§ 4.29 p.m.
§ Debate resumed.
§ Baroness Faithfull
My Lords, as a retired Director of Social Services, it is perhaps inevitable that my special area of concern with regard to the need of management in the health service is to ask the Minister: what is managers' particular role under the Griffiths Report in connection with the setting up of joint projects as between health, social services and voluntary organisations in the community? If hospitals are to be run efficiently, giving services to those in need of treatment and medical care, then it must be the managers' concern to see that those in hospital who could and should be treated in the community have the facilities to receive such a service. 1172 I refer of course especially to the elderly who are able to live in the community with support, the mentally ill on the way to stabilising, and other patients who I understand at the moment in many cases have to take up hospital beds, but who could be cared for in the community were there community projects available.
It seems to me that, first, there must be in each area an overall strategy and. secondly, that that strategy must be worked out in each area and region to meet local needs, and must be solved locally. Thirdly, the primary care team and the social services and voluntary organisations must together be able to meet the needs, so that people do not languish in hospitals, taking up beds.
Is the Minister satisfied that managerially the joint planning teams throughout the country are able to give this service and are assessing the needs, without undue endless rounds of consultative committees, consultations, and final implementation? I know that this is a grey area in the sphere of management of the health service, but I would submit that it is an important area.
I realise that perhaps today we cannot discuss resources. However, as I understand the position, once a scheme has been approved by a joint financing committee of the health and social services, then ultimately, after it has been running for two or three years, the bill for its continuance, from the point of view of resources, must be provided for by either the health service or the social services. Should not this question be determined at the beginning of the project, rather than at the end of it? I ask that because I have been told that many projects which have been set up have closed due to the fact that neither organisation—the health service, nor the social services—was able to meet the bill in the end or carry on with the expenses. Surely from a management point of view that is a waste of time of personnel of both the health and social services, and it could be said to be poor management.
I should like for a moment to turn to the question of the type of person a manager should be. and here I wish to make special reference to my noble friend Lord Mottistone and the noble Lord, Lord Taylor. I should have thought that it is the type of person who counts, and not necessarily his background. It seems to me that there are many doctors who make splendid managers and equally there are many lay people who make splendid managers. What is important is the type of person and his qualities. Perhaps I may mention that a cousin of mine who was a doctor was the medical superintendent of the Neath Hospital, which dealt with all the accidents from the mines in Wales. The management team consisted of the doctor, the matron, and the secretary—that was all—and it gave service of a superb nature to that area. Therefore, I would beg that the best person be chosen, be he doctor or layman.
§ 4.34 p.m.
§ Lord Perry of Walton
My Lords, I, too, am grateful to the noble Lord, Lord Hunter of Newington, for giving us this opportunity to debate again the problems of running the National Health Service. The present Government have a remarkable record of diagnostic skills. Once again they have come to a 1173 correct conclusion—that there is something wrong with the National Health Service, it is not fit and healthy, it is, to say the least, a bit under the weather. But, once again, I am afraid the Government have failed to match their diagnostic skills with the wisest kind of treatment.
We on these Benches consider that the nub of the problem is the inevitability of a real reduction in front line staff and patient care. We believe that the Government are not facing up to that problem. Instead, they are rushing into a new management scheme in the wake of the Griffiths inquiry and, as has been said, this is the third major reorganisation of the service in 10 years, and is being introduced hastily and without proper consultation.
We are not against improvements in management, and the new proposals may indeed lead to improvement; nor are we wedded to the status quo. But we have serious doubts about the wisdom of imposing the new management structure nationwide, in a blanket fashion, and we should have preferred to see a preliminary pilot study in one region.
In any case, bad management, where it exists, is only a symptom, and the introduction of new managerial structures is only symptomatic treatment. What we need is a more radical cure. I should like to concentrate upon the relatively simple problem of the hospitals and how they are run.
On 10th March 1982 in your Lordships' House we debated the state of the National Health Service and I then said that I thought that what was wrong was a lack of leadership. The same is still true, and it lies at the root of the problem. The Griffiths recommendations recognise this, but the introduction of general managers is seen as the solution. Like the noble Lord, Lord Mottistone, I never cease to be amazed—I suppose I have a simple mind—that intelligent people can believe that consensus management, as that term is understood in the National Health Service, can ever work. Yet in many of the papers that have been written about the Griffiths inquiry the concept is defended, often with passion.
Much is made of the multiprofessional nature of the National Health Service; much is made of the problem of having one kind of professional take decisions that affect the work of another kind. And so the idea that the spokesmen of every professional group must all agree before anything is ever done is given the semblance of credibility. But, my Lords, it is only a semblance. In reality it is a recipe for doing nothing. A decision to do nothing is every bit as important as a decision to do something, but the current system requires a consensus to do something and yet requires no consensus whatsoever to do nothing at all; for if only one voice is raised against a proposal it cannot be proceeded with. It is a ludicrous system.
Even the basis on which it is defended has only superficial merit. Let me illustrate what I am trying to say by making an analogy with the university world, for in many respects a large university is not unlike a hospital. A university and a hospital are there to provide services to students and patients respectively. They are both staffed multiprofessionally, and they depend on a large variety of craftsmen, technicians 1174 and tradesmen. Both expend vast sums of public money.
Like other vice-chancellors, I ran a large university. I am not a trained administrator, and I do not think that I am a particularly gifted manager. All that I can claim to have given to the Open University was leadership. To be a successful leader requires, I think, three things. First, it is vital to be able to command the respect and loyalty of the staff. Secondly, you must be able to formulate and enunciate the policies of your institution, borrowing ideas—where they are appropriate—from your colleagues, ensuring that they are acceptable to a majority of the staff before espousing them, but ensuring, too, that they are in the best interests of your institution. That is true consensus management. Thirdly, and just as important, you have to pick the right people to do the jobs that have to be done. You must, as I did, appoint a first-class administrator to administer, especially if you are not very good at it yourself.
I am sure that there are lots of able managers and administrators around; but being a good administrator is not of itself any guarantee of being able to provide leadership. Many such men, worthy and skilled as they are, are faceless bureaucrats, grey men with no charisma whatever. Making the books balance and answering all letters by return never fired the imagination of staff nor raised their morale in times of trouble. I am sure that the NHS has many good administrators and now the Government propose to give it more good managers. However, this will not necessarily do anything to provide the leadership that is so badly needed. There is one reason why it cannot do so.
If I can return to my university analogy, there are many experts in the university. Each professor was appointed because he was the most distinguished scholar that could be found in his field. The vice-chancellor, if he is lucky, may be as distinguished in one field of scholarship as the professor in that field, but he cannot be the equal of all the others in theirs. His administrative staff has usually been trained in the standard career of university administration and probably knows far more about it than he does. His staff includes laboratory technicians and gardeners, cleaners and caterers, hoteliers and drivers, surveyors and craftsmen. It is as varied a staff as that in any hospital. And, believe me, academic staff are every bit as much a bunch of prima donnas as hospital consultants. Yet in a university there is no doubt whatever where responsibility lies.
The vice-chancellor is the chief administrator and the chief academic officer of the institution, responsible for the health of the whole university to the governing body. He usually has, on the other hand, very few statutory powers. He is the antithesis of the harlot. She has the power without the responsibility. What he does have is enormous influence. He takes decisions every day, but he takes them because he knows that they will be acceptable by a majority. He is in fact a leader. He is also drawn almost always from the ranks of the university academic community. This is supremely important. Where that pattern has been broken the results have rarely been happy. High-powered academic staff readily give their loyalty only to someone who commands their intellectual respect. 1175 Those who lack scholarship have therefore a formidable obstacle to surmount. It is very creditable that a few people have, indeed, surmounted it.
In a hospital the only person who can command a similar loyalty and respect from all the staff is one drawn from the ranks of the senior consultants. I hope that I can allay the doubts of my noble friend Lady Robson about this. Of course, there are many consultants who would refuse the job of running a hospital. But there are also just as many professors who would refuse the job of running a university. However, there is never any difficulty in filling a vacancy. I do not believe that there would be any difficulty in the hospital service either. What is necessary is to make the job financially attractive. That means competing not only with consultants' salaries but with distinction awards as well.
As many groups have pointed out, it would be retrogressive to go back to the old system of the hospital superintendent. It is a tarnished image. Many superintendents were of a calibre quite insufficient to command any respect from the consultant staff. But to refuse to go back to that system should not be used as an argument against all systems of medical control. I argue that only medical men can provide the leadership that is required. Of course, it is true that other people can provide management, but leadership is very difficult for anyone who is not medical. Unless that is accepted and acted upon, we can have reorganisation after reorganisation without significantly affecting the situation. In the end, the whole of the National Health Service is about giving the patient the treatment he needs. That treatment is the responsibility of the doctor. It includes not only medical and surgical care but also the standard of nursing, the cleanliness of the wards and corridors, the quality of the food and the handling of trolleys and stretchers. It includes the operation of the whole hospital. Every employee is there to help the doctor provide the patient with the treatment required. Let us, for God's sake, recognise that fact and get some sense back into the system.
But what, you may say, of the control of cost? And the Government will certainly say it. Even we vice-chancellors have to live within our budgets. So, too, I believe, would the medical director of a hospital. He would also have the necessary charisma and power of leadership to get his senior consultant staff to back him up. When the available funds were not sufficient to provide for all the facets of patient care, he could make that fact public. He could show that it is a myth that public funds can provide a wholly comprehensive service at an open-ended commitment on cost.
Finally, let me add, as a footnote, that I believe that a similar change is needed at the very top of the National Health Service. The Griffiths inquiry recommends that there should be a National Health Service management board with a director general as head of the service. This is a role, I believe, that can only be filled adequately by a distinguished medical man given the public authority to lead the service. I shall not labour the point. Let me simply say that I believe that such a move could restore a little hope to a service that is sadly demoralised, a service that we all want to be proud of. It is one of the most successful 1176 social innovations of all time and it deserves the best that we can give it.
§ 4.46 p.m.
§ Lord Rea
My Lords, I should like to apologise to the noble Lord, Lord Hunter, for not being able to be here at the beginning of the debate. I would have liked to be able to say that I was detained because of my duties with the mental health care planning team for Bloomsbury—but that actually meets on a different Wednesday. I was detained by other professional cares. I wish to make only a short statement.
The debate is timely in that National Health Service staff are worried because of the hiatus, now six months long, between the publication of the Griffiths recommendations and a definitive Government statement about their response. While we are reasonably happy that there will be no further drastic shake-up of the National Health Service (and Griffiths itself is mindful of that), we still remain uneasy. The British Medical Association has given a guarded welcome to Griffiths and the House of Commons Standing Committee on the Social Services has also some positive things to say. No-one maintains that the management of the National Health Service is ideal. But neither is it wholly bad. The system of consensus management, while slow and often tedious, does at least give everyone a chance to put their view; and decisions, when finally arrived at. are thus more acceptable.
The Griffiths recommendations are not precise, and our unease comes from the introduction of another group and a powerful group of appointed rather than elected administrators. Many others are concerned that the Minister, with Cabinet pressure on him to cut spending, may appoint managers whose main aim is to prune, with the welfare of patients low down on the list of priorities. Some of the appointees will come from outside the National Health Service, from commerce and industry, which suggests that they may be inclined to encourage private practice as a means of off-loading pressure on the National Health Service. We debated this in the last short debate introduced by the noble Lord, Lord Hunter. Many feel that this would be uneconomic in total cost to the nation and divisive and destructive of the National Health Service.
Having voiced these doubts, I must say that there are some true and positive points made in the Griffiths recommendations. Paragraph 2 on page 10 states:The NHS does not have the profit motive, but it is. of course, enormously concerned with control of expenditure. Surprisingly, however, it still lacks any real continuous evaluation of its performance against criteria"—which were mentioned earlier.Rarely are precise management objectives set: there is little measurement of health output: clinical evaluation of particular practices is by no means common and economic evaluation of those practices extremely rare. Nor can the NHS display a ready assessment of the effectiveness with which it is meeting the needs and expectations of the people it serves. Businessmen have a keen sense of how well they are looking after their customers. Whether the NHS is meeting the needs of the patient, and the community, and can prove that it is doing so, is open to question".I believe that many of the challenges contained in this statement could be met from within the present structure, and there are already research projects 1177 looking at some of these questions, funded by the department. But if Griffiths strengthens and raises the priority of this type of evaluative research, it will be on the right track.
On the private sector, the report also says something which is rather reassuring. It says:Management … should … be asking … and examining why, if functions can be performed more cheaply (outside the NHS) the NHS itself should not do so".In drawing these short remarks to a conclusion, I was going to read some of the remarks which the British Medical Association made in its letter to the Minister in January. But in my haste to get here I am afraid that I have left the letter behind! However, the gist of the communication from the BMA is that, although it fully agrees that improvements in management are necessary, it is very concerned that, where clinical matters are involved, the new managers should not be empowered to overrule decisions taken on clinical grounds.
My noble friend Lord Pitt has just handed me a copy of the letter but, in fact, the passage that I wanted to read is not marked and I have a summary of it in my head. The basic feeling of the BMA about consensus management is that, although it is sometimes slow to make decisions, the best way of increasing the speed of its decision-making is to increase the powers of well-trusted managers who are already there, rather than to bring in new people from outside who are not so familiar with the local problems. That is all I have to say at the moment. As I promised, it was a short statement.
§ 4.53 p.m.
§ Baroness Cox
My Lords, I must begin with an apology, because I deeply regret that I may be unable to stay for the latter part of this important debate for which we are so indebted to the noble Lord, Lord Hunter. At present I am absconding from an international conference which I must rejoin no later than six o'clock. I shall be very sorry if I have to miss the latter contributions, but I very much look forward to reading them in Hansard tomorrow.
I wish to offer a contribution from the perspective of the nursing and midwifery professions. I am most grateful to the noble Lord, Lord Hunter, for recognising the concern that they are currently feeling. I offer this contribution, not to plead for sectional interests, but because nurses and midwives comprise the largest occupational group in the National Health Service and it might, therefore, assist your Lordships' debate if their views are put. In so doing, I shall confine myself to recent developments in the form of the Griffiths Management Inquiry Report and the ensuing report from the Social Services Committee, because it is these which are of paramount concern at the moment.
In order to comment succinctly, I have endeavoured to subsume some of the main concerns under three headings: financial accountability, professional responsibility, and provision for education. The first is financial accountability. The first point which I wish to emphasise is that my colleagues in nursing and midwifery have consistently pledged their commitment to endeavours to promote efficiency and cost-effectiveness. As the Royal College of Nursing 1178 wrote in its evidence to the Social Services Committee:The Royal College of Nursing also welcomes the general emphasis in the inquiry on seeking to improve effectiveness and efficiency in the National Health Service. The College is always prepared to welcome recommendations which seek to achieve these ends, provided that they are commensurate with maintaining high standards of patient care and professional practice".Moreover, there is general acceptance that there is room for improvements in management in the National Health Service. For example, Royal College of Nursing members "welcome" the:emphasis on more vigorous management in the National Health Service",and:the need for more attention to be paid to crisper decision-making".However, as is well known, many of the specific recommendations made in the Griffiths Report have aroused great dismay, largely because of their implications for my two remaining topics— professional responsibility and accountability, and provision for education. These issues have been considered by the Social Services Committee and most of its recommendations have been warmly welcomed by nurses and midwives.
I should like to turn briefly to professional responsibility. It is the concern of the nursing and midwifery professions that they should continue to have a formal role in decision-making at all levels in the National Health Service—not for reasons of self-interest, but because of the special contribution that they can make, based both on the numbers of staff which they represent and on their particular role in the provision of health care. On the first point, it is relevant to remember that there are approximately 500,000 nurses employed in the National Health Service—about 44 per cent. of the total workforce. They therefore account for a very high proportion of National Health Service funds. On the second point, it is nurses who, by the nature of their professional work, are in the closest day-to-day contact with patients and are, therefore, often in a particularly good position to act as their advocates.
Consequently, the nursing profession has welcomed the recommendations of the report of the Social Services Committee which would help to preserve the nursing influence in decision-making. I refer, first, to the recommendation that the chief nursing officer of the DHSS should be appointed a member of the Health Services Advisory Board. Her exclusion from this top-level decision-making body was perhaps the most disturbing example of the failure, throughout the Griffiths Report, to give serious consideration to the key role of nurses and midwives in determining health policy. I sincerely hope that your Lordships may see fit to support the recommendation of the Social Services Committee that the omission of the chief nursing officer from the advisory board should be remedied.
Concern has also been expressed over other proposed changes in the structure of management at other levels in the National Health Service. For example, in its evidence to the Social Services Committee, the Royal College of Nursing claimed:Royal College of Nursing members found many of the proposals relating to the management of the National Health Service at regional, district and unit level disturbing, and believe that more specific clarification would be needed as to their impact and intent".1179 In particular, they are concerned about the rejection of the concept of consensus management and about the possible loss of professional autonomy and accountability. Although recognising that consensus management has not been without problems in some places, they argue that in many places it appears to have worked satisfactorily, and that the Griffiths inquiry gave no evidence to justify jettisoning it; and the proposal to introduce general managers at unit level has caused considerable consternation. As the report of the Social Services Committee argues:There is widespread agreement that the 1982 reorganisation has not even now been fully implemented at unit level. Some posts are still unfilled. The relationship between unit managers, clinical staff and nurse managers is still at a very early stage. To disturb them, and in a manner as yet unspecified, would be the height of folly".The nursing and midwifery professions wholeheartedly endorse this view. Moreover, they argue that early indications of the management performance of units are very encouraging, and they consequently urge that a structure which, while still establishing itself, is showing great promise, should not be interfered with so soon.
I must repeat once again that my professional colleagues are not motivated by self-interest or professional self-aggrandisement. Their anxiety is caused by their sincere and, in my view, realistic belief that another major upheaval now in the National Health Service could have disastrous consequences for efficiency and for morale. Moreover, the changes proposed by the Griffiths inquiry are seen as in some respects structurally unsound. For example, the introduction of general managers at unit level would destroy the line of professional accountability between a director of nursing services and the district nursing officer.
This loss of direct professional accountability has serious professional implications and is something which the professions would oppose to the utmost. And the removal of responsibility for the nursing budget from those responsible for providing nursing services would impair rather than enhance efficiency and cost-effectiveness. For example, in any general hospital a great deal of fine tuning is constantly taking place resulting from changing priorities and pressures on the nursing services. This fine tuning is an extremely complex process and requires nursing expertise to ensure that the available resources are used to maximum benefit. It would be anomalous and unsatisfactory if the person who has responsibility for the control of a budget lid does not have responsibility for the deployment of staff paid for by that budget.
It is on these grounds that the nursing and midwifery professions endorse the Social Services Committee report in their recommendations that:the Secretary of State clarify his intentions as regards the future of district functional management, including nurse management … and that the issue of general management at unit level be considered separately from general management at district and regional level.This brings me finally and briefly to my third topic: provision for education. The omission of consideration of this subject from the Griffiths Report must be seen as serious. The nursing and midwifery services rely on 65 per cent. to 72 per cent. of a student's time being devoted to providing service, and they consequently make a crucial input to the delivery 1180 of patient care. Also, the salaries of the student and pupil nurses and of student midwives are part of the total district nursing budget, and there must be a facility for virement between units to take account of fluctuations stemming from their training programmes. This is yet another reason for retention of the control of the nursing budget by the district nursing officer—an argument which has been put very forcefully by the Association of Nurse Administrators in strong representations to the Secretary of State.
I conclude by summarising the main concerns felt by my nursing and midwifery colleagues. They are not opposed to endeavours to improve efficiency and to enhance cost-effectiveness in the National Health Service. They appreciate that resources are scarce and that efforts must be made to "sharpen" management so that resources are used to the best advantage. However, they believe that the maintenance of high standards of professional practice will not be facilitated by the proposed changes in professional accountability; rather, they believe that preservation of nursing's contribution to policy-making and decision-making at all levels is a prerequisite for efficient and effective use of resources. And they also urge that no precipitate changes are made within the National Health Service which will damage the morale of staff, which is already at an unprecedentedly low level due to repeated change, sustained uncertainty and understandable feelings of insecurity.
The National Health Service has the benefit of the dedication of thousands of able and altruistic men and women. Many of these, especially in the nursing and midwifery professions, are now anxious and demoralised. They have been cheered by the reassurances offered by the report of the Social Services Committee, which advocates caution, together with further debate and clarification of certain areas of confusion, before implementing any further major changes.
I hope, passionately, that the concerns and reservations expressed by these professions will be taken seriously so that they may be enabled to continue to try to provide nursing and midwifery care of the highest possible standard. I also hope that their members, who are generally held in such high esteem and affection by the public whom they serve, will not be subjected to unnecessary pressure and distress by precipitate implementation of policies which may not achieve the goal which they are intended to achieve—a goal which we all share: the efficient provision of the best possible health care for everyone.
§ 5.6 p.m.
§ Baroness Gaitskell
My Lords, I should like to thank the noble Lord, Lord Hunter, for allowing me to speak today very shortly. My speech is going to have few facts and is going to be really a slight eulogy of the National Health Service hospital, the Royal Free, which I attend, and have attended several times over the last few years. I may say that it will be a eulogy about this hospital rather than a talk about what the noble Lord, Lord Hunter, was speaking about.
I have been ill over the last few months and have had one accident. How would one have dealt with that had there not been a National Health Service? We do not think of things like that. Who is going to look after us? I had two X-rays on an arm that I could not move at 1181 all for a little time. I found the situation completely inadequate, and my daughter took me to the hospital. I do not know what people do who have not got either cars or nice daughters who can help them on these occasions.
I do not understand all this talk about managers. What do people mean by managers in the National Health Service? I cannot see any use for them there—none at all. Let them stick to business, not to health. That is what we want. Maybe things can be improved, but what could they do? Bring their business knowledge to the hospitals? I do not believe a word of it. No one who has spoken has convinced me of any job for such managers. I do not know what we want them for. The good hospitals are doing extremely well, and surely, if they are not doing so well, they can be taught by all sorts of people to do better.
My experience of the hospital was wonderful; one day I could not move this arm at all and I could not walk, or do anything. On the next day, having been at the hospital and having had two X-rays, there it was, waggling away. That is the kind of thing we ordinary people want to have done, if we have to go to a doctor.
One thing that troubles me is that many women are shy about going to their own doctors at certain times. They have spoken to me about it, and they have told me that they are shy and cannot do it, whereas they will go to a hospital, where they are not shy, and they are attended to. Altogether it seems to me that we are barking up the wrong tree when we talk only of managers. There are several hospitals in this city which are first class. The people who go to them get service for nothing, and the people who will not go to them have to pay £15 for a five-minute interview. Really there is only one thing we can do: the National Health Service and the hospitals are absolutely first class, and if they need to be better, we can make them so.
§ 5.10 p.m.
§ Lord Ennals
My Lords, I am naturally delighted that my noble friend Lady Gaitskell paid the warm tribute that she did to the National Health Service for restoring her to full health, enabling her to give a bit of passion to this debate. I am also grateful to see the noble Baroness, Lady Faithfull, return because the noble Baronesses have distinguished themselves today. I should, before saying that, have thanked the noble Lord, Lord Hunter of Newington, for enabling the noble Baronesses to do so and for the excellent speech which he made. I am sorry that Lady Cox has had to leave, but she left after making what I thought was an outstanding speech. I hope she reads Hansard tomorrow, because there was not one word in the speech which she made with which I would not totally associate myself. I cannot say that about any of the other speeches, except for that made by the noble Baroness, Lady Robson of Kiddington. I have a special affection for Lady Robson, as on these issues we do not touch on party issues. She was an excellent chairman of a regional health authority; we had the closest relationship.
1182 All those who have spoken did so with a great deal of experience. I am a little worried about Lord Taylor because he seems to think that a manager is clapped out after seven years. What about a Secretary of State who does not have a manager? What is his state after three years? I do not feel clapped out, and I tell him I am not clapped out. I do not know whether the Secretary of State will find his life easier if, with the responsibility that he has to Parliament for the running and provision of a health service, he has also to cope with a manager paid three times as much as he is paid. But we will leave that for the moment. Whatever we feel here, none of us—excluding my noble friend Lady Gaitskell—feels that we do not have to improve, if we can, the management of the National Health Service.
I am glad that the noble Baroness, Lady Cox, has returned to her place. I have just been saying some lovely things about her, saying that everything she said I agreed with. Of course we want to improve management, but there are a lot of provisos involved: provided that we can achieve it without loss of effective inter-professional consultation; provided that it will improve patient care; provided that it will not undermine the consensus and agreement between the professions and provided that we can do it without extra cost.
Inevitably in this debate we have been concentrating our minds on the Griffiths report. I think I have read every bit of evidence submitted to the House of Commons Select Committee and I listened to a number of sessions in which there was oral cross-questioning of Ministers, Mr. Griffiths and the organisations themselves. I feel myself steeped in the Griffiths report, but I am not really very happy about it.
I was staggered by the fact that the Secretary of State did not publish the report as soon as he received it; he published it at the moment when he said: "And I accept it". I do not believe this is the way to go about things at all. He should have published it; as I feel about the Greenfield report, as I feel about the Binder Hamlyn report. You publish a report, allow people's views to be reflected and you then make up your mind. He may be going slower now than he was in his first bout of enthusiasm, but it is, I fear, a habit of Conservative Governments constantly to reorganise the National Health Service. We had the 1972 reorganisation under Sir Keith Joseph. I think it was a disaster, although some good things were done. I supported my predecessor, Barbara Castle, who decided that, even though she thought it was a pretty unfavourable mess of pottage—I shall now mix my metaphors—she did not intend to unscramble the egg. You cannot do that.
If there is a change and the health service is thrown into great disruption, the Secretary of State cannot say: "I don't like that. I am going to do another one", and reorganise it all over again. Management has to keep to its job and all those working in the health service have to see a reasonable future. I resisted all the pressure upon me, when I was Secretary of State, to put right what had been done by the previous Administration.
We had the 1982 reorganisation and, as has already been pointed out by the noble Baroness, Lady Cox, it 1183 has not even been completed; posts are not yet filled and people are still settling in to the new posts. Now we are to be presented with another reorganisation. Quite frankly, it is too much for the National Health Service. I believe it would do great damage to do it now. There may be time and that time will come. But, if one considers the evidence, the Royal College of Nursing was extremely strong in its opposition. The noble Baroness, Lady Cox, made reference to Trevor Clay, who told the Select Committee in another place that:The response from RCN members was clear and angry from the outset".Some of the reasons have been given by the noble Baroness.
The BMA also made it clear that they were opposed to the recommendations. All right, they have some commendations, as I have, about the critique which Griffiths made. Many wise things were said by Griffiths in his critique of the National Health Service, but not in his remedy for the weaknesses.
Some members of the National Association of Health Authorities took a variety of different views but, on the whole, they were extremely critical and the unions were also opposed in varying degrees of fury.
I believe that if the Secretary of State proceeds, even on the slightly slower timetable that he seems to envisage, the National Health Service will be thrown again into confusion and conflict by what will be a third reorganisation in ten years. The absurd thing is that each reorganisation seems to run contrary to its predecessor. The 1982 reorganisation was designed to undo the 1972 one and Patients First, which was published in 1980, was the basis of the reorganisation. It specifically rejected the idea of managers, of chief executives, as the Guillebaud report did back in 1956, and as Sir Keith Joseph had done in 1972. Each has considered whether this sort of business management should be brought into the National Health Service and each has turned it down.
Inevitably, Roy Griffiths and his team, in considering the National Health Service, looked at it from the point of view of a business structure. I do not believe one can compare the National Health Service with a business structure. Someone has mentioned the profit motive; that is a small part of it, because every section of the health service, indeed every organisation, has to be efficient, whether there is profit or whether there is not.
There is another factor. The law of the land requires that the Secretary of State himself—unless the law is to be changed, and he does not propose to change it—is responsible to Parliament for the provision of a health service. Thirdly, decisions in the National Health Service must be taken in the interests of millions of individual patients whose needs are best known by a variety of different professional people—trained doctors, nurses, professions supplementary to medicine, not management consultants or consumer surveys. The National Health Service cannot seriously be compared with a business enterprise.
There is a second fallacy; that is, that the National Health Service is badly managed. There seems to be a great assumption that it is badly managed. Nothing is perfect and we can find errors. I guess we would find 1184 errors if we did an analysis of the Sainsbury organisation, Marks and Spencer or any other commerical organisation. The NHS, as was said by the noble Baroness, Lady Robson, is administered on a very tight budget of now marginally less than 5 per cent. She and I know well that this is an operation that has been going on for several years; tightening, tightening, tightening the management proportion of the National Health Service. But I believe that for efficiency and value for money it is better than that provided in most countries in the world and in most enterprises in Britain—commercial enterprises or not commercial enterprises. The real trouble with the National Health Service is not its management; it is that it is under-financed—and I am not going to go any further on that because I think across the Floor of the House there will be agreement that we can try to improve management as much as we like, but if the funds are not there to sustain and develop the growth of the National Health Service, then we are going to be in a grave difficulty.
Looking at some of the evidence that was presented to the Select Committee in another place, the National Association of Health Authorities, who represent all the different health authorities in the country, said—and it is worthwhile quoting—in paragraph 15:It would have to be recognised that there would be major practical difficulties in introducing a chief executive system into the National Health Service.They give three reasons:(a) It would require the understanding and co-operation of the major professions".Well, it has not got the co-operation of the major professions: that is absolutely clear. Secondly:(b) There may be a serious shortage of suitable qualified and experienced officers, especially at unit level".I think that to bring people in from outside would be a very risky operation to undertake. Thirdly, they say:(c) It would cause further disruption and seriously affect morale in a service which is still in the process of implementing the 1982 reorganisation".That is their view, it is the view of the noble Baroness, Lady Cox, it is the BMA's view and it is my view; but it is not the Government's view and I do not understand why.
Perhaps I may quote from paragraph 16, which says:Moreover, a chief executive system is largely untried. There will be no guarantee that it will work better than consensus management which in many places is working well".I agree with that. I think that it is absolutely essential in decisions that are taken with a variety of different professions seeking to work together that, in the end, even if you may delay for two weeks in taking a decision, you get the decision right and you get the professions and all those who are having to operate this service doing it together and not arguing together. Many health authorities—and I am quoting from their evidence:… would be reluctant to make a radical change in their management arrangements unless the advantages of so doing have been clearly demonstrated in practice. As in any other organisation, the effectiveness of the arrangements for executive authority depend upon the personality and capabilities of the individuals concerned".I think that that is absolutely right.
I was very interested in what was said by one of the 1185 members of the Select Committee—a Mrs. Edwina Currie, who is a Conservative Member of another place and who served on the Select Committee. She said:Nurses must understand budgets, administrators must grapple with clerical choice. Doctors should grasp the intricacies of industrial relations. The management team all have to seek to understand the problems that other members of the management team must operate".She went on:Consensus management is a reflection of the ineradicable plurality of the National Health Service, not a cause of it. And, generally, it is working".I want to say that I agree with her.
My Lords, before I end. I want to raise just one other issue which was raised in the Sunday Times the week before last and which certainly affects management. The Sunday Times pointed out—and I think that there has been no denial—that a civil servant from the DHSS, a Mr. John Rogers, whom I greatly admire, who was my deputy private secretary and a very able man. was seconded to a crucial position at the Merseyside Health Authority in Liverpool. According to a document, he had been given remarkably wide-ranging duties, acting as deputy to the region's chief administrator, also retaining important responsibilities to Ministers. Part of the job description said that he would have to visit each of the 10 districts, that he would have toexplain departmental policies, answer queries, and assess performances of ministerial appointees".I must say that if management is to include people checking on whether lay or professional members of health authorities are satisfactory in the eyes of the Minister, that is a very dangerous thing. I quote again from the job description document published in the Sunday Times saying that he will also be:Providing information about the region to other parts of the division"—and that means divisions within the department—.in connection with national policies and strategies".My Lords, I believe that there are grave dangers in the centre dominating the place where the job is done. This was the great mistake that was made in the establishment of the area health authorities. It took decision-making further up the line, away from the point at which patients are cared for. I believe that increasingly—and it may seem strange from a former Socialist Secretary of State to say so about a Conservative Secretary of State—in this field as well as in local government, we are seeing the Government seeking to intervene excessively and increasingly in the affairs which are best managed by people on the spot who know best. When Griffiths said in his report that this would give greater influence at a local level, I am afraid that I do not agree with that at all. I think that we are going to see, if this is carried out, a management structure that will go down from top to bottom, and I have great fears about that.
It is always dangerous to give advice to the Secretary of State because, if I give it, he will not take it. So what am I to do? It may be that the noble Lord the Minister will at least accept it. I am not saying that everything in the Griffiths report is wrong. All I am saying is that to introduce it now without much more consultation with all the professions may leave some gaps. The 1186 noble Baroness, Lady Robson, referred to some of the gaps. Perhaps they can be filled, through consultation, over the next two years. But I would put the implementation of the Griffiths recommendations on the back row for two or three years, not only to ease the National Health Service from having another disruption but to enable it, if we are going to make another change, actually to get it right.
§ 5.28 p.m.
§ Lord Glenarthur
My Lords, I join with others of your Lordships who have congratulated the noble Lord, Lord Hunter of Newington, for choosing this important subject for debate today, and for succeeding in getting his name drawn out of the hat. I particularly welcome the opportunity that it has given all of us to hear the thoughtful, stimulating, sometimes even emotional comments, mostly based on direct experience of the National Health Service, which he and others have made on the many far-reaching issues raised by the report of Mr. Griffiths. This is the first time, apart from at the initial announcement, that the report has been discussed either on the Floor of your Lordships' House or in another place. Therefore, it will enable your Lordships to participate in the process of consultation. But I have to say that the Government are not yet in a position to respond to many of the detailed points which have been raised here and in other fora. No final decisions have been reached on how precisely to carry forward all the recommendations contained in the Griffiths Report. However, I am pleased to have the chance to make some more general observations about the Government's views on the report, and I shall do my best to clarify any of the more specific points that I can.
So far as the debate in another place is concerned, that is a matter for another place. I have no doubt that they will want to discuss the report which has been so frequently referred to. I should like to begin by placing the report in the wider context of the Government's general policy on the National Health Service. Throughout our term of office we have been concerned about improving the efficiency of the health service. We regard it as a major priority to ensure that the huge amount of money we spend on the service each year—currently £13 billion in England alone—reaches its target; and its target is the patients. To help to do this, we have set several initiatives in hand already. For example, the establishment of the annual accountability review process, the introduction of improved manpower control and planning systems which regional health authorities are now required to link with their service plans and available resources, the setting up of pilot projects for management budgets and improving audit procedures. Behind these individual initiatives has been the Government's overriding concern to see the management of the health service is geared to the interests of the patients and to the more efficient use of what must always, I fear, be limited resources.
It was against this background that my right honourable friend the Secretary of State for Social Services set up the management inquiry, under Roy Griffiths' leadership. The Government's purpose was to seek advice, from professional managers with experience in other large organisations, on our current 1187 initiatives to improve management and efficiency in the service, and on what more we, at the centre, and health authorities, should do to get the best value for money and the best possible service to patients. The inquiry team report has, in our view, provided us with valuable and constructive advice. We were encouraged that the inquiry team endorsed the management action we were taking already, and we welcome—as do the majority of those working in the health service—the aims and objectives which led the team to suggest a challenging future programme of management action—not, I should stress, to bring about another restructuring—as was suggested by the noble Baroness, Lady Robson, and by the noble Lord, Lord Ennals—but to make the existing organisation work better in practice.
What we are doing is not changing the system but building on what we have done so far: the establishment of a general management function would add to the existing management arrangements. It is introducing something new into the National Health Service which, in our view, is not there at present. It is certainly not replacing existing arrangements.
Many of the team's recommendations call for continued action on the initiatives already under way, such as the further development of management budgets. And the importance of these aspects of the report's recommendations should not be overlooked, though, naturally, those in the health service have been concentrating their attention primarily on the establishment of a general management function and the greater involvement of clinicians in management which my right honourable friend asked about particularly in his consultation letter to health authority chairmen last November. And similarly, it is these two aspects which have been primarily engaging the interest of your Lordships today. I am particularly pleased about the emphasis that has been placed on the crucial role of clinicians.
As I said earlier, I am not in a position to give any detailed response on how the report's recommendations will be carried forward. What I can report is progress made so far. As your Lordships will know, my right honourable friend, having accepted the general thrust of the Griffiths Report—which I think was the point really made by the noble Lord, Lord Ennals, when he said he accepted the report willy-nilly—initiated a consultation process, beginning last November, with health authorities, professional bodies and others with an interest. The intention then was to issue guidance to health authorities early this year. We are still broadly on schedule to do this. However, since then, the Social Services Committee—which I mentioned just now—decided to make the Griffiths Report the subject of their first inquiry this Session, and my right honourable friend has indicated that he would like to have the opportunity to debate their report before reaching any final conclusions on guidance to be issued to health authorities. The Government hope to secure time for a debate in the course of the next month or so, the intention then being to issue guidance to health authorities without undue delay.
We are well aware of the points made by my noble friend Lady Cox that the National Health Service is 1188 geared up and waiting for guidance. I can assure her that we intend to keep to our intention to issue guidance as soon as possible in May.
One point I should like to make clear: the Government are firmly committed to establishing the general management function in the National Health Service on the lines recommended in the Griffiths Report. As your Lordships will be well aware, the inquiry team found that the general management function is not clearly defined at any level of the health service. They define this function as the responsibility, clearly vested in one person, for ensuring that the whole organisation runs smoothly and that things get done. I must say that here I share wholeheartedly the views expressed by my noble friend Lord Mottistone. What he said I think summarised so many of the thoughts which Griffiths and his team put forward: in other words, the establishment of the general management function is designed to meet the very point made by my noble friend Lady Faithfull; it should co-ordinate the drive to ensure that local and national policies and priorities are translated into effective action.
The inquiry team believed that only by establishing a personal and visible responsibility for the general management function could we achieve a guaranteed commitment throughout the health service to that constant search for improvement and concern for the experience of every individual patient which should be the universal hallmark of our National Health Service, of which we are justly proud. It is just this commitment to the needs of the individual patient which is at the heart of the care and community policies and to which the department is asking health authorities to give priority. That of course also lay behind much of the concern expressed by my noble friend Lady Faithfull. The inquiry team were not undervaluing in any way the importance of consensus management in the National Health Service.
Consensus works for a variety of reasons. It works either because everybody agrees that the decision is obvious, or more often—and I think this is probably true generally—it works because where a decision is particularly difficult one particular person in the group which is making these decisions stands out pre-eminently and leads the team which is making the consensus view. Teams are important; but at the end of the day nearly every successful enterprise is successful due to the taking of decisions by one person, however hard those decisions may be. Of course, people can still put their point of view before decisions are reached.
The fact is. as I have said, consensus on its own does not always lead to effective decision-making and management action; but perhaps, more importantly, as a management style it does not promote the kind of dynamic approach that we need in the health service to ensure that we get the best quality of care and value for money for patients. I share the views—
§ Lord Ennals
My Lords, may I ask the Minister one question? The noble Lord the Minister is arguing his case very effectively. I simply want to know why the view he now holds was not held and carried into practice at the time of the 1982 reorganisation.
§ Lord Glenarthur
My Lords, I am sure that the noble Lord, Lord Ennals, will agree that everything in life develops, and the National Health Service cannot be immune from that. The fact remains that what we hope to do with Griffiths is to try to improve what was started in 1982, and that is the purpose of the Griffiths report.
What I was going on to say was that I entirely share the views expressed by the noble Lord, Lord Perry of Walton, when he said leadership was a prerequisite in matters of successful management. I am quite sure that my noble friend Lord Mottistone would agree with that. We share the view of the inquiry team that the lack of clearly defined general management function is a weakness in present management arrangements, and it is this which had led us to believe—as my right honourable friend said in his November consultation letter—that we will begin to achieve the improvements we need and want in health service management by implementing the inquiry report's recommendations to identify a general manager at each level, as we have heard this afternoon: unit, district and region. He or she might come from any discipline, and should simply be the best person for the job. But the team hoped that, at unit level in particular, clinicians might be attracted to taking on this responsibility.
That, I hope, will please my noble friend Lady Faithfull. I am grateful to her for making the point so effectively and also to the noble Lord, Lord Perry, for his vivid description of the invigorating personality he sees as the right person for general manager. I would not disagree with him one jot. I should add that the team did hope that at unit level in particular clinicians might be attracted to taking on this responsibility.
The inquiry team's recommendations about the department have also received a lot of attention. I want to make it clear that we are not taking over to run the National Health Service directly from the Elephant and Castle, as I know some people fear. What we are doing is to strengthen the existing arrangements so that Ministers are provided with a better, more responsive tool to help them fulfil their responsibilities. My right honourable friend the Secretary of State has already set up a health service supervisory board as recommended by the inquiry team. Members of this board include, so far, health Ministers, the Permanent Secretary and the chief medical officer. Mr. Griffiths himself has also agreed to serve. My right honourable friend may consider making additional appointments to the board and he is of course aware of the views of the nursing profession, in particular that the chief nursing officer should be a member of the board. My noble friend Lady Cox spoke eloquently on this point. The Secretary of State has made it quite clear that the chief nursing officer will be involved in all matters concerning the supervisory board which might affect nursing interests, and in fact she has been present at the meetings held so far. Nurses need have no fear that my right honourable friend does not give full recognition to their essential position within the National Health Service.
The board's job is to advise the Secretary of State on overall strategy and planning for the health service. Directly accountable to the supervisory board, the 1190 inquiry team proposed a management board which would bring together all the present management functions now within the department. My right honourable friend said in evidence to the Social Services Select Committee that the aim of the management changes was to reduce functions at the centre and, following from that, reductions in staff. Arrangements are now in hand to set up the management board, including the appointment of a chairman, as the noble Baroness, Lady Robson, said; and the appointment has been advertised.
Yes, my Lords, it will be a difficult job. Any job which is of such huge importance and involves so much money, so many people and such an essential service is going to be a difficult job. The chairman of the National Health Service Management Board will rank as a Second Permanent Secretary in the Civil Service. His salary, however, will not be tied to that rank but will be negotiable. The noble Lord, Lord Taylor, particularly stressed that point. I hope he will accept the fact that I cannot name a figure because no figure has been fixed. The important thing, again, is to get the right person for the job; and the type of calibre of man or woman he identified in his speech is the person of considerable eminence that we feel is essential to do the job that will be required of him.
My Lords, may I interrupt the noble Minister for a moment? I am delighted to hear what he has just said, and particularly that the amount is negotiable. That is the best news we have had for a very long time.
§ Lord Glenarthur
My Lords, I am glad the noble Lord is pleased with that. I ought also to make it clear that of course there is no intention to appoint the personnel director before the general manager is in post.
I should stress—this answers the point made by the noble Lord, Lord Ennals—that these changes at the centre will not in any way change Ministers' existing statutory responsibilities; and present accountability arrangements will remain unchanged. I hope that this reassures the noble Baroness, Lady Robson. My right honourable friend has gone on record as saying this will be the case, and of course Ministers will chair reviews as is done at present. Rather, the point of these changes is to give a clear lead from the top towards implementing the general management function and other changes. This in turn will give impetus to devolution.
The inquiry team believe firmly, as we do, that management responsibilities should be devolved as near to the patient and the community as is practicable. Most decisions can and should be taken at unit level. This means, among other things, that clinicians should play a large part in managing resources since they make the decisions about individual patients that determine how many of those resources are used. I was glad to hear the most helpful analysis of the noble Lord, Lord Hunter, regarding the importance and the difficulties of involving doctors in management. I also share the views expressed by my noble friend Lord Mottistone on the importance of an enhanced programme of management training for clinicians and others—something which I am sure will 1191 be an early task for the management board and for the health authorities to consider.
I am also grateful to the noble Lord, Lord Rea, for raising the points which the BMA have already raised with us. I am sorry that he forgot to bring his notes with him. I have a list with me and if time permitted I would welcome the opportunity to read out the answers to some of the points that were raised. However, perhaps I can make it known to your Lordships that the department has replied to the 27 questions raised by the BMA, and no doubt your Lordships would be interested to hear the answers. I can certainly let the noble Lord have a copy of them, but I do not want to take up more time on that now.
Coming to terms with the realities of clinical freedom in a world of limited resources is the subject of wide debate in the medical profession. It is encouraging to hear the views of the noble Lord, Lord Hunter, and others, on the growing recognition among doctors that they should take the lead, through clinical audit and other forms of peer review, in ensuring that available resources are used where most needed.
The Government fully recognise the point that the noble Lord also made about the need for relevant and timely information if clinicians and others are to be able to reach properly-informed decisions about the services they provide. The noble Lord, Lord Hunter, and the noble Baroness. Lady Robson, raised this particular point on costs. The Government recognise the point they made. Action is in hand and more is planned. To try to get this information involves a long-term programme: there is the question of computers, which is a point that was particularly raised. We cannot hope to achieve this overnight, but the important thing is to start now and not to believe that because it is a difficult task it is not worth doing. We have already set in hand a good deal of work to help develop the general capability which is sought, for example, through the work being done on basic health service information needs by the group under the chairmanship of Mrs. Edith Körner, to which the noble Lord referred.
I am particularly pleased that the noble Lord, Lord Hunter, and others, placed such emphasis today on the importance of winning the hearts and minds of all those involved—particularly the doctors and nurses—in looking after patients and in bringing about this fundamental change in philosophy of health service management. The management inquiry team stressed that the greatest benefit to patients could result from management changes at unit level—and I cannot say often enough that this is what any change we introduce is all about.
I share the views expressed by those who have praised the health service, particularly the noble Baroness, Lady Gaitskell, and the compliments she paid to it. There is so much to praise about it, but nothing is perfect in this world; no one can sit back and say, "All is well; there is nothing more to be done." It would be arrogant and foolish to do so. There are many within the National Health Service itself who see scope for improvement and welcome the aims and objectives of the Griffiths Report.
Finally, I should like to thank all your Lordships for 1192 the many helpful points that have been made and, in particular, about the problems and complexities of achieving changes in management at unit level. These remarks will be studied with care and will provide a most useful contribution to the general debate which has been going on on the report's implications and on how to carry forward its recommendations. I am certain that my right honourable friend will study carefully the views expressed today and will take them into account in deciding what guidance he will issue to health authorities.
§ Lord Hunter of Newington
My Lords, I hoped at the start of this debate that most of the principal issues that will have to be looked at squarely would be looked at. I must congratulate all the speakers for contributing in the way that they have. Most of the main problems have been looked at—sometimes from widely differing points of view—but I hope the opportunity now exists elsewhere for this debate to be studied and for due weight to be given to the views that have been expressed by the experienced Members of your Lordships' House. I beg leave to withdraw my Motion for Papers.
§ Motion for Papers, by leave, withdrawn.