to it would be a management board which would bring together the present management functions of my department relating to the hospital and community services, the family practitioner services and special health authorities. A new chairman of the management board would be appointed, probably from outside the service. The report also proposes that a personnel director should be recruited.

"At the regional and district level the report recommends the identification of a general manager for each authority. Such a manager would be drawn from any discipline—that is, from any of the professions engaged in the management of the National Health Service—and his job would be to secure effective management of the authority's services.

"The report also recommends that hospitals and other units of management should as far as possible take all the day to day management decisions. Doctors should be closely involved in local management through the development of management budgets for which they would be accountable. The team also recommends the identification of a general manager for every major hospital and other unit of management.

"In short, the key recommendation is that a clear management responsibility should be identified for carrying out all National Health Service management functions and that this responsibility should be devolved as near to the patient as is practicable. The report is also in no doubt that major cost improvement programmes can and should be initiated in the National Health Service aimed at much higher efficiency to be sustained over much longer periods than at present.

"There are three additional points to make on this report. First, the report does not propose any further structural reorganisation. All its recommendations are designed to take place within the existing statutory structure and without affecting the constitutional position of Parliament, Ministers and the health authorities.

"Second, the recommendations will not add to existing costs or staff numbers. Indeed, inside the Department of Health they should lead to a reduction of activities and staff.

"Third, the report emphasises that the National Health Service is about delivering services to people. It is not about organising systems for their own sake. The team say that the driving force behind their advice is their concern to secure the best deal for patients and the community within available resources; the best value for the taxpayer; and the best motivation for staff.

"Mr. Speaker, the Government very much welcome the general thrust of this advice and are very grateful to Mr. Griffiths and his colleagues. I shall be setting up within my department the Health Services Supervisory Board as recommended. Among its first tasks will be to establish the management board and to initiate action in respect of health authorities and professional and other health authorities and professional and other interests involved, but subject to the outcome of these consultations I would hope that authorities would be able to start implementing the general management function from April 1984.

"The National Health Service is one of the largest undertakings in Western Europe. The service needs and deserves the very best management we can give it. One of the best contributions we can make to patient care is the improvement in National Health Service management along the lines recommended by the Griffiths Report".

My Lords, that concludes the Statement.

5.20 p.m.

Baroness Jeger

My Lords, on behalf of my colleagues, I thank the noble Lord the Minister for the Statement that he has made. Of course, we shall need time to study this report because, owing to the arcane traditions of this House, it came into our hands only this afternoon. I hope that there will be opportunities for further debate.

However, today I must ask certain questions. The Minister said that all the recommendations were designed to take place within the existing structure. But in his Statement the Minister is adding two, if not three, more tiers to the structure. We are to have a health services supervisory board, a management board and district managers for each authority—I make that 192 district managers, and I think that the Minister will correct me if I am wrong. How many more quangos are to be introduced into the National Health Service?

There is to be: a general manager for every major hospital and other unit of management", whatever that is. Despite all the criticisms that have been heard for a long time about the National Health Service, I thought that there was party agreement that above all we must tackle the administrative and bureaucratic element in the National Health Service. Now the Minister comes to the House today and tells us that the result of this report is that we are to have more and more administrators. The only difference is that now they are to be called "managers". I must ask the Minister who is to appoint the health services supervisory board and the management board, what are their powers to be? Will they be able to ride roughshod over local decisions, local committees and community wishes? Who will appoint the general managers of the 192 authorities and what will be the general managers' powers in relation to committee decisions? How many more staff will be needed to implement the recommendations that: "every major hospital and other unit of management"—whatever that is—should also have a general manager? For instance, how many family doctors make up a unit of management? I should not like to be the manager who managed a nest of general practitioners.

Have the Government considered the effect on personnel in the National Health Service, where teamwork and sensitive co-operation at every level is essential before bringing in this new "boss" structure? The Minister said that the responsibility should be as near the patient as possible, but how does the insertion of managers help to bring services closer to the patient? I should have thought that it was one more obstruction in the tier of responsibility.

Can the Minister say whether the committee consulted the trade unions at all? What is to happen about the Whitley machinery? What is to happen about the people who are actually working now in the service who, according to this Statement, are to be invaded by an army of new people called managers? What is to happen to the present administrators? Are they to be upgraded to something called "manager" and to be paid more because their title has changed?

The Minister said that there is to be a personnel director. What are his powers to be? Is he to go from hospital to hospital and from general practice to general practice saying, "You have a nurse too many" or "You have a kidney machine operator too few"? What are his powers to be?

The Statement said that these plans will not add to the costs or to staff numbers. But how can all these new managers, right down to unit level, be appointed without adding to staff numbers unless other staff are sacked? If other staff are sacked, they must receive redundancy money, so that will add to the cost. It makes no sense at all. What sort of salary range can these managers expect? I believe that it is usual in business—even in successful supermarkets and chain stores—for managers to be paid more than those they manage. Therefore, are these managers to be paid more than the consultants or are they to be put on the works manager salary scale? How can the Minister say that this will not cost any more when he is adding to staff who must be paid at a high level? You cannot introduce into a situation someone who is called a manager who is paid less than the people he is managing.

I know that it is late and that many people want to speak in the main debate today; but I must say to the Government that the approach of the Statement seems to indicate to us a total failure to appreciate all the complexities—especially the human complexities—in a service already working under severe pressures and financial anxieties. It appears to bring commodity economics and the attitudes of the marketplace, the high street shops and the chain stores, however efficient those chain stores might be, to the totally different problems of a national service which was set up to promote good health and to care for those suffering from ill health.

Therefore, at this stage we do not welcome the Statement. We do not think that these proposals will alleviate the problems of the National Health Service; we do not think that they will shorten the outpatient lists or that they will bring one more kidney machine into use. We see the Statement as proposing a new structure of something called management which can only add to what most of us would consider to be top heavy bureaucracy and administration in the National Health Service. But I hope that the Minister will be able to say that the Government will find time for a debate so that we can go into these matters in more detail.

Lord Winstanley

My Lords, on behalf of my noble friends on these Benches I should like to thank the noble Lord, Lord Glenarthur, for repeating this important Statement. We welcome those parts of the Statement which suggest some devolution of powers from the centre to the grass roots in the National Health Service, a move which would be applauded on these Benches, as would in certain localities the appointment of individuals with management functions. That too is something which we have been recommending for years.

Having said that, does the noble Lord agree that no amount of administrative manoeuvring within the present constraints of the National Health Service resources could possibly make those resources adequate to cope with the present increasing workload? Further, will the noble Lord note that on these Benches we agreed with Sir John Hoskyns in some of his criticisms of the machinery of Government and, indeed, of those who operate the machines. We agreed that the deployment of resources—once those resources had been fixed—is indeed a matter for business methods. That, of course, is a matter to which Mr. Griffiths' committee has rightly and properly addressed its attention.

However, we do not agree that the fixing of resources as between one Government function and another is a business matter at all. That is a matter of choice, a choice to be made by those who provide the resources: the electorate. In that connection, is the noble Lord aware that polls now show clearly that the majority of the electorate would choose to spend more on the National Health Service even if that means spending less on defence or perhaps some other Government function?

Finally, will the noble Lord resist the temptation to pick on overworked and efficient administrators at the grass roots of the National Health Service as whipping boys for the inadequacies of the service? If the Minister wants to find superfluous bureaucrats, he need look no further than the Elephant and Castle. Nevertheless, we welcome much of what is stated in the Statement and we look forward to the implementation of some of these proposals.

Lord Glenarthur

My Lords, I am grateful to the noble Baroness, Lady Jeger, and the noble Lord, Lord Winstanley, for their remarks, even if they are not altogether pleased with what they think the Statement contains. First, may I say to the noble Baroness opposite that many of the questions she asks will become much clearer when she has time to study the report more fully. I appreciate the administrative arrangements which lead to the report reaching her hands rather late in the day. Nevertheless, I think it will become much clearer to her when she does read it.

So far as adding another two or three tiers to the existing structure is concerned, this simply is not the case at all. There are plenty of managers within the National Health Service but there is not coming from them sufficient management. That is exactly the point that the Griffiths Report is trying to get across. Nor is this a question of another quango being set up. The people concerned will be firmly within the DHSS and the existing statutory framework, so no question of a quango arises.

The noble Baroness asked whether the trade unions have been involved. The trade unions were consulted when the inquiry was setting about its business, and so far as I understand it they did not produce any adverse views on those which were expressed and discussed at the time this consideration was going on. The noble Baroness referred to what she called the "boss" structure. It really takes me back to what I said earlier. The fact remains that there are many managers but they are not actually getting on with the job of management. Management by consensus is all very well, but in many walks of life it is clear that at the end of the day somebody has to be responsible and accountable. This is the whole point of the recommendations that my right honourable friend has accepted.

May I quote from Page 12, paragraph 6, of the report. It says: Absence of this general management support means that there is no driving force seeking and accepting direct and personal responsibility for developing management plans, securing their implementation and monitoring actual achievement". It goes further than that, and no doubt the noble Baroness will read it.

The noble Baroness also asked about the appointment of the general managers and others. She also referred to the question of who will be on the supervisory board. The members of the board will be as recommended by Roy Griffiths' letter. My right honourable friend the Secretary of State will chair it. The other members initially will be my honourable friend Mr. Kenneth Clarke, the Minister of State; Sir Kenneth Stowe, the first Permanent Secretary; Sir Henry Yellowlees, the Chief Medical Officer, who will be accompanied by his successor, Dr. Acheson; and my right honourable friend is considering non-executive appointments to the Supervisory Board. It is far too early to name the chairman of the NHS Management Board, who will also be a member of the Supervisory Board, but Ministers thought it important to let all know that they are anxious to make an early start following through the inquiry's advice. This they are arranging rather than wait for every appointment to be made.

So far as appointments at district, region and unit level are concerned, what I can say is that one of those involved in the actual administrative functions as it stands at the moment would be selected, or appointed, to do the job. It might be a nurse, it might be an administrator, it could be a doctor or whomever, but it would be for a fixed-term period and that person would be accountable and would not necessarily be reappointed. The noble Baroness asked various questions. I hope that I have been able to answer most of them, but the rest will become clearer to her when she studies the report more fully.

The noble Lord, Lord Winstanley, raised a couple of questions. The first was to do with the question of the report on administration. He was referring to Sir John Hoskyns's report. That goes rather wide of the report that I am concerned with and the Statement that I am repeating today. So far as polls are concerned and spending more on the National Health Service, I think that that really is a little bit of a red herring on this occasion. The important thing is to get efficiency out of what we have got, and at the moment it is clear that the National Health Service is not as efficient as it ought to be. This seems to be a widely held view, and the whole purpose of the Griffiths' report is to achieve management which works to make the whole system more efficient.

5.35 p.m.

Lord Molloy

My Lords, this seems to be a much more comprehensive report than we had anticipated. We have an amazing number of recommendations such as, for example, the suggestion that the RHAs should be strengthened considerably as they are responsible for running the health service in their regions, and they are almost nearest to the patient. May I ask the Minister not to reply to me now but to consider with the Government, and put it to the Government, that this is a matter that we ought to debate for a few hours in this Chamber?

Lord Glenarthur

My Lords, I think that that request, which I note, is really a matter for the usual channels. I am sure they will take note of it.

Lord Kilmarnock

My Lords, there is one brief question I should like to ask the noble Lord, Lord Glenarthur. It is probably not sufficiently recognised in this country that the administrative costs of the National Health Service, which run between 5 per cent. and 6 per cent., are among the lowest in the world. Of course, in any administrative system there are bound to be some inefficiencies and some room for improvement. It is possible, as a result of Mr. Griffiths' report, which we have not had time to read, that some improvement will be made. If any efficiency savings are made through this new management scheme, will they be ploughed back into the National Health Service at the coal face, where the money is required, and not simply spent on other things?

Lord Glenarthur

Yes, my Lords, that is the whole point of the system. The idea of filling the National Health Service with administrators who do not directly affect patient care but indirectly affect patient care has been discussed widely over the last few months, as the noble Lord, Lord Kilmarnock, knows. If we can achieve efficiency here in the way that the Griffiths' Report recommends, then the results of that would go directly towards the patient.

Lord Auckland

My Lords, clearly since few of us have had a chance of seeing this report it would be inopportune to ask too many questions at this stage. However, I wonder whether my noble friend can say, in view of the last observation he made about the composition of this board whether the General Nursing Council will be represented? It would seem that there is at least one Minister going to be represented on the board, but this whole Statement seems to lack any direct involvement of nurses and those who are undertaking the therapeutic side of medicine itself. While not expecting my noble friend to give a detailed answer at this time of day, could he ascertain whether the General Nursing Council will be represented, because it seems to be most important that they, of all people, should have an important point of consideration here?

Lord Glenarthur

My Lords, these are all matters to be taken into account when the composition of the board is further discussed. As I think I made clear, the Secretary of State is considering non-executive appointments, and whether or not the General Nursing Council is one of those concerned is a matter for my right honourable friend himself, but no doubt he will take note of my noble friend's views.

Baroness Masham of Ilton

My Lords, may I ask the Minister whether the new managers' salaries are to come out of the present regional health authority budgets? In the old days the nurses used to be accountable to the matron; and would not an appointed matron wearing a uniform have been a cheaper way of getting accountability of nurses than yet just another manager, who will probably be wearing a suit and will not be recognisable? He will just be yet another manager.

Lord Glenarthur

My Lords, the noble Baroness asked the question which was asked by the noble Baroness, Lady Jeger, about the payment of general managers and whether they will be paid more and how they will be paid. The answer is that we have got to look at what general managers in the district do when appointed, and consider then in fact whether they should be paid more—because they will be coming anyway from an existing function. It is a point that has not yet been firmly sorted out, but it will be. So far as matrons are concerned, the suggestion made is something I would rather like myself, though I am speaking entirely personally. I do not think that that point has been covered by the report. The professional functional responsibility of functional managers such as nurses is not decreased. A unit director of nursing services, for example, would continue to manage the nursing staff within the budget and would be responsible for their professional competence. The general management function will tighten up the environment within which the professional managers' work, clarify where professions may be at cross purposes, and ensure that sensible decisions are taken. However, I think that the appointment of a matron is rather a different story.