§ Motion made, and Question proposed, That this House do now adjourn.—/Mr. Boscawen.]9.37 am
§ The Secretary of State for Social Services (Mr.Norman Fowler)
This debate provides an opportunity for us to hear the views of the House on the report by Mr. Roy Griffiths and his colleagues on the management of the National Health Service. It also enables us to discuss the views expressed by the Select Committee on Social Services in its report on the same subject, and I am pleased to see the Chairman of that Select Committee, the hon. Member for Wolverhampton, North-East (Mrs. Short), in her place, as well as my parliamentary private secretary, my hon. Friend the Member for Eltham (Mr. Bottomley), who has temporarily left the Chamber, doubtless for good reasons after last night's elections.
I am grateful to the Select Committee for the speed with which it undertook its inquiry, as this has enabled a wider range of views to be presented and has made it possible for the Government to take full account of them without unduly delaying the timetable within which we wish to reach final conclusions on the report's recommendations.
In the same way that I have found it helpful to be able to consider the Select Committee's report and the evidence submitted to it, so I wish to listen to and consider the views which may be expressed in this debate. I do not intend, therefore, to announce final conclusions on the Griffiths report today. I expect to announce those and to publish my conclusions probably later this month. I shall publish those conclusions in guidance to health authorities and, at the same time, publish my formal response to the Select Committee.
I should remind the House, as I made clear when published the report last October, that there are certain basic issues on which I have always been, and remain, strongly inclined to support the Griffiths view. I shall later set out for the House what those issues are. But I wish first to say something of the context in which I believe the recommendations of the Griffiths team should be considered.
There is no question about the commitment of the public to the NHS. Health care is available on the basis of need. There is no doubt that the best clinical attention available within the NHS matches the highest standards in the world. The basic concept of a health service that is available to all and financed largely from direct taxation has proved itself over nearly 40 years. It has proved itself in the most fundamental way—by providing an everߝimproving service to its patients.
In the first 30 years of its existence, the number of inpatients treated in the Health Service doubled — to about 5.5 million a year. That record has continued to improve over the past five years. Since 1978 the number of inpatient and day cases has increased by half a million; 2.25 million more outpatient and emergency cases are being treated each year; and nearly half a million more people are being visited at home by health visitors and nurses.
Those facts demonstrate not only that the Government have continued to provide real growth in resources for the Health Service but that staff working in the Health Service 643 have been able to go on making more effective use of the resources available to them. We have seen, for instance, a steady reduction in the time which patients spend in hospital for acute treatment. We have seen dramatic increases in the availability of new treatments that can save lives or offer real improvements in the quality of life for patients: a 90 per cent. increase in the number of coronary artery bypass grafts; a 30 per cent. increase in total hip replacements; and a 50 per cent. increase in the number of kidney patients over the past five years. Those are symbols of the success of the Health Service—a Health Service that is treating more patients than ever before—but they are by no means the whole story.
The strong sense of pride that most people have in our Health Service is one of its great strengths: the public, patients, doctors, nurses and others providing care and managers all show a supportive loyalty to the service. Those same groups of people are united also in a less happy feeling: from their different viewpoints, they feel that there are many ways in which the service could, and should, work better. We have all had complaints from individual members of the public and from representative bodies. These should not be brushed aside. People using the Health Service sometimes feel that their individual needs are not really being met and that the service is being run not with them in mind but more to suit the purposes of the organisation.
People working in the service, whose dedication to their work is undoubted, do not always feel confident that the system allows them to care for patients in the way that they would wish or to ensure that the available resources are channelled where they are most needed. The Griffiths team encountered many doctors who felt frustrated in this way. Management themselves often feel frustrated by the system. That the service works so well in many places is a tribute to the quality of individual managers in the service, but the system can often be a recipe for inertia. Finally, Parliament, on behalf of the taxpayers who fund the service, needs reassurance that the £13 billion spent on the NHS in England is being used in the way that they want—in the best interests of patients and others using the service.
It is one of my major responsibilities as Secretary of State—indeed, it is the responsibility of any Secretary of State — to ensure that the Health Service runs as effectively as possible. We all know that it can work superbly in delivering services to patients, but we need to make sure that the whole organisation is dedicated to that end, and to ensuring that the best possible value is obtained from the resources provided for that purpose.
It is easy to see that in several important ways we are not getting the best value for money in all those areas. The programme of National Health Service scrutinies which I set in train a year ago, on the lines of those undertaken by Lord Rayner within central Government, has already demonstrated that several areas of Health Service activity could be organised and provided in a more cost-effective way. Each of the scrutinies, which were undertaken not by members of the Department of Health and Social Security but by officers of the NHS, has found scope for substantial savings without there being any adverse effect on the services provided.
We have had a scrutiny, for example, of the transport system which shows that, surely alone among transport 644 undertakings in the western world, the Health Service has more vehicles than people to drive them. The result is a large number of expensive vehicles standing idle. The hon. Member for Holborn and St. Pancras (Mr. Dobson), who used to speak on transport matters, will know that that is a unique way of running transport. Action in that area could save £15 million a year.
I do not believe that that is the lesson of the report. We have found that the NHS spends £8 million a year on advertising jobs in national newspapers and journals. Better management and accounting for non-emergency ambulance transport could save us about £9 million a year. That is by no means an exhaustive list, but it shows that there is scope for improving value for money inside the Health Service.
A concern to see the Health Service working more effectively is at the heart of the Government's approach to it. When we took office in 1979 we embarked, as we had promised, on the process of simplifying the organisational structure of the service. Having done that, we have been able to turn to the still more fundamental problem of helping to ensure that the Health Service will operate more effectively within that structure. Frankly, my view of the Health Service is that the debate about the formal superstructure of the Health Service — be it regions, districts or areas—has gone on for far too long and has absorbed too much of the energy of the people working in the service. We should move on from there. None of us wants another reorganisation. A continuing and sustained strategy for improving performance in the existing structure of the Health Service is needed.
The Griffiths report is a key element in that strategy, but it is not the only one. We have already taken a major step forward through the introduction of the annual accountability review system. That ensures that, at each level, those in charge are called to account for their performance and to set out their plans and objectives for the period ahead. Ministers carry out detailed discussions of the performance of each region with its chairman and his officers. In his turn, each regional chairman does the same with his districts. In each case, we identify objectives for the year ahead and for the longer term.
All those developments are important. But perhaps the most fundamental issue with which we must be concerned is that of how the Health Service works, how it gets things done, or, sometimes, fails to get things done. That is the issue which I asked Roy Griffiths and the other members of the management inquiry team to address.
I am grateful to the inquiry team not only for their report but for the speed with which it was completed and, unusual amongst Government reports, the brevity with which it was expressed. I am grateful to Mr. Griffiths. I am grateful also to the members of the team, Mr. Michael Bett and Mr. Jim Blyth, with their considerable management experience, and to Sir Brian Bailey, a former regional health authority chairman. The team devoted a great deal of time to its researches and was able to meet many people working at different levels throughout the Health Service. The team's report went straight to the heart of the question it was asked to examine.
I should like to remind the House of some of the key points that the Griffiths report made. First, and perhaps 645 most important, the report provided a welcome restatement of the principle that should guide anybody responsible for the Health Service — concern for the individual patient. The report reminded usIt … cannot be said too often that the National Health Service is about delivering services to people. It is not about organising systems for their own sake … the driving force behind our advice is the concern to secure . . . the best motivation for staff. As a caring, quality service, the NHS has to balance the interests of the patient, the community, the taxpayer and the employees.The report outlined a demanding programme of future management action for the Government and health authorities, but, significantly, it also endorsed the lines on which the Government are already working to make health authorities properly accountable for the performance of theservices that they provide. In particular, it wanted the system of accountability reviews to be extended and clarified so that it would operate at all levels down to hospital level and to individual units; better ways of budgeting — by introducing management budgets that clearly identify and bring into balance the input of resources and the output of services for people; better manpower control and planning; a clearer understanding by health authorities of what they are there to do and what they should demand of their officers; closer involvementof clinicians in management; and a clear responsibility placed on DHAs to find ways of improving the cost-effectiveness of all their services. But the most important single step that it though could be taken was to establish at all levels in the Health Service a clearly defined general management function.
As the House will know, I issued the Griffiths report for consultation with health authorities and key professional interests last November. I asked for comments by January so that we could get started on making changes as quickly as possible. Of course, when I learned of the Select Committee's decision to look at Griffiths, I decided that it would be right to await its report before going ahead with decisions on guidance. That has meant some delay in my original timetable, but the slight delay has brought considerable benefits. First, the Select Committee report in itself is a generally helpful contribution to the debate. I see that some members of the Select Committee, including the Chairman, are present today. They will speak for themselves on their own conclusions.
I do not interpret the report as a hostile document. Indeed, the Committee has provided, as I read it, clear confirmation that the basic Griffiths analysis of the Health Service management is right. Although it had reservations about some of the individual measures recommended by the team, the Select Committee said quite clearly:the general critique contained within the Report commands general assent.Secondly, and in many ways just as important, the Committee has provided many people and organisations with an opportunity to develop their reactions to the report in the valuable oral evidence sessions.
Several of the Griffiths report's recommendations tied in directly with action that the Government already had in hand. For example, the extension of the accountability review process to units was, and is, a natural development of its successful introduction at regional and district level. But it is undoubtedly the case that the question of the general management function has been seen both inside and outside the service as the key to the recommendations.
646 It epitomises the fundamental message coming from the report—the need for a more dynamic management style in the Health Service: getting things done, rather than waiting to be told.
The team's concept of the general management function — the responsibility, clearly vested in one person, for the planning, implementation and control of performance—is clearly of fundamental importance, and the need for it was already being demonstrated through the other initiatives that the Government had taken.
§ Mr.Ralph Howell (Norfolk, North)
I am pleased to hear that my right hon. Friend fully supports the idea of single-person management at unit level. Will he explain why, if he supports that and it is right, there should not be a chairman in overall executive charge of the NHS?
I think that my hon. Friend has argued his case before, and that he is arguing for an independent corporation. That would presuppose a fundamental difference between, for example, a nationalised industry and the NHS as it is organised and financed at the moment. The NHS is financed crucially by taxation, so to that extent it is incorrect to regard it as an independent, free-standing body. That is my initial reaction to what my hon. Friend has said. No doubt he will want to develop that argument in his speech.
The accountability review system enabled us to identify programmes of action that should be undertaken by regional health authorities and district health authorities, but it was far from clear that there was anyone below authority level with the responsibility for carrying through those programmes of action. Responsibility is diffused and spread between several officers. Ultimately, of course, the authority itself and, on its behalf, the chairman have that responsibility. But the members of authorities are appointed for their ability to contribute to broad strategic decisions on policy and priorities, and work on a part-time basis. Theirs should not be the prime executive responsibility for seeing that policies are implemented.
Equally, there are occasions when it is far from clear who is responsible for securing action. For example, we have now developed nationally some indicators of performance that allow health authorities to ask themselves basic questions about their efficiency in delivering the services that they provide—for example, whether they are expensive in terms of both money and staff time. But who has the manifest duty to ensure that those questions are asked and that, once they have been asked, effective action is taken to improve performance? Inevitably, if the question that has to be answered is why one hospital keeps a patient in for a hip operation twice as long on average as a similar hospital, or why the overall cost of running a service in one place is higher than running a similar service elsewhere, the responsibility for obtaining the answer or for changing local practice may not, at present, lie in one pair of hands. In that situation, at the moment, it is too easy for nothing to be done.
That danger is well illustrated by the NHS Rayner scrutinies to which I referred earlier. In several cases, the scrutineers found instances of slack local management that had persisted for many years. In other words, the diagnosis set out in the Rayner scrutinies that we have published and others that we shall publish in the near future is not new. The problem has been that no one has taken action in a situation that many have known to exist inside the NHS for many years.
647 Therefore, it is important in the areas that have been identified through the NHS scrutinies to ensure that action is taken. That is the crucial point of those scrutinies. Health authorities in which general management was effective would in any case be looking to tackle such issues without outside intervention.
When I issued the Griffiths report for consultation, I said that I accepted the broad thrust of its recommendations. That remains my view. I also said that I intended to implement the recommendations as far as they affected my Department. That I am doing. I have already established the health services supervisory board, which will bring together, under my chairmanship, the key people within the Department — both my ministerial colleagues and senior civil servants—to help me in setting the direction and policies for the NHS, and also outside people of the quality of Roy Griffiths, who has joined the board for that purpose.
In the course of consultation, I have received many representations. In particular, I have received many requests to include my chief nursing officer as a full-time member of the board. The Select Committee report made a specific recommendation to that effect. I have already told the Committee in my oral evidence that I was sympathetic to that proposal. The chief nursing officer has, in fact, been present at all the meetings of the supervisory board that have been held so far. I accept that nursing advice is a crucial component at that level of decision taking. Accordingly, as I told the Royal College of Nursing on Monday, I have decided that my chief nursing officer will be a full member of the board from now on.
I am also working towards the creation of an NHS management board within the Department under a full-time chairman to be recruited by open competition. The chairman, who will be appointed at second permanent secretary level, will have full-time responsibility for all the Department's work in relation to the management of the NHS—finance, personnel, service planning and so on. The process of recruiting the chairman of the management board is already under way. We are also preparing to appoint a personnel director to the management board, again from outside the Civil Service. That reflects the great importance which the Griffiths report attached to the personnel function and the need to review pay and industrial relations practices in the NHS. I expect that this post too will shortly be advertised.
I want the House to understand that, although these are new posts, they will not add to the total staff of the DHSS headquarters—a fear expressed by one or two members of the Select Committee. Offsetting savings will be made elsewhere. Indeed, I fully expect that the successful implementation of the Griffiths recommendations in the Department will enable me to make further reductions in headquarters staff numbers beyond the 20 per cent. reduction which has already taken place since 1979. I also expect the same principle to apply in the NHS. There should be no overall increase in staff because of the introduction of the general management function in the NHS, and I expect it to lead to real savings in due course.
Although the NHS management board cannot be fully established until the chairman has been appointed and we have been able to take his views on its structure and composition into account, I have already set in hand action 648 aimed to improve the way the Department carries out some of its management functions. As an interim measure, we have set up an NHS management group of the relevant senior staff to provide a better focus within the existing structure. We are also setting in hand a review of the communications passing between the Department and the various levels of the NHS to reduce the volume of such communications and to make sure that they have a clearer and better defined purpose. That review is being carried out by a senior Health Service administrator.
I should stress that none of these changes at the centre of the organisation will affect either my existing accountability to Parliament for the Health Service or Ministers' relationships with health authority chairmen. I know that there has been some concern about this, both in the Select Committee and in the Health Service. All the changes that I am setting in hand will be made within existing statutory arrangements. I should make clear that the two boards are within the Department and do not have any separate corporate status. There have also been fears that what we are doing will pave the way for increasing my Department's involvement in running the Health Service from the centre. Nothing could be further from the truth. The principal aims of the new arrangements are, first, to enable me, through my Department, to carry out my responsibilities for the management of the Health Service as effectively as possible; and, secondly, by providing a clear and coherent lead from the centre, to promote stronger local management capable of taking the decisions which only it can take, within the framework of policy and accountability which I have set.
§ Mr.Toby Jessel (Twickenham)
My right hon. Friend has referred to stronger local management. Earlier, he used the word "clinicians" when talking about the possibility of doctors having a say in what happens in the hospitals. The Select Committee also used the word "clinicians", but the Griffiths report used the word "doctors". Is there any significant difference in meaning, or could the general practitioners also have a say in the management of local community hospitals?
I do not think that the terminology implies any significant difference, but basically what we are concerned about is the management of the hospital service and the way in which consultants, in particular, can be incorporated into the management structure. I shall take up that point later.
My commitment to the approach of the Griffiths report is demonstrated by the action that I have already taken within my Department. But, for those changes to be fully effective, it is still more important that we should establish the general management function inside the NHS. I am firmly committed to that. The real issue is not whether we should do that, but how. The general management function is certainly a function that should be implemented. In parenthesis, let me say that there has been some confusion about what that function means.
In particular, there is sometimes thought to be a contrast or division between good management and consensus. I know that the Select Committee was concerned on that count. Consensus is vital to the management of any organisation. It is particularly vital in a multi-professional body such as the NHS where the objective of management is to enable professionals to provide better services to patients. There is no opposition between the two concepts.
649 A good manager, by definition, takes others with him. Decisions need to command the confidence of those who have to carry them through, if they are to be effective. We are talking about building on existing management arrangements—improving on the system established in 1974 and carried through in the 1982 reorganisation. We are not embarking on another major structural upheaval. We are moving forward in pursuit of our common aim to find the best management style to meet the needs and challenges of a modern health service. I know that concern has been expressed particularly by some doctors and nurses about what this implies for them. But there is no doubt that the role of professional chief officers and their participation in wider decision making will still be essential. Good general management requires that responsibility for ensuring that conflicts are resolved and that action flows from decisions will be clearly identified. That is the key: to focus management effort on the mobilisation of all resources within the organisation to best effect.
That does not mean, as I know some clinicians fear—I apologise to my hon. Friend for using that word—that management decisions will somehow place new constraints on existing clinical freedoms. Of course doctors and nurses will continue to make their own decisions about how they treat their patients. But equally it would be foolish to deny that there are practical constraints imposed on consultants in a world of necessarily limited resources. It is this situation which led the Griffiths team to urge the greater involvement of clinicians in management decisions. It is, in my view, clearly desirable that those chiefly responsible for providing care for patients should have a say in ensuring that resources are used where they are most needed.
Though I have views about the basic Griffiths concept of the establishment of a personal and viable responsibility for general management at all levels of the Health Service, there is room for discussion about how it should be implemented.
The purpose of the consultation in which we are engaged—and I hope that it will be the purpose of some of the speeches today—is to seek the advice of all those with an interest in how we can best introduce individual general managers into the Health Service. The many comments that we have received so far have helped greatly in clarifying areas where people feel that there will be problems and where they would welcome a lead from the centre.
My broad aim is to keep formal guidance to health authorities to a minimum, compatible with providing the service with a clear direction about what I expect to be done. That is what Griffiths is all about — a clear direction from the centre which requires authorities to make and account for their own proposals about how to meet the target. In framing my guidance on general managers, therefore, I shall give full recognition to the point made in the Griffiths report, and endorsed by the Social Services Select Committee, that health authorities should be given as much flexibility as possible in making their own management arrangements. For example, I am well aware that authorities wish to be given some latitude in the timing of the changes that they will be asked to make. The point has been made strongly that arrangements, especially at unit level, might take longer 650 to complete than at regional and district levels. I readily acknowledge that and will ensure that the guidance I issue will set realistic time scales.
§ Mr.Michael Meadowcroft (Leeds, West)
When telling us that health authorities will be given some flexibility in the timing of what they must implement, is it implicit in what the Secretary of State is telling us that they will have to implement some change? Is he now moving away from the extent of flexibility that he implied in reply to questions asked by the Select Committee?
No. I have already made it clear that I support the general thrust of the report. There should be some flexibility, and timing is simply one of the areas in which we shall allow it. Timing is one of the central points that has emerged from the consultations and it is at unit level that flexibility with timing is most required. I am glad to have the Select Committee's approval and support for my belief that local authorities should not go ahead with general managers on a pilot basis while others wait and see. There is a difference between flexibility and the pilot project idea which I know a few hon. Members might still argue in favour of.
I am less at one with the Committee, however, in its view that, because of the greater potential complexity of introducing general managers in some hospitals and units, we should not yet make a start in addressing the problems. The Griffiths report made the point that achieving changes at unit level was the fundamental purpose of the team's programme of recommended action. The primary objective for health authorities must be to achieve observable improvements at that level—in other words, improvements that the patient as well as management can see, in hospitals and in the community. If that is not achieved, there would be no point in making changes elsewhere in the system. Our intention is to build on the progress that we are already making, to secure better services for patients at the point at which they are delivered. That has been set firmly on the right path with the 1982 reorganisation and with the steps that we have since taken. The next step is to work towards introducing general managers in all of the various types of unit in hospitals and in the community.
The consultation has also opened up discussion about some of the practical issues involved in introducing general managers in the Health Service. In general, I would expect individual authorities to develop their own proposals to suit their circumstances, but there are some issues which may need to be settled centrally such as whether the general manager should be full time or part time. My preliminary view is that the general manager's task will normally need a full-time commitment, but I recognise that in some authorities and, especially at unit level, it might be possible to combine the general manager job with some other duties. That possibility is clearly important if clinicians are to be encouraged to take on the general manager task, as the Griffiths report recommended.
The report was, of course, strongly in favour of the greater involvement of all practising clinicians in the management of the Health Service. The point is to make sure that doctors and nurses and others whose day-to-day decisions about treatment and care of patients affect the way in which resources are used have a proper say in the management decisions which affect them. I recognise that 651 many of those professionals feel that that is difficult, first, because they do not wish to spend time away from patients and, secondly, because we are still at the early stages of providing the kind of relevant information that is needed in this respect. I do not think that the short-term difficulties should deter us from making a start, however, and I am sure that steps taken now to develop management information and to strengthen management training, especially for clinicians, will enhance the management potential already in the service and enable the professions to play a more active role in management, particularly at unit level.
Although I have not given the Government's final decision on the Griffiths report before the House has had the opportunity to express its view—I am sure that that is right—I hope to give our full response to that report and the Select Committee report later this month. I intend and hope then to issue guidance to health authorities.
The Griffiths report said—and the Select Committee accepted the argument—thatthere is no driving force seeking and accepting direct and personal responsibility for developing management plans, securing their implementation and monitoring actual achievement.That is one of the central messages of the report and our central objective is to remedy that problem so that the Health Service will be better equipped to get the best value from the resources provided for it in the interests of giving better care to patients.
§ Mr.Michael Meacher (Oldham, West)
From press comments on the Griffiths report, which have varied from euphoria to excoriation, it has been clear from the outset that at the heart of the issue surrounding the proposals is much less their content than the manner in which they might be implemented and the overall objectives that they might be adopted to serve. On that count it became important to know how and with what aims in mind the Secretary of State regarded the proposals being used. We looked forward to his speech as a statement of intent with more than usual interest. I can only say that we were disappointed, but perhaps no more than usual. Five months after forcing everyone into a rushed consultation process, the Government are still flopping about all over the place, even on fundamental issues, on how to handle the report.
I shall give just one example from the Secretary of State's speech. He was clearly trying to get the best of both worlds by saying that clinical freedom would not be interfered with or restricted and that general managers would exert a more restrictive control over resources. I do not think that it is unfair to paraphrase that part of his speech in that way. Those two attitudes are fundamentally irreconcilable and for them to be delivered one after the other without explanation is not good enough.
The Secretary of State had several important questions to answer, but he answered almost none of them. First, why the rush? Local authorities and other interested bodies were given just six weeks—
§ Mr. Fowler
With great respect, the hon. Gentleman cannot have it both ways. He started his speech by accusing me of great delay. He is now accusing me of a great rush. The hon. Gentleman had better answer the 652 question: did he or did he not want me to wait for the Select Committee's report on social services before coming to decisions and listening to the debate in the House? Surely the House of Commons would want decisions to be taken in that way. If the hon. Gentleman does not want decisions to be taken in that way, let him say so.
I was not suggesting that there was a great delay and then a great rush. I was suggesting that consultation was undertaken in an unnecessarily rushed way and that therefore the Government were not taking the matter seriously. I suspect that were it not for the excellent Select Committee report of my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) we would not be having this debate today. We would have had a much more rapid and unthought-through introduction of the report's proposals. That is what I object to. Health authorities and other interested bodies were given just six weeks, including Christmas and the new year, to consider, discuss and comment on what is, despite what the Secretary of State said, yet another major reorganisational upheaval in the NHS. I know that he denied that, but that is undoubtedly what it represents. Perhaps the Secretary of State will comment on that.
Moreover, the Government could not have signalled more clearly how perfunctorily they regard the consultation process than when they decided to accept the proposals for the health service supervisory board —incidentally, the chief nursing officer was not a member of that board, although I am glad to say that that has now been reversed—and an NHS management board with no public discussion of those extremely important innovations.
Secondly, why are the Government so unnaturally anxious to embrace a new management structure for the NHS which in large part overturns their previous long-held policy, which was reiterated yet again only recently? It is only two years since the last Tory restructuring — a development dictated by the chaos and confusion created by their previous reorganisation in the early 1970s. We are always hearing from the Tory party about the need for steadiness and stability in industrial and economic policy, yet here they are overthrowing the previous Health Service structure even before all the new appointments under it have been completed.
In "Patients First", a document on which the 1982 reorganisation was based, the Government explicitly rejected the idea of a chief executive. Page 7, paragraph 11 of that report, says that the Governmentbelieves that such an appointment would not be compatible with the professional independence required by the wide range of staff employed in the Service. Instead, each authority should appoint a team to co-ordinate all the health service authorities of the district".Amen to that. Nothing could surely be much clearer that that.
Why have the Government now decided so soon after that statement only two years ago to throw the service into a fresh organisational turmoil? Why have the Government changed their mind so easily? Nothing that the Secretary of State has said today answered those questions. Why is he proceeding, have made such a change with such inordinate haste?
§ Dr.Brian Mawhinney (Peterborough)
I am interested in the hon. Gentleman's theological aside. He read from 653 "Patients First". He talked about the team approach and the lack of a chief executive. Then he said, "Amen to that." "Amen" means so be it, or so let it be. Is the House to deduce from that that he is now committing the Labour party, if it should ever get back into government, to undoing the thrust of the Griffiths report and going back to what we presently have?
The hon. Gentleman certainly has more knowledge of theological derivation than I. I am saying that the case against consensus management, which was made excellently by the Government two years ago, has never been properly made out. There is a great deal of anecdotal evidence, a little of which has been repeated by the Secretary of State today, but there has been no considered refutation of the merits of a system that has lasted for a long time. Indeed, the Griffiths report contains no rejection, on the merits of the case, of the principle of consensus management. Clearly, on that basis, we shall have to wait and see, and that is an important part of what we are saying. We want to know exactly what the Government will do, and how. In the light of that we do not believe that consensus management should be thrown over. First, we are doubtful whether it will be, but if it is we shall certainly consider reintroducing it.
After the initial courtesies, perhaps we can come to the real meat of the matter. It is clear beyound doubt to us that the Griffiths report is primarily about centralisation of control — whether in the hands of the Secretary of State's right hand man, the chairman of the NHS management board, the new personnel director or the general managers at authority or unit level. That message comes over loud and clear to anyone who reads the report. Centralisation is in, democracy is out.
The same signal comes through in other ways, too, from the enforcement of the chairmen's role at regional and district level—both Secretary of State appointments—the consequent downgrading of the role of RHA and DHA members, and also, ominously, from the speeding up and so-called simplification of consultation procedures. It is the same principle that is now being implemented, outside the Griffiths proposals, in the Health and Social Security Bill, in the hiving off of the family practitioner committees, the waiving of any pretence of democratic or consultative selection of their members, and the concentration of direct appointment, not only of the new chairmen, but of all the 30 members in each case—about 2,800 new appointments—all in the hands of the Secretary of State. The same trend is already apparent in the 1982 reorganisation, with the reduced level of local authority representation on the health authorities and the Government's constant threats to the existence of community health councils, where central funding has now been cut.
All those proposals are united in one main theme—the dangerous potential that they imply of increasing the power of the Secretary of State at the expense of local community representatives and professionals within the service. That is one of our central criticisms of the Griffiths proposals. They extend to the NHS the same disturbing centralisation, the new Tory authoritarianism, which is so alarmingly manifest in other areas of the Government's policies, from abolishing trade unions at GCHQ to the abolition of the GLC and the metropolitan counties, from rate-capping the councils to the extinguishment of the metropolitan elections. The same 654 underlying trend runs through all those measures — an anti-democratic bias and the consolidation of a centralist state to an unprecedented degree, contrary to all British historical traditions. It is the resonance of that in these measures and in the Secretary of State's speech today that we so strongly oppose.
We are disturbed that the whole tenor of Griffiths—again the Secretary of State echoed this strongly today—is how to run the NHS on fewer resources. Let me make it clear that nobody is suggesting that resources are unlimited—of course they are—but it is equally wrong to suggest that the NHS is now adequately funded and that it is simply, as the Government repeatedly like to try to make out, a matter of extracting better value for money. The fact is that the NHS already gives excellent value for money. It is probably better than any other health care system in the Western world and, although the Government do not often repeat this, it has the lowest administrative costs of any comparable Western health care system. On OECD figures, it is 2.5p in the pound in the United Kingdom, compared with 5p in West Germany, 5.5p in the United States and 11p in France.
The fundamental problem with the NHS is that it is underfunded. We still spend only 5.5 per cent. of our GNP on health care, compared with 6 to 8 per cent. in the European Community, 9 per cent. in Sweden and 9.5 per cent. in the United States. The scale of that underspend can be illustrated by saying that if we spent the same proportion of our GNP on health care as the United States does, our budget would be increased by £11.5 billion.
I repeat, and I am sure the Government want me to say it, that we should, by all means, try to improve the management process and general cost consciousness within the NHS. We should be constantly vigilant and disciplined to do that, but let the Government not try to pretend that that is all that is wrong with the NHS, or that that is even mainly what is wrong with it. It is not.
However good the management, one cannot get a quart out of a pint pot. Other problems in the NHS are much more demanding, including the deteriorating capital stock in so many of our hospitals and other institutions, the regional imbalance in the service, the class inequalities in the delivery of health care and the need for a major buildup of community health care on the basis of identified need in each locality.
None of those is primarily a management problem. All would cost considerable sums of money to resolve. But it is not true to say that the money is not available and that we must therefore go down the Griffiths route of getting better management out of fewer resources.
As long as the Government spend £10 billion on Trident as a new and unnecessary nuclear weapons system, fritter away £17 billion a year on keeping 4 million people unemployed, make massive tax handouts to the rich, cumulatively valued by the Government at £13 billion since 1979, and stick to such ill—advised and obnoxious priorities, the deflection from the real issues of the NHS, which the Griffiths report in part represents, can be seen for the head-in-the-sand diversionary exercise that it is.
It is because of that background that we are so suspicious of the general tenor of the Griffiths report, which says, for example, that the main task of regional and district chairmen isto initiate major cost improvement programmes for implementation by general managers.655 If that is not a euphemism for cuts, I do not know what is.
It is because we suspect that the real message of the report has less to do with management than with the use of Secretary of State appointees at every level of the NHS to batten down the financial hatches—now that Binder Hamlyn and cash ceilings have had to be shelved—or to force through privatisation which would otherwise be so strongly resisted, that we are so sceptical about and distrustful of the Government's motives in rushing through this latest upheaval which is contrary to their earlier assertions about the need for consensus management and team work.
The overturning of consensus management and the adoption of general managers are central to the report. Anyone who read the report or listened to the Secretary of State's speech would agree that there was great uncertainty, both in the report and in the Secretary of State's opaque references to the Select Committee, about the exact role of general managers.
We were not enlightened today, which is surprising and alarming, considering that such a major reorganisation is imminent and it is based on such vague, sloppy and even inconsistent thinking in a number of cases.
It is time that the Secretary of State gave us some straight answers to some direct questions. Will general managers have the power to become autocratic bosses, which is clearly what the BMA fears, or will they just be high-powered co-ordinators
We must also consider the question of sanctions. If non-medical administrators are appointed at regional and district levels, will they enforce their way, in the event of a dispute, through their ultimate control over resources? Would that not be a recipe for conflict with senior medical and consultant staff? How else will they settle a dispute? Will they, more modestly, act as a sort of tie breaker in the event of deadlock, as in the German Mitbestimmung system? Perhaps they will act as a sort of high-level chairman, with increased powers to resolve disputes and knock heads together. Those are major differences of concept and it is astonishing and worrying that the Government have not given clear answers about those concepts.
There is also uncertainty about whether the job of general manager could be seen to be—as it is in some quarters—a part-time function, or whether it represents a major new and separate purpose. Is the appointee to be only a nominal general manager? Will a member of the district management team be appointed general manager, while retaining his existing functions as an administrator, medical officer or whatever? I suspect that many in the BMA would prefer that system. However, an alternative is that the general manager will be a supernumerary and will be replaced in his previous post by a fresh appointee.
I suspect that it may be in Mr. Griffiths' mind, though I am not sure what the Secretary of State thinks, that the intended model is that the district management team should become an executive board, with a chief executive officer and a distribution of responsibilities based on management functions rather than professional position.
In a management reorganisation those are fundamental differences of approach and it is staggering that no clear sign has been given by the Government of which approach is favoured. We seem to be presented with an 656 organisational overhaul that means all things to all people. That is certainly how I interpreted the Secretary of State's speech. Contrary to his declared aspirations, that is not flexibility; it is rudderless drift, which is not good enough.
§ Mr.Roy Galley (Halifax)
If the Secretary of State had come to the House with clear and firm decisions about what he intended to do, without consulting Parliament, would the hon. Member for Oldham, West (Mr. Meacher) have welcomed that? That seems to be the drift of his remarks.
The Government rushed the consultation process through in six weeks over a holiday period and I certainly expected that five and a half months later we would have a much clearer sign of the general thrust of the Secretary of State's thinking.
The hon. Gentleman must stop repeating this total rubbish about rushing the consultation through in six weeks. He knows that it has gone on for much longer than that and that I announced that it has been extended. The hon. Gentleman is deliberately seeking to mislead and to make mischief, and it is not in anyone's interests that he should seek to do so.
Mr.Deputy Speaker(Mr.Harold Walker)
Order. Mr. Speaker has recently ruled that hon. Members, no matter how distinguished, should not accuse other hon. Members of deliberately misleading the House. I hope that the Secretary of State will withdraw that remark.
To judge from his language, the Secretary of State is clearly very disturbed. If the consultation period was supposed to go on for six months, why did he end it after six weeks, on 9 January? The fact is that this debate is being held now only because of the attention that my hon. Friend the Member for Wolverhampton, North-East and the Select Committee have drawn to the report.
That was a rather embarrassing intervention for the Secretary of State, because he was suggesting that the consultation period had gone on for much longer than that. To spend six weeks on a major and fundamental reorganisation is rushing things through precipitately, and is quite unreasonable. However, I shall not spend any more time on that point.
I come to the important question of the relationship with clinical freedom. Griffiths seems to take the view that clinicians—I am also quite happy to use that word—should be more involved in the management process, consistent with clinical freedom for clinical practice, but is there not a fundamental contradiction between a commercial attitude towards running the NHS and the continuation of professional freedom of action, which would not be tolerated anywhere in the private sector? Others have read the Griffiths report in a quite different way and have seen it as involving the key flaw that, in 657 relation to clinical freedom, the general manager will be something of a toothless tiger. Again, that only illustrates the point that there is general uncertainty as to the thrust of the report and the way in which it might be implemented. We have still not received any clear answers on that today.
Surely the fact that such irreconcilable conclusions can be drawn from the same report is a little unnerving. To take up the theological point of, I think, the hon. Member for Peterborough (Dr. Mawhinney), theologians always used to say that the fact that the concept of the Holy Trinity was riddled with internal contradiction was somehow proof of its validity. Whatever the facts about the Holy Trinity, I am certain that the same criterion does not apply to the concept of management in the NHS. If there are genuinely contradictory views, it must be because the proposals have not been properly thought through, or are so conceptually malleable as to be a blueprint for anything. That is hardly the spirit in which to enter upon yet another major organisational upheaval.
These questions are all the more important because, after the initial enthusiasm, such a widespread tide of criticism has built up—as we have all seen—in the past few months. In particular, there has been strong criticism that, whatever may be decided at regional and district level, it would not be appropriate to appoint general managers at the unit level. I think that the Secretary of State failed to touch on that point today, although it is important and we need clarification. Perhaps the Minister will respond to it later.
The potential for conflict at unit level is much greater than any at other level. It is doubtful whether the full consequences in this case were fully recognised by Griffiths. That is also the Select Committee's view. Indeed, I pay a warm and sincere tribute to its report. Much has been written and published about Griffiths. I suppose that Griffithsana is one of the few thriving industries left in Britain. However, no assessment has achieved such a balanced and trenchant analysis of the report as that of the Select Committee, and I very warmly congratulate my hon. Friend the Member for Wolverhampton, North-East and all the members of her Committee on a very valuable statement to the House. Although I differ about the odd detail—for example, the location of consultant contracts should not be put under permanent review, but should be fixed unequivocally at district rather than regional level—I believe that the Select Committee got things broadly right, and certainly more correct than anyone else.
In that spirit, I commend, in particular, the Select Committee's conclusions on the general management function. It proposes—and it uses very weighty words—that the regional and district health authorities should be obliged to check, in regular accountability reviews, how the general management function is being performed and to show that it is being performed from within the previously existing administrative budget. The Committee insists that the Secretary of State should provide "specific guidance" on the relationship of the general manager to team members, other bodies and to other staff groups, and should also clarify his intentions regarding the personnel director and the future of nursing management, as well as resolving the contradictions that are clearly apparent in functional management at district and regional levels.
I very much endorse those considered views. One has only to state them and to outline what needs to be done to 658 lay bare how skimpy and how far short of requirements the Government's response has been. I accept that the Secretary of State says that this is merely an interim statement, but we are putting down a very clear marker as to the nature of the response that we expect from him at the end of the month, or whenever. The fact is that consensus management is under fire in Britain, although the case against it has never been properly made out either in the Griffiths report or elsewhere, except perhaps anecdotally.
We recognise, and the Government previously appeared to accept, that effective patient care in the NHS depends on team work among a wide range of professionals. Griffiths and, in particular, the Government appear to be more concerned with getting the quick rather than the right decision. We believe that there is a real danger of the proposals upsetting that vital teamwork on which the care of the patient properly depends.
There are times when the mentality of Sainsbury Man obtrudes. I shall quote just one instance of that from the Select Committee report. Mr. Griffiths said:there are quite a lot of areas where one can see . . . that moving things either into the general practitioner territory or into the hospital would in fact give better value. I am not simply talking in economic terms, but total service value.The Chairman asked:
By 'things' do you mean patients? They are what doctors treat.Mr.Griffiths replied, "Yes, indeed." I am not suggesting that Mr. Griffiths is always quite so mechanistic—I take his report much more seriously than that—but it would be extremely inadvisable to swallow his report whole and to implement it precipitately without far more careful testing of its implications in practice.
In particular, it would be quite wrong to go ahead with such a radical restructuring nationwide until the evaluation studies of the six experiments undertaken are published and publicly debated. The Secretary of State knows that I have twice sought to get the Government to do that, but they have resolutely refused to do so. If, as I suspect, no proper experiment has been conducted as yet, it would be quite wrong to go ahead until it has been undertaken and the results have been evaluated and made public. Unless and until either of those things is done, rushed implementation will not be a creditable act of radicalism but, far more, an abrupt and unpredictable imposition of dogma.
For those reasons, and because of the sheer open-endedness of the report, where everything depends on exactly how each item is applied, we reject the initial euphoria that greeted it as wholly misplaced and insist that the Government now have a duty—which which they have patently failed in today—to unveil their intentions so that further uncertainty for the Health Sevice is avoided. Then, and only then, can we make a definite judgment on the only proper basis of the strict merits of each proposal.
Order. Clearly many hon. Members are seeking to take part in the debate. The shorter the speeches the fewer the hon. Members who will be disappointed.
§ Mr.David Crouch (Canterbury)
I have seen the National Health Service at work personally for nearly 15 years. I have worked in the Health Service since 1970 and 659 through the major changes that occurred in 1974 and in 1982. I have not seen the Health Service from Alexander Fleming house—that is my disappointment—but I have seen it from on the spot, among the administrators, the treasurers, medical officers, nursing officers and works officers. I have worked with the rest of the staff—the doctors, consultants, nurses, ancillary staff and ambulancemen. I have also seen the NHS from the patients' point of view and from inside hospitals.
I do not think that the Griffiths report is the greatest thing since sliced bread or Sainsburys, but that is not to say that I do not agree with the report's conclusions. The report is not an in-depth study of the Health Service; it is little more than a cursory look at how management decisions are made.
Griffiths was clearly not impressed with what he saw. In a sentence, he could not find the boss. He found no managing directors—and Mr. Griffiths is a managing director. In short, in his concise report, he recommends that we appoint such people to work throughout the National Health Service. The difference is that he calls them general managers. I am glad that he does, because there is a great difference between a general manager and a managing director. Griffiths acknowledges that difference. He is not light on the subject.
What is meant by a general manager? He is certainly not a managing director: Why is he not meant to be a managing director? I have studied closely the Griffiths and Select Committee reports. Presumably Mr. Griffiths accepted the need for some consensus management to continue. At the same time, he said that he wanted a better management dynamic.
What was Griffiths looking for? — a single boss. What sort of boss? He said that he should not be a 19th century ironmaster. That is fine, but who will the person be? Where will he or she come from? Will it be from within the service, from among existing management teams, or recruited from outside? I have come to the conclusion that general managers are expected to emerge from within existing managements, but I wonder what the result would be.
I suggest that the person to emerge will have the most obvious qualities of leadership. If such a person already exists within the team of management, that character will be turned into a general manager overnight by statute. Will the result be any different from what happens at present? If that character had obvious leadership qualities and was leading a team of officers at district or regional level before he emerged, the danger is that things might go on just as they are. Everything might be as before.
I was glad to hear the Secretary of State emphasise that the general manager should be a full-time appointment so far as possible. I realise why he has left that open because it may be right for the general manager not to be full time if, for instance, he comes from a medical discipline and is a doctor or consultant. The Secretary of State today cleared up a major uncertainty in Griffiths. We are grateful to him.
I sense a danger in accepting the idea of general managers as the treatment to cure the National Health Service of its present sickness. The likely side effects could be serious and could even lead to stopping the treatment to let the patient recover. We are not talking about a wholesale reform of the National Health Service.
660 As my right hon. Friend said, it is not a major structural upheaval, but an adjustment of management responsibilities.
Griffiths was clear about what he was looking for. He wanted someone—one person—to make up his mind and take decisions. He did not, however, tear up the idea of consensus management. He was wise about it and spoke of harnessing the best of consensus management. He said that the general manager would base his decisions on a consensus rather than act like a 19th century ironmaster. That is fine. Griffiths is clear on that matter. That is what is good about the report. Of course, the general manager must listen, take advice, consult and be accessible, but he must be prepared to take decisions.
Our reflections about Griffiths are in the Select Committee report for the House to study. We had a valuable opportunity in Committee, and we made a thorough study of the problems that Griffiths raised. We had to work fast and produce the report fairly quickly.
I am concerned that there is a lack of clarity about the general manager's exact position. Nothing could be worse at the start of a general change in management structure than for us and district and regional health authorities not to know exactly what is expected of the general manager. We must establish the general manager for what he—or she—is. We must not leave anyone in any doubt about who he is and what is expected of him.
Wherever he or she comes from, I believe that the general manager should be separate from the team of officers. He or she should be above them and seen to be so. In that way, it will be clearly seen that there is a general manager above the rest to whom the staff can go and to whom they can give advice and can consult. Those are the thoughts of one of a team of officers. The general manager must consult, listen and take advice. He must also inspire confidence in all those under him. I repeat that he must be separate from the administration, finance, medical, nursing and works departments and from their demands. He must be distinct and separate.
If the general manager is appointed from any of the departments and has to do two jobs—that of general manager and administrator, finance officer or medical officer—we should not move from where we are now. If the general manager wears two hats, we should end up with an unsatisfactory hotch-potch. I ask the Secretary of State to leave no doubt in the minds of the health authorities about exactly what is expected of a general manager. As matters stand, the position is not clear. It is a little too relaxed—a little too flexible.
§ Mrs.Renée Short (Wolverhampton, North-East)
I am pleased to have the opportunity to debate Griffiths and the Select Committee's response to his report. I am pleased to see seven members of the Select Committee apart from myself in the Chamber hoping to take part. I apologise if my speech is a little long, but I hope that some latitude will be allowed the Chairman of the Select Committee, because such a range of aspects of the reports must be put to the House. The only regret that I have about being here today is that I was not able to go to my local count last night to cheer on my colleagues — who achieved a larger majority, I am pleased to say.
It is always fascinating to see how initial enthusiasm for certain proposals and lines of action fade after close examination. The idea of a chief executive to run the 661 Health Service has been suggested and discarded several times. In 1978 the suggestion was made by Jacques, and in 1979 by Kogan for the Royal Commission. It was discussed in "Patients First" and rejected by the Government. One thought then that the matter had been disposed of once and for all.
Two major reorganisations have taken place during the past decade without producing chief executive officers. Even though the Bains report had stimulated discussion about chief executive officers in local government, that was not translated to the NHS. The Griffiths report has resurrected the idea. It has been interesting to note how the professional bodies, which were initially quite enthusiastic, discarded the idea when they realised that a general manager at regional, district and unit level would overturn consensus management, which, in spite of its problems, is working reasonably well, though certainly there is room for improvement.
The British Medical Association, the Royal College of Nursing, the Association of Health Service Treasurers, the National Union of Public Employees and the TUC all supported consensus management as being the only appropriate management for the NHS.
The House expects the Secretary of State to inform it of the cost of replacing present officers who may be identified as general managers. Presumably their present work will have to continue. If each regional and district authority had to replace whoever was identified as a general manager, it would cost between £3 million and £4 million. If that process was carried out at unit level, the cost could be four times as much. If nominal general managers are suggested as a cheap solution, that would be disastrous and clearly would not improve the present position. The Secretary of State rather skidded around the question of costs. Perhaps the Minister will give some thought to it before he replies to the debate. There are a number of points that I would like him to consider before he replies.
It is fair to say that the proposed general managers will come from within the existing establishment. How can we find £20,000 for a general manager in each district, and funds for unit general managers also, presumably at a cost of between £10,000 and £15,000—I do not know what scale of salary the Department has in mind. In a typical district, it will cost about £100,000 to provide managers at those levels—and that is without the supporting staff of secretaries, clerical workers and so on. It will be a considerable amount of money to find if the Secretary of State will not increase the sum to meet the costs of administering the NHS. Which present costs within the Service will be used to finance the new management costs? Will the Department fund health authorities to pay for the administrative posts? Will it instruct health authorities to fund general management within existing management costs? On team management, we still have no idea of the future role of the district management of nurses or of the medical team members who, I suppose, will be general practitioners, consultants and district medical officers. That point needs to be clarified.
A fundamental critique of Griffiths arises from the lack of serious investigation into the management of the NHS before conclusions were reached. I do not think that Griffiths would do that in his own business. He would have a clear insight into the problems and would be keen to 662 ensure that the utmost economy was used to remedy them. That is a major reason why the Select Committee had to produce a detailed report.
None of the Select Committee witnesses showed a great deal of enthusiasm for the report, although many accepted that better management generally would benefit the NHS. They do not agree with the solution offered. They said that management should be crisper and more effective and that it should not and could not be obtained through the mandatory appointment of managers at every level.
The Select Committee decided to call for a broad range of evidence from the BMA, the Royal College of Nursing, the Royal College of Midwives, the Health Visitors Association, the Institute of Health Service Administrators, the AHST and the TUC health services committee. It also called to give evidence regional chairmen and the Nuffield Institute and heard Mr. Griffiths, Sir Brian Bailey, the Secretary of State and his permanent secretary. It was a good cross-section of responsible and reasonable opinion from bodies and individuals involved in the administration of the NHS. The Committee also had the benefit of several academic memoranda on the report. Individual health authorities sent their views to the Secretary of State, and they should be available to the House at some stage. We are grateful to all those who helped us during the inquiry.
The Committee felt that a major problem for Mr. Griffiths and his team was a lack of real understanding of the NHS. It is a rather peculiar and complex creature to administer, but it is not concerned with profits and objects. It is a large and immensely diversified organisation that employs many well trained, highly motivated individuals who may not have anything to do with management in the sense understood by Griffiths.
Senior consultants heading their teams may well be below management level, but are still independent in their use of resources and are not accountable to unit management for their clinical decisions. Across the whole spectrum of professions and specialties within the NHS responsible for patient care there are people who make decisions and contribute to this complicated business working as a team, exercising their professional and technical skills in a way that is without parallel in any aspect of our society. Therefore, it is difficult to introduce into the NHS the industrial idea of general managers.
I urge hon. Members to study paragraph 61 of the report. It reveals the tip of the iceberg of the complexity of the NHS. With respect to Mr. Griffiths, the NHS is not only doctors and patients. He just about managed to refer to nurses—of whom there are 500,000—but many other people are involved. His report would call them functional.
It is important to recognise that directors of nursing services are to be responsible to a unit general manager. Mr. Jones of NUPE told the Committee:
The Service has been through this. We did have a situation years ago when we had medical superintendents who were powers and laws unto themselves. God help us from having that again.The same thought must be in the minds of many others working in the NHS, and the Secretary of State must take account of those anxieties when implementing the report.
Closely connected with the question of functional management is the question of clinicians. They made their view clear to the Select Committee. Will they be willing either to be told what to do by a general manager or to 663 become more involved in general management themselves? If they become more involved, that takes time and energy from patient care, which is their main concern. I do not believe that they want to become involved in general management. Clinicians are perhaps more willing than in the past to be cost-conscious, but they want to carry out their professional work.
The NHS management board, chaired by a strong chairman from outside the NHS or Civil Service, with a personnel director and others responsible for finance, works and technology, would be answerable to a supervisory board chaired by the Secretary of State and including the Minister for Health, the permanent secretary, the chief medical officer, the chairman of the new managerial board and two or three non-executive members.
In spite of that, the Secretary of State hopes that his relationship with regional chairmen will remain unchanged and says that there will be the same access to Ministers as there is now—they were worried about that—so they will not be responsible to the management board, although their directives will come from it. One can see that problems could arise from that. The Secretary of State will need to clarify this complicated part of the relationships.
The Secretary of State believes that the parliamentary power to question him about the NHS will remain unchanged, although the report says that there will be less ministerial intervention and thatthe requirement for central, isolated initiatives should disappear once a coherent manpower process is established.As the King's Fund put it:
The Secretary of State will have to be scrupulous not to intervene . . . however much he may be tempted to do so".The Nuffield centre said:
the need will necessarily arise from time to time for him to intervene for legitimate political reasons in the various levels of management.Parliament will be concerned, because Parliament votes the money.
The role of authority members remains far from clear—from the optimism of Griffiths that nothing will diminish their role, to the fear expressed by chairmen and members. That shows the dilemma that they face, and it is clear that conscious efforts will have to be made to redefine and ensure a proper role for them. As we point out in paragraphs 26 to 30 of the report, there is a strong feeling that authority members are too often overlooked and that general management business will move them further away from their statutory responsibility for the provision of health services. The Government must admit that the Griffiths report appears to lay undue emphasis on chairmen. It will be chairmen who will be responsible for identifying general managers, encouraging management budgeting and so on, but the members will be discouraged if they are to become mere rubber stamps for what has already been agreed elsewhere.
Management budgeting will be a major task of the new management board. Where will responsibility for hospital hotel services, for pharmacy, nursing and radiography lie? The Royal College of Nursing was concerned about the clinical unit budget including nursing costs, but with the director of nursing services retaining management responsibility for nursing. The BMA and the IHSA expressed the view that clinical budgeting at unit level should be tried out and carefully discussed with medical 664 and other disciplines first. The Select Committee urges careful evaluation of the four management budget trials being held in Basingstoke, North Tees, Southmead and Ealing, with full consultations with all the professional bodies. It would be extremely imprudent to race ahead too fast. I hope that the Secretary of State will feel able—although it may not be his inclination—to look at these budget trials first, evaluate them and discuss them carefully before any further steps are taken.
The medical profession is aware that management budgets raise the spectre of clinical freedom, and there are implications of the cost of more sophisticated financial information systems to control their budgeting and the staff to operate it. The strong opposition of nursing bodies and others to the report stems from the fear that Griffiths proposed separation of management and professional responsibilities, especially an end to nurses' management at district and regional level. For example, the Royal College of Nursing saw the director of nursing services reporting to a unit general manager, instead of to the district nursing officer, with the district nursing manager becomingsimply an advisor to the district general manager.It is concerned about that.
The Secretary of State must make his views clear on the future of district functional management, including nurses' management. The nursing bodies insist that the chief nursing officer should be a member of the supervisory board, which the Secretary of State has conceded. We are pleased about that, as I am sure the nurses will be. I do not think, and this was the view of the Select Committee, that the Secretary of State will find it all that easy to reconcile the proposals with the strong body of opinion opposed to them. The Select Committee recommends the postponement of any general management function at unit level until reviews at higher levels are completed, although that should not prevent district management from accepting and acting on the need for more effective management at unit level.
The BMA, the RCN and the National Association of Health Authorities all proposed that there should be pilot projects to see how the Griffiths management proposals work in practice. The Health Service management centre at Birmingham university made a similar proposal, but those professionals and others who are so suspicious now are hardly likely to be persuaded, and this will merely cause more uncertainty about the future.
The Secretary of State told the Select Committee that"the maximum flexibility to suit local circumstances seems a more sensible way to go.I hope that that will be the guiding principle. We agree with that and, as there is clearly no single solution for the whole of the NHS, the Secretary of State has plenty of scope to be flexible. He could let the whole matter drop and be satisfied with the stimulus to self-examination and better efficiency that has been given by the report to the NHS. All the bodies, professional and others, have been looking at this. It is clear that better management could be achieved within the present system, especially if team chairmen took all this on board, but the Griffiths proposals will mean another upheaval, and I doubt whether that is what the NHS and patients need.
When the present Secretary of State for the Environment was Secretary of State for Social Services he said in "Patients First":
665We are determined to see that as many decisions as possible are taken at the local level — in this hospital and in the community. We are determined to have more local authorities, whose members will be encouraged to manage the service with the minimum of interference by any central authority, whether at region or in central government departments.I should have thought that that was the general view expressed by the Select Committee and the bodies concerned in the running of the NHS. I hope that the Secretary of State will proceed with great caution.
§ Dr.Brian Mawhinney (Peterborough)
Not every Government consultation paper gets debated in the House, so I begin by thanking my right hon. Friends the Leader of the House and the Secretary of State for Social Services for the input that they have made in allowing us to debate the report. I also thank my right hon. Friend the Secretary of State for the fact that he has not yet made all his decisions and is allowing hon. Members to contribute to the consultation process before he finally makes up his mind.
I welcome the Griffiths suggestion, already implemented by my right hon. Friend, to have a management board within his Department. I know that he and my right hon. and learned Friend the Minister for Health, and their predecessors, have worked hard to improve the effectiveness and efficiency of the Department. That has taken place, and we pay tribute to them for that. Even if they are not in a position to say so, I suspect that others could say that there is still room for improvement. I am sure that the management board will be effective in that it will make the work of the Department more sensitive and responsive.
I have one example of what I have in mind. I remember the last meeting that I attended as a member of the Medical Research Council, in which we approved minutes of a meeting that had taken place eight months before, only to learn that the minutes had come not from the MRC but from the DHSS. My hon. Friend the Member for Canterbury (Mr. Crouch) will be interested to know that, needless to say, the administration of the MRC was not especially disturbed by the time lag, either.
I am sure that the management board will be able to help in communications between the DHSS and the district and regional health authorities. Right hon. and hon. Members hear repeated complaints about the amount of information—sometimes conflicting information—which is put out.
I welcome the concept of the general manager, and perhaps I may be allowed to discuss briefly the idea of consensus. The hon. Member for Oldham, West (Mr. Meacher) made a point about consensus management. In one sense he was right. Anyone running a hospital, which is by definition a co-operative venture, knows that there has to be a degree of consensus. There has to be a meshing of the various disciplines for the benefit of the patient. In that sense consensus will always be part of the treatment of patients.
That is not quite the issue. The issue is consensus management. The need to work with professional staff is beyond doubt. However, I have to ask the hon. Gentleman whether consensus in that form is effective management. I say this also to my hon. Friend the Member for Canterbury. Management involves not only making decisions and implementing them, but ensuring that there is a degree of accountability after the decisions have been 666 implemented. By that I mean follow-through and ensuring that what is intended happens. That is the failure of the concept of consensus management, and that is the role that the general manager would perform, because it is lacking at the moment. He would not be a dictator. A hospital could not operate on that basis. However, there is a need for someone with responsibility not only to participate in the decision-making process with the professional staff, but to see that those decisions are implemented and that there is a degree of accountability which at present is lacking.
The hon. Member for Oldham, West suggested that there was a basic incompatibility between general management and clinical freedom. I disagree. have a growing concern about what passes these days for clinical freedom. The medical profession attracts to itself ever greater powers and responsibilities. When challenged, it covers them all with the blanket expression "clinical freedom".
The House will appreciate that I am a stout defender of the concept of clinical freedom, but there has to be some understanding of where clinical freedom stops and general management responsibility starts. Having been a member of a Government who cash-limited the National Health Service, as all Governments have, the hon. Member for Oldham, West must understand that he is a party to setting a limit on clinical freedom. I am not anticipating where the limit should be, but that by definition is the case. We all concede that there is a limit on clinical freedom and an interface between that and general management. We are debating how best that should be implemented.
I give the hon. Member for Oldham, West one example. It is right for doctors to say, "In the treatment of this patient I need the following tests to be carried out." It is unacceptable for the doctor to be presented with the results of tests which have been carried out in a different hospital and to reject them and say that he wants them done again in his own hospital, for no other reason that they should be done in his hospital. Many clinicians would claim that to be clinical freedom, but in my view it is an abuse of the system.
I defer to the hon. Gentleman's experience, but is not the case for consensus being better able to cope with the constraints on clinical freedom when the lack of resources demands that there must be an inhibition on the general view of the discussion, debate and decision-making process in which the clinician takes part and has to accept the team decision? If there is one individual who at the end of that process has the power on his own authority to say that he will decide and implement, as was said in evidence to the Select Committee, the clinician will retain direct access to a higher authority and upset the whole system.
The hon. Gentleman cannot have been listening. I was at pains to say that the general manager had to work with the professional staff and that there was always an element of consensus. However, there are also some fundamental decisions to be made. The doctor is free to say that he needs certain tests taken, but the general manager is free to say that the tests have been taken already and that the doctor will not be allowed to repeat them and so waste resources. That is the role that is lacking in the present system.
My right hon. Friend the Secretary of State discussed whether general managers should work on a full-time 667 basis. I hope that they will be full time and that the same will apply to any clinicians who are appointed. The nature of the job of a doctor in a hospital is such that legitimate demands are made on his time by patients which do not fall into administrative or management time slots. If the clinician is to be a general manager, I hope that it will be on a full-time basis.
I hope also that the general manager will take on board the role of assessing the management information within the National Health Service. As far as they have gone, the Korner reports are extremely helpful, but they point up the need for still more management information to assist better management application.
I welcome the emphasis in the Griffiths report on the personnel director. He will be appointed at the centre, but I am sure that his influence will be felt especially at district levels. Griffiths says that he should concentrate on training and securing maximum devolution to the districts. I am convinced that that is right.
There are problems in industrial relations in the National Health Service, and some of the actions of the unions exacerbate rather than help to resolve those difficulties. However, many of us feel that there is more to be got out of the workers in terms not of economics but of morale, in commitment to the service and in a desire to make them feel that they contribute to the system. I have in mind especially those who are less skilled among the non-professional workers in the service.
I was intrigued by what happened in my constituency. My right hon. Friend did us the honour of visiting the hospital in Peterborough recently. I hope that he was impressed by the morale of the staff there. I pay tribute to the new chairman of the district health authority, Mr. Gibson, and the members of the DHA who have gone out of their way to make everyone feel part of the system. The unions have responded. It was the unions which asked management for a list showing the cost of every item used in the hospital. From that they could see where it was possible to make savings. The unions took the initiative in that, and they are to be respected for it. It came about because they were made to feel part of the system.
It may be said that if that is happening already, we do not need a general manager. However, my experience tells me that what is happening in my patch is unique and that a personnel director will have a considerable role to play to the advantage of the National Health Service.
I urge my right hon. Friends to implement Griffiths as speedily as possible, commensurate with the other pressures on them, for a quite different reason. I pay tribute to them for generating a momentum for improvement within the NHS over the last few years. For 35 years we went without seriously challenging the way in which the service was run and the ideas and attitudes behind it. In the last few years my right hon. Friends have started a momentum for change which is to the benefit of the National Health Service.
I think of the work that they have done in the general practitioner services, in the drug industry, in improving efficiency, in improving the hospital stock, in manpower control, in the emphasis on patient care and on competitive tendering and in the reviews of benefits that have been carried out. All of that has been to the advantage of the Health Service because at the end of the day we shall have 668 a service in which more resources are available for patient care. I see this management involvement in the same light, and I wish those concerned well.
§ Rev.Martin Smyth (Belfast, South)
I welcome the opportunity to take part in the debate, having had the privilege of serving on the Select Committee. I wish at the outset to apologise for the absence of the hon. Member for Macclesfield (Mr. Winterton), who asked me to tender his apologies. He was a member of the Select Committee and asked me to point out that it produced a unanimous report. I hope therefore that when the Minister makes his recommendations he will be clearer than he was in his speech today. That is why we were anxious to have a full-scale debate, for if the mind of the House is to be tested we must be aware of the principles which the Government will follow in leading us forward, and those principles must be put into practice.
When we discuss management in relation to the Health Service, we must reflect on the criteria applying in business, commerce and industry — that of profit— because by that means it is easier to make assessments. My right hon. Friend the Member for Down, South (Mr. Powell), referring to the discussion of such matters, made an interesting comment, and although his remarks were made some years ago, they are worth bearing in mind today. He said:
If nothing is ever right and no sum of money is ever sufficient, intelligent appraisal of resource management and priority selection flies out of the window. All that you are left with is the grubbier end of market ethics—the elbowing and the jostling around the till—with none of the discipline of profit and loss.He then gave this warning:
Those who conduct the debate entirely in these sort of terms are playing into the hands of the other critics who question the very foundations of a publicly financed health service with free access to all.Perhaps unwittingly, the hon. Member for Oldham, West (Mr. Meacher), in his defence of resources for the Health Service, played into the hands of others, because, having referred to administrative costs being a low percentage, he immediately went on to say that we lacked funding for the Health Service. I am not sure that the more money that is spent on administration the better the NHS, especially in terms of the care of patients. At the GP level, for example, many people have discovered that even with greater back-up it is harder to obtain the services of a GP. With an appointments system designed to serve the patients, one must be almost dead before one can obtain an appointment. That has been the experience of many people as a result of administrators taking on more clerical work.
I did not suggest that because there were low administrative costs there should be more expenditure on administration. I said that the overall funding of the NHS was low by international standards and that it could and should be increased.
§ Rev.Martin Smyth
When the hon. Gentleman reads the Official Report of his speech he will see that he linked one with the other. We are discussing the management of the NHS. Whatever the funds are—whatever they have been in the past or will be in the future—we must improve the management of the service, and to that extent the Select Committee took the view that there was 669 tremendous room for improvement. However, we were not convinced that the simple proposal of having general managers would achieve that objective.
Like others, I question the simplistic conclusion that the appointment of good general managers will result in savings in the NHS. When we queried that the answer seemed to be that there would be savings, but from the experience we have had—even from the figures that the Minister gave today of the reduced numbers involved in personnel activities—we are bound to wonder whether it is simply an exercise in book-keeping.
For example, when the recent legislative changes in housing benefit were going through Parliament we were assured that there would be tremendous savings among those involved in administering that benefit. In the event, they seem to have moved from one office to another, and there has been no saving. That is why I question whether the savings which we are assured will take place in the NHS as a result of this change will occur.
In any event, we are not just after savings. We are looking for a more efficient Health Service. I am concerned about the representations that I have received from the public querying whether we shall, in following this principle of using general managers, have medicine by management. The feedback that I am getting is that that would be no more acceptable than the prescribing by porters which, on occasion, has been evident when, in industrial disputes, porters have had authority to say who might have priority for surgery or other medical treatment. That is why we query whether the implementation of the principle of general managers will improve patient care. In our view, improved management would achieve that, and I wish to develop that theme.
Much has been said about clinical freedom, but those who know something about what is happening in the Health Service agree with the doctor who says, "The meeting of your demands results in a decrease for me. In other words, if your demand for more money for your discipline is granted, less is available for mine." There is no clear clinical freedom in the way in which some people fondly imagine. That applies even when concerned citizens try to help the NHS by fund-raising activities. For example, some people believe that the provision of a scanner will solve a hospital's problems. Having raised funds to buy a scanner, demands are immediately placed on the local authority to provide accommodation and money for the upkeep of that scanner. I am endeavouring to explain that it is not simply a question of one group pushing its ideas and another group achieving its, all concerned thinking that their effort will improve the overall service of the NHS. That must be appreciated, Mr. Walker.
We need good management, but there are other problems to be considered. I welcome the tribute which the Minister paid to his Parliamentary Private Secretary, the hon. Member for Eltham (Mr. Bottomley), who achieved some success in improving matters for hon. Members and their families in relation to their activities in this place; a success unlikely to be achieved by many others. If the Minister could emulate the success of his PPS throughout the Health Service, it would be better managed.
The Under-Secretary of State for Northern Ireland, who is responsible for the Health Service in Northern Ireland, recognises the force of the argument that has been 670 adduced, for example, by the Royal College of Nursing, the Royal College of Midwives and the health visitors, who pointed out in a collective submission:
There is widespread agreement that the 1982 reorganisation has not, even now, been fully implemented at unit level.The hon. Gentleman, when introducing a discussion on the Griffiths report—admittedly we were a wee bit late in our reorganisation compared with England—felt that it was too soon to take action. The hon. Gentleman recognises that the implementation of the Griffiths report will mean a colossal reorganisation of the Health Service. He is wisely encouraging us to isolate methods of management rather than concentrate on the concept of a general manager. That is one of the conclusions of the Select Committee.
The Select Committee believes that the changes that have already taken place in the top echelons are good. We welcome the fact that the Secretary of State has included the chief nursing officers in the management process. Nurses are part of the providing services in a way that no other group is. Often, one observes nurses in district health care services or hospitals when one does not see doctors. Nurses guide patients. Will the Secretary of State, before making his conclusions, consider the statements of the Under-Secretary of State for Northern Ireland and isolate the methods of management so that management at unit level is improved? That is preferable to a wholesale allocation of new managers in the Health Service.
Order. I did not want to interrupt the hon. Member's speech, but he should refer to me as Mr. Walker when I am in the lower Chair and Mr. Deputy Speaker when I am in the upper Chair.
§ Mrs.Edwina Currie (Derbyshire, South)
Like the hon. Member for Belfast, South (Rev. Martin Smyth), I am a member of the Select Committee on Social Services. I believe that all hon. Members welcome the hon. Gentleman's membership of that Committee, because it serves to remind us that, whatever the difficulties in the Province, life goes on. It is a pleasure to serve with the hon. Gentleman.
I apologise to the House if shortly I have to rush off. This time last week I went to the dentist, and, perhaps because of my remarks in the House about him, the treatment the dentist gave me was not successful, and I must have some more treatment which I hope will be more successful.
In my last proper job—this is similar to the position of my hon. Friend the Member for Gillingham (Mr. Couchman)—I was chairman of the central Birmingham health authority. That is the teaching authority for Birmingham and for the west midlands health authority area. We had 10 acute hospitals but no long-stay hospitals. The health authority area was a centre of excellence and part of the city centre. We were resource allocation working party losers. We had every problem in the book it was possible to have. I have always felt that it was a great privilege to work and serve in the NHS in that way, but it was a deeply frustrating job.
The problems were especially apparent when we tried to make decisions. The decision-making process was too slow, which meant that delays led to inappropriate provisions and to excessive costs and overspending. The examples of those problems are legion, not just in my local 671 authority but throughout the country. The process was also indecisive. Frequently we received no provision because of the failure to take decisions. There was no feedback, monitoring or checking of results. Frequently, we did not know what we were doing or the results of allocating a chunk of money to a plan. That occurred because of the need to consult everyone. I remind the Minister that frequently there is a statutory responsibility to consult everyone.
There was a desire to avoid conflict. We tended to proceed only if we reached full agreement, and therefore we got what Mr. Griffiths called "lowest common donominator decisions", in which we concentrated on trivia and failed to deal with some of the serious problems. I suspect that that was typical of many large organisations of all types, especially in the 1960s and 1970s. The private sector organisations have gone the way all bad organisations go. That attitude remains only in the public sector.
Partly because of the general election, I was able to move to a different area. The southern Derbyshire health authority is a complete contrast to the central Birmingham health authority. I pay tribute to the southern Derbyshire health authority. The team works together, and decisions have been taken and implemented. I do not always agree with those decisions, and occasionally I wish for the cozy doziness to which I was accustomed. I believe that the authority is, for example, about to close a hospital in my constituency, and I wish that the authority's efficiency in undertaking such actions was not so intense.
The difference occurs because the pressures of big city hospitals are missing. The southern Derbyshire health authority is not a teaching authority. It has more resources and is a RAWP gainer. Because the authority has an excess number of long-stay beds, it has money in the bank, and therefore is able to make decisions more effectively. A great deal of the NHS is similar to the southern Derbyshire health authority. We should not be misled by the troubles, especially those in the London teaching area, which dominate our discussion of the NHS. We should not believe that the difficulties in the London area occur throughout the country, because they do not.
Mr. Griffiths examined the NHS more quickly than many of us have done. Some of his analysis was right and some was wrong. As was pointed out by at least one of the papers we received, Mr. Griffiths produced a critique which should be judged as such. It was not a thoroughgoing study of management in the NHS. He was right in saying that consensus does not work, or work sufficiently well where strong leadership is needed. It does not work where we are dealing with resource-hungry decisions in teaching, hospital services and acute hospitals in our cities. Conflicts are bound to arise and careful and deliberate argument is needed before decisions are taken when emotions are most readily aroused and judgments about the allocation of resources between competing demands are required.
Guess what? Five of the six hospital authorities which Mr. Griffiths examined were teaching authorities. He did not look at any others. Mr. Griffiths looked only at hospitals, not at community services, family practitioner committees or at most of the NHS with which most 672 patients come in contact most of the time. His antagonism to the NHS management system is understood when we consider the aspects at which he looked.
Mr. Griffiths was wrong in the notion that, by imposing a general manager, all the problems and difficulties of the service will disappear. That will not happen. I shall quote two short pieces of evidence which illustrate that fact. Leeds university said:
consensus decision making has been basically successful, and many of the criticisms which have been levelled against it are misconceived in that what is complained about is the natural pluralism of the NHS which is the cause, not the effect, of the need for consensus decision making.In other words, many doctors will not be told what to do by any other profession. Frequently, they draw a smoke-screen of clinical freedom to hide what they do not understand and cannot do. The faster that problem is resolved, the better. Frequently nurses serve on management teams and stay dumb until someone mentions nurses or nursing—then they are interested. They fail to take the opportunities presented.
My hon. Friend said that Mr. Griffiths was wrong to identify the general manager as one who would cure all the problems. For the sake of the record, Mr. Griffiths actually said that a general manager should becharged with the general management function and overall responsibility for management's performance in achieving the objectives set by the Authority".The regional and district chairmen shouldorganaise the mangement structure of the Authority in the way best suited to local requirements and management potential".On reflection, I believe that my hon. Friend will accept that that falls a good deal short of saying that general managers will be imposed to solve all the problems.
I agree with my hon. Friend. I would not dream of trading quotations with him. Mr. Griffiths said that he wanted a fairly strong-minded approach to general management. He saw that approach involving people, not just skills. The tragedy of the Griffiths report is that one could read almost anything into it and pick out quotations from different parts of it.
Pluralism exists in the Health Service and will not disappear if we impose general managers. There are administrators who would not say boo to a goose, and I have seen some of them. There is a lack of basic management at every level of the Health Service. There is almost a Peter principle with a vengeance. People tend to rise through their profession to the point at which they must start managing when they have not been encouraged, trained or forced to acquire the training that would provide them with the necessary skills.
Another reason why Griffiths was wrong—it is not his fault —is that he was considering the matter too soon. The committee was set up in February 1983, and it reported in October. We were still appointing unit managers and setting up structures at the time. As anyone who has done it knows, it takes a year or two for people to settle in. I think that many of Griffiths's criticisms will prove to be unfounded.
Griffiths was also wrong because there is not a ready supply of good managers just floating around waiting to be captured like a collection of butterflies. Our nation is not renowned for a ready supply of managers or managerial skills. If we were, I suspect that British industry would not have suffered all the difficulties that it 673 has in recent years. The fact that managers are in short supply in the National Health Service does not mean that we should raid industry, commerce, banks and so on, perhaps denuding firms such as Sainsburys so that in years to come they do not make the profit that they make now. They might be better at applying their skills where profits are to be made that will fund the Health Service in future.
The main problem in the Health Service has nothing to do with its management style. The Institute of Health Service Administrators said:
Better management alone will not solve the main problems facing the NHS—issues of priorities and limited resources in light of the ageing population, medical innovation and rising public expectations.The problems will not go away.
I should like to warn the House against two diseases endemic in the NHS. Anyone who has ever worked in the NHS ends up suffering from one or the other. The first is input-output disease. The characteristics are a passionate conviction that all that matters is what is put into it and a total failure to examine what comes out. The Secretary of State and I both suffer from it. We quote what we spend on the NHS. We say that there has been a 17 per cent. real increase in expenditure on it between 1979 and 1983. We say that there are 40,000 more nurses and 5,000 more doctors and dentists. We talk about the new hospitals. However, what we do not talk about very much and what matters is the results. How many patients are there per bed? I am aware that there has been a large increase. How many patients are there per member of staff? How many patients are there per £1 spent?
Examining the results in the NHS is regarded as being not quite nice. It is as if one were questioning the probity and ethics of all those involved. It is deeply disliked and much avoided. It is not enough to say that we are working hard and doing our best. We should say that we are working as well as we can with the resources that we have and getting good results. I continually harbour a deep suspicion that much of the money is not being put to good use.
The other disease is what I would call "structuralitis". It is a nasty variant of input-output disease. The characteristics are a repetitive cry of: "Let's alter the structure; that will put the NHS right." We have done it twice in the past decade—in 1974 and 1982. I fear very much that if we implement Griffiths entirely we shall do it again. Some people in the NHS say that the structure is at fault, which is why progress cannot be made. That is an excuse for a failure to perform—another version of the workman blaming his tools.
I was at an Institute of Health Service Administrators regional conference at Warwick university recently. I was told by earnest and honourable people that they could not talk to the new family practitioner committees set up by my right hon. and learned Friend the Minister for Health under the recent legislation because they are a different body. I asked, "What is stopping you picking up the telephone and just talking to them? There is no boundary between the two organisations." People also say that it is difficult for the health authorities to talk to the local authorities about transfer of patients, for example, at long-stay hospitals. However, they are talking about the same people. Just because the NHS calls them patients and the local authorities call them clients that should not stop them meeting and talking together.
674 Both diseases produce cloudy vision and an inability to see what is under one's nose. Both diseases produce over-strong facial muscles and atrophied limbs — in other words, too much talk and too little action. The remedy is not just to change the structure again because that exacerbates the diseases and does not cure them.
However, I am optimistic about the NHS, its management and health care. We have the best health care in the world. I should like to see us stopping the vague comments and criticisms. We should give the NHS a chance to get on with providing the best service possible with the resources available to it.
§ Mr.Tony Lloyd (Stretford)
This is the first time that I have found that I support much of what the hon. Member for Derbyshire, South (Mrs. Currie) has said. That might be simply because I have a much happier and less jaundiced view of the citizens of Birmingham today than I did yesterday. I am sure that the hon. Lady will agree with those sentiments.
I should like to re-emphasise the point made by the hon. Member for Belfast, South (Rev. Martin Smyth). It is a pity that we are having this debate on the Adjournment on a Friday. It means that the attention of the media is not focused on the debate and that if the Government wish to get off certain hooks they can do so. My disappointment at not having the opportunity to vote on a substantive motion is ameliorated by the fact that the Secretary of State gave us almost no information, so possibly no useful purpose would have been served by a Division.
We should recognise that, while the conclusions of the Griffiths report are important, the NHS has a broader backdrop. In the same way as we are all against sin, we all subscribe to the virtues of value for money, efficiency and good management, but we must also recognise that the fundamental problems of the NHS are not necessarily management structure but global funding relative to the real human need for the services provided. There should be no attempt to change the nature of the debate from one about the Health Service as a whole to a narrow debate on its structure and nature.
The Griffiths report made recommendations about central management such as the role of the Department at the Elephant and Castle and what flows directly therefrom. The Secretary of State told us some time ago that he accepted those recommendations. He has set up the supervisory board and is about to set up a management board. In its report, the Select Committee recommended thatthe Secretary of State lay before Parliament the details of the reformed structure of his Department, in time for the debate on the Report.That has not happened, and it is a great disappointment to me, and certainly to other members of the Select Committee. There is almost no room to deny that the central management of the NHS leaves something to be desired. We heard in the public expenditure review that redundancies have been made in the Department, but some of the individuals who were made redundant at great cost have been reappointed simply because there was almost no control over that situation. We are extremely concerned, and are right to be concerned, about the central structure of the Department. Therefore, it is right that the House should have some information about precisely what will 675 happen in the central organisation of the Health Service. I hope that when he replies the Minister will give us some details.
§ The Minister for Health (Mr. Kenneth Clarke)
I think that the hon. Gentleman has misunderstood. I do not believe that anyone who was given early retirement or made redundant has been re-employed in the Department of Health and Social Security. I think that that is against the rules of the Civil Service early retirement scheme. As the hon. Gentleman will know, the Government have taken vigorous steps to ensure that the re-employment of officers who are given early retirement inside health authorities is brought to an abrupt end.
§ Mr. Lloyd
I am grateful for that clarification. I shall reread the report. The general point is that there has been concern about the redundancy programme and some of its results. I shall check the details and be in touch with the Minister if I find that his views and mine still differ.
The role of the district and regional health authorities is of great importance. The Select Committee pointed out the real danger of the marginalisation of the authority member. If there are to be powerful general managers and a continuation of the strong powers of the chairman of the authority, it seems to me and to others to be inescapable that the individual member will become increasingly irrelevant to the operation. That would be not only a mistake but a real disbenefit to the NHS, because the individual member, as opposed to those appointed by the Secretary of State or those within the career structure of the NHS, represents the input from society writ large, and we should ensure that his role is maintained and enhanced. The Select Committee asks how the Secretary of State intends to guarantee that the role of the authority is enhanced rather than undermined, and I should be grateful for some information on that point.
The major issue raised by the Griffiths report is that of consensus management versus the appointment of general managers. That is how the battle lines seem to have been drawn. The Griffiths report, the Secretary of State and everyone else is in favour of getting the best out of consensus management. That is a platitude which none of us would dispute. Equally, we are all in favour of crisper management and all such concepts. The problem is how to achieve that crisper management while maintaining the benefits of consensus management.
My own view, based on the evidence put before the Select Committee, is that much can be done to make management in the Health Service crisper without resorting to the appointment of general managers with all that that could imply in terms of the relationships between the general manager and members of his staff.
As the hon. Member for Derbyshire, South has said, we are still very close to the second reorganisation of the Health Service. There is some evidence—not, I admit, systematically obtained — that the Health Service is beginning to settle down in the wake of that reorganisation and that management performance is already improving, although it is not improving enough.
Conclusions 9 and 10 of the Select Committee's report are relevant here. The Committee recommendsthat the new Training Authority be charged with instigating a significantly increased programme of management training for clinicians".676 It also recommends thatas clinician involvment in management grows … the Government keep under review the location of consultant contracts".The Committee was talking specifically about the need for management skills and management training in the Health Service. We could make considerable moves in that direction.
When I have been in contact with the authorities in the past, I have noted the almost appalling quality of management information in the Health Service. That is a far more significant factor in the quality of managerial decisions than is the appointment of any long-stop or umpire to resolve disputes when consensus breaks down.
It is not clear to me that consensus management has failed or is failing. Indeed, the Select Committee obtained evidence to that effect. Because of the multiple constituents of the Health Service, it can be argued that it can only logically be run by consensus. It will be necessary to define rigorously the scope of the general manager's responsibility if we are to preserve, as we should, the principle of consensus management.
As the Select Committee report points out, there is a need for a leap of faith, because in order to find out whether we can improve consensus management by improving general management we have to appoint general managers. We have heard this morning about two important concepts: responsiveness and accountability. Responsiveness does not depend on the appointment of a general manager per se. What is important, as I have said, is the quality of information. It is unrealistic to believe that an organisation can be responsive if it is operating on almost farcically inadequate data. That is a more real problem than the question of appointing individuals to specific roles, and if we addressed it we could make much progress.
It is not clear to me that a general manager is more accountable than anyone else. I suspect that in many ways he is less accountable. The doctor, or clinician—that appears to be the buzz word of the morning—has a direct relationship with his patients and therefore he has an automatic accountability. A member of an authority has generalised accountability to the community and, if he is the chairman, to the Secretary of State. The accountability of a general manager is not at all clear, except in the more rarefied sense in which every member of management is already accountable. The appointment of general managers will not increase accountability one whit. It may act as a barrier to the accountability of those who serve the patient and of those who operate at a strategic and policy-making level in the authority.
We need far more reassurance about the role of the general managers. No doubt the Secretary of State is waiting with bated breath for the views of the House. One can tell that by his absence from the debate at present. However, we need a public debate about the possible recommendations of the Secretary of State, because what is involved is another fundamental reorganisation of the NHS. This time, we hope that the new arrangements will be sufficiently long-lasting to enable the NHS to shake down and operate efficiently. It is therefore necessary that the decisions should involve the greatest possible public consent.
We all welcome Griffiths, even if we disagree with specific recommendations, because it has trained a spotlight on certain areas of the NHS. That has already had 677 its effects, so the process has been worthwhile. Whether the outcome will be worthwhile will depend on the decisions. However, it would be a tragedy if the process of considering the internal structure of the NHS led us to ignore the important questions about the overall resources available in the NHS.
§ 12.7 pm
§ Mr.Ralph Howell (Norfolk, North)
I welcome the findings of the Griffiths report in general and—subject to the reservations that I have mentioned—believe that a great service was done by the setting up of that inquiry. I congratulate my right hon. Friend and his team on the vigorous efforts that they are making to bring greater control to the NHS. A call for such a report was first made, I believe, in May 1982. It is now May 1984 and we are discussing whether the report is to be put into operation.
In his letter to the Secretary of State, Roy Griffiths said:
Speed of implementation is essential.I totally disagree with the Opposition's view that we are rushing our fences in this matter. There is a great need for urgency in implementing those parts of the report that are sound.
The report clearly condemns consensus management, and I am sure that that is right. It condemns ineffectual accountability.
§ Mr.Kevin Barron (Rother Valley)
Will the hon. Gentleman tell us on what basis he comes to the conclusion that to condemn consensus management is definitely right?
Consensus management is condemned throughout the report, which calls for individuals to manage every unit. In that respect, I fully support it. That is my opinion.
The report shows that the NHS has lost its way—its aim is defective. It is highly disorganised and has almost reached the point of non-organisation. The fault was built in on the day of its birth when Aneurin Bevan failed to give it a chairman or a head. It is remarkable how well the NHS has done, considering that it has never been properly led.
The Griffiths report calls for a general manager at every level and for proper budgetary control. That problem is not unique to the NHS, as proper financial, budgetary and auditing control is utterly pathetic in the entire public sector. The report also calls for proper management control of property. There, too, the NHS is a dismal failure. However, the report falls down principally because it fails to call for a chairman with complete executive control. It talks of a general manager and describes him as being the right hand man of the Secretary of State. The type of person who could manage the NHS would be the right hand man of no one. We must think the matter through carefully. We should remove the NHS from day-to-day political pressures.
My right hon. Friend the Secretary of State has argued that the NHS is much too sensitive to be in the hands of an Ian MacGregor or a Sir Michael Edwardes. Nothing is more sensitive than the mines and the National Coal Board, but we entrust them to a chairman who is responsible to the Secretary of State for Energy. My right hon. Friend has done a better job than any of his predecessors since the inception of the NHS. Real efforts are being made, but my right hon. Friend is attempting the impossible. My remarks are not intended as a personal attack, but as an attack on our expecting a Member of 678 Parliament and of the Cabinet who is responsible for 40 per cent. of public expenditure to manage a giant organisation in 10 to 15 per cent. of his time, as that is all that he is able to give to the management of the NHS. Only the Red army and the Chinese army are bigger organisations than the NHS. There is no bigger private organisation, even in America. It is therefore unreasonable to assume that my right hon. Friend can manage the NE-IS in his spare time.
Proof of my argument lies in the fact that manpower has expanded out of control despite what previous Secretaries of State have done and the numerous reports from the Committee of Public Accounts and from the Comptroller and Auditor General throughout the past 36 years. I welcome the Griffiths recommendation for overall manpower control. I should like to illustrate how utterly out of control manpower matters are. There are now three times as many nurses per bed as there were in 1960. How can that be justified? Furthermore, in 1981 there were 1,710 grades of nurse and 10 grades of ambulance personnel. As a result of questioning we have reduced the number of grades of nurses to 1,020, but there are now 100 grades of ambulance personnel. That must be explained.
It is no good the Secretary of State saying that he has real control of NHS expenditure, in view of what has happened with early retirement expenditure. Such retirement was supposed to cost £8.6 million and about 400 people were to retire. In the event, about 3,000 people received early retirement at a cost, when the Comptroller and Auditor General reported in November, of £45.2 million. By the time the Committee of Public Accounts reported in January, that figure had increased to £56 million, and when I asked the DHSS about the latest figure, in March I was told that it had risen to £67 million. Can there be any greater proof that we have no control of NHS expenditure? That illustration is nothing short of scandalous.
Mr. Roy Griffiths has successfully reorganised Sainsburys. I am sure that that reorganisation occurred far more quickly than the reorganisation that is envisaged for the NHS. As he said, speed is essential. He quickly instituted spot checks and achieved early changes at Sainsburys. We must move on much more quickly. I am sure that he used existing staff. There is not time to train staff, so we shall have to do the best that we can with what we have. My right hon. Friend should appoint the most able administrator that he can find to take on the supreme job of chairman of the NHS to reorganise and improve it as quickly as possible in the interests of the nation's health.
I conclude with a quotation from an NHS pamphlet, "Facts and Solutions". It ends by saying:
The recently published Griffiths Report has exposed the inadequacy of concensus management at all levels in the NHS. Most of its recommendations are sound. However the entire report is destroyed by the failure to accept the need for an overall Chairman with full executive powers—unencumbered by day to day political expediency.
The Report leaves the Secretary of State for Social Services in supreme control, with the Chairman of the proposed NHS Management Board as his 'right hand man'.
It is impossible to visualise anyone of the calibre of Mr. Ian MacGregor or Sir Michael Edwardes being anybody's 'right hand man'. Every organisation, every ship, needs a captain—the NHS is crying out for one.
The NHS must be taken out of the day to day political arena. We have been told the NHS is 'safe in our hands'. The NHS is not safe. It is in mortal danger. The seeds of its destruction were sown on the day of its birth when Aneurin Bevan failed to give it a head. The NHS is destroying itself.
679 Only radical change can save it.
§ Mr.Michael Meadowcroft (Leeds, West)
I shall endeavour to concentrate on the general management aspect, although one might put a marker down and say that the changes at the centre of the NHS may turn out to require more attention. Nevertheless, I agree with Mr. Griffiths when he says that he regards the general management proposal as being at the heart of the report.
I deprecate some of the slighting references to Mr. Griffiths and Sainsbury's. They are easy debating points, but all those who examine any organisation or function cannot come to it value-free. They come to it with experiences and personalities. Surely what matters is that one must apply a political assessment and decision to whatever report is being made, taking into account the background that one brings to the production of such a report.
The Secretary of State said that he does not regard the Select Committee's report as hostile. However, will he accept that it is critical? It is critical of several aspects of the Griffiths report. The evidence that was taken tends to bring out those critical aspects. There is an interesting parallel in the fact that the strength of the Select Committee's report is its unanimity. Although individual members of the Select Committee would emphasise different aspects and tend to draw out particular points on which they would want to put greater stress or to go further, in a sense it is a good example of the best of consensus. However, that is rather more apparent in the diagnosis than in the prescription.
The Secretary of State also said that fie does not regard the proposals in the Griffiths report as being another reorganisation. I suspect that in saying that he may well be undervaluing the crucial role of leadership in any organisation or project. If one were to ask those in the personal services, the education service or the NHS, which factor in any unit of that service had the greatest impact on the delivery of that service, they would invariably say that it is its leadership. It is not necessarily the buildings or the detailed management structure, although they are important; it is the character, personality, charisma and drive of the person who heads that particular unit that is important. Therefore, it is because the Griffiths report and its implementation are aimed at producing people of that calibre and style and giving them a particular remit which can have an effect, for good or ill, on what they do in the NHS, that it is a more fundamental reorganisation than the Secretary of State admits.
The other fact which I suspect illustrates that point is that many parts of the Health Service now, whether regional or district health authorities or individual units, already have a powerful or even dominant personality. In many cases that is clearly beneficial to that service, but there are occasions when a powerful personality can be destructive. That may well be the case whether the influence comes from a chairman, a consultant, or indeed an administrator.
The whole question is how a structure can be evolved which accommodates the best and inhibits the worst. I am concerned that the reality of the proposed style of general management that comes out of the report is at one with the former—a personality who is beneficial to the service 680 but is rather superfluous, because such people exercise their influence anyway. It is rather more likely to be disastrous when the leadership is not so benign. There cannot be a structure which gives power to an individual with a beneficial personality but which tries to combat the influence of a strong personality when it turns out not to be as helpful as first thought. Therefore, the flexibility which the Secretary of State has espoused is vital to the method, time scale and extent of the implementation of the report.
For instance, we had a debate in the Select Committee on the Secretary of State's evidence on the impact of relationships within the NHS and the trust that exists there and whether general management, when appointed, will be full or part time. The Secretary of State was asked whether there would be a conflict of interests if general managers were part time. The Secretary of State must have reflected upon his answers since then, because I for one was pleased to hear that he now tends towards the belief that they should in virtually every circumstance be full time. That is what Mr. Griffiths seemed to be saying.
The problem for the Secretary of State in coming round to that view was that he found himself in something of a dilemma before the Select Committee. He wished to minimise the cost of the implementation of the proposals and therefore left a larger loophole for the management to be part time than he might otherwise have wished. That was simply because the cost of implementing the proposals in the early days would be so much more if they all had to be full time. I recognise his dilemma, but it is inherent in wishing to have the style of management that he has espoused in his acceptance of the Griffiths report.
The hon. Member for Norfolk, North (Mr. Howell) is in a sense approaching the crucial problem of the NHS from the opposite end of the telescope to myself, but there are aspects of health care which are mutually exclusive. If, as the hon. Gentleman believes, they are all soluble by having some dictator at the top and at each level who can crack a whip, causing everyone to jump into line—I take his analogy of the military services to heart—he is not coming to grips with the problem of the balance between clinical freedom and the conservation of resources. They are in conflict, and always will be.
The crux of the problem is the dilemma at the heart of the NHS—the split between the power to tax and the power to spend; they are not in the same hands. When those functions are separated, there will inevitably be a problem about conserving resources while encouraging the development of the service. The Griffiths report does not come to grips with that.
That dilemma poses immense problems for management. The hon. Member for Wolverhampton, North-East (Mrs. Short) mentioned the Bains report and its recommendations about chief executives in local government. However, the crucial difference is that, at least until the Government's rate-capping powers come into effect, local authorities have the power to raise funds and to spend the money. There is not the same split between the power to tax and the power to spend.
The sensitive management of clinical freedom requires an emphasis on consensus rather than on individual decision making. Otherwise, recourse to the direct access to higher authority, which the Secretary of State told the Select Committee would still be available, is likely to be provoked. Those who wish to develop the clinician's right to freedom will demand access if that freedom is 681 threatened. Within the consensus process a person can feel that he or she has had a proper hearing, without the imposition of an individual's self-determined policy. That may inhibit undue recourse to direct access.
§ Mr.David Crouch (Canterbury)
Does the hon. Gentleman not think that perhaps he and other hon. Members have put too much emphasis on consensus and not enough on consultation in the development of better management?
I shall reflect on that, but if people believe that nothing will be imposed on top of the consultation, or consensus, they will be more prepared to accept its general conclusions. They may be reticent to accept that if they feel that something will be imposed on top of that process after consultation. Consensus goes beyond that, and may persuade people to accept the longer process in return for a more beneficial decision.
In the private sector, the decision-making process is held in private. In the NHS that process is, to a large extent, held in public, which inevitably has an impact on the style of papers produced for a health authority and the way in which people present their arguments. People approach decision making with a view to diplomacy and balancing the disparate personalities and their known predelictions for priorities. That would not necessarily be the case if we had a general management system. The papers produced would be different, because those producing them would know that the general manager had the power to make decisions.
One of the great British diseases is the desire for uniformity. We too often wish to see neat, constructive systems that will apply in all parts of the country. That approach is disastrous. I was heartened to hear the Secretary of State talk about making his proposals suit circumstances. If that is his watchword in the implementation of the report, some of our fears and doubts may be allayed.
I beg the Secretary of State to be flexible, and I desperately hope that he will not seek to impose the general management principle where it is clear that there is general acceptance for the present consensus machinery and it is working satisfactorily.
§ Mr.Toby Jessel (Twickenham)
I pay tribute to Mr. Griffiths for his report and to the members of the Select Committee, six of whom have already spoken in the debate. They have clearly gone into the matter in great depth.
My hon. Friend the Member for Norfolk, North (Mr. Howell) said that every ship needs a captain. I was brought up in the Royal Navy and I served in ships. I know that a ship needs someone in charge, and so does a hospital. I could not help being struck by what Mr. Griffiths wrote in that connection:
if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge".A hospital, like a ship, needs someone in charge, preferably someone with leadership qualities so that everyone feels fully involved. That is plain common sense. The alternative is chaos, and that means a worse service for patients. One does not make chaos any better by calling it consensus.
The hon. Member for Leeds, West (Mr. Meadowcroft) spoke about the British disease of, as he put it, desiring 682 uniformity, but I believe that the great British disease is that of committee-itis—the concept of doing everything by consensus and so taking minutes and wasting hours. If that is allowed to grow unchecked, it must be to the detriment of NHS patients.
In debating the Griffiths report, we are faced with a paradox. The figures produced officially for Ministers by senior civil servants clearly show that the amount of money spent on the NHS has increased from £7.75 billion in 1978–79 to £15.5 billion in 1983–84. Even allowing for inflation, there has been an 18 per cent. increase in expenditure in real terms. That £15.5 billion comes to an annual average tax bill in total of about £900 for each household in Britain.
It is easy to give, as we all do, illustrations of how that extra money is being spent. There are more general practitioners. There is now one for every 2,100 patients, as against one for every 2,400 only a few years ago, and that enables GPs to provide their patients with a better personal service. More expensive surgery and other treatment is available for serious illnesses such as heart disease and cancer. Due to demographic trends and improving health, we have an aging population which is increasing in number by 100,000 or 200,000 per year. We now have 9 million old-age pensioners and so more people need medical services each year. As my right hon. Friend the Secretary of State has said, more patients are being treated every year.
Yet despite all that, there is a widespread feeling that NHS resources are severely constrained. The word "cut" is widely applied, and those in real need of treatment sometimes cannot be given it speedily enough. All that means that action along the lines of the Griffiths report is most urgently needed.
We must ensure that the resources of the NHS are applied to the essential task of caring for patients as efficiently and effectively as possible, and to bringing them the maximum benefits. It is not good enough just to care. We must care effectively and efficiently for patients. That means being prepared to cut out waste. It is no use turning a blind eye to waste in the NHS and then complaining that there is not enough money to provide for the services that the patients need. That is how I interpret the basic theme of the Griffiths report, which is to improve management.
In my constituency there is a small community hospital, St. John's. I should be grateful for the particular attention of my right hon. and learned Friend the Minister for Health on this subject. St. John's is performing a vital task in the care of sick people, but it is under imminent threat of closure by the Hounslow arid Spelthorne district health authority. I am in no doubt that if the Griffiths principles were carried out the money could be found to save it. My right hon. and learned Friend has agreed to see a deputation which I am to bring to meet him on 24 May. I fully appreciate that he has been as helpful as he could have been in that he has already stepped in to save the Teddington memorial hospital. However, there is acute and widespread anxiety in Twickenham, which was reflected in the fact that this Wednesday more than 2,600 letters were delivered by local doctors and others to No. 10 Downing street. Local doctors have expressed genuine fears, because they often find it difficult to obtain operations, urgently needed X-ray and other examinations for their patients and surgery and other treatment. They will find it even harder if St. John's is closed. The detailed 683 case will be put to my right hon. and learned Friend when we see him on 24 May. I share the doctors' fears. I am anxious for my right hon. and learned Friend to hear direct from the doctors, so the delegation will consist mainly of local GPs.
My right hon. learned Friend will find that the doctors have a constructive approach. Consistent with the Griffiths report, they will suggest how money can be found so that St. John's hospital can be saved while the Hounslow and Spelthorne district health authority keeps within its budget.
The current cost of running St. John's is about £400,000 a year. That could be reduced.
§ Mr.Steve Norris (Oxford, East)
On a point of order, Mr. Deputy Speaker. I understand that the debate is on the Griffiths proposals for the reorganisation of management in the Health Service. With respect to my hon. Friend the Member for Twickenham (Mr. Jessel), I have heard nothing about that in his speech. He has been making a plea for a particular hospital, and many hon. Members would like to do likewise.
Mr.Deputy Speaker (Mr. Ernest Armstrong)
Order. I was listening carefully to the hon. Member for Twickenham (Mr. Jessel). He should address his remarks to the subject of the debate, although it is on the Adjournment.
My hon. Friend the Member for Oxford, East (Mr. Norris) cannot have been listening because I have referred to the Griffiths report at least four times. I have been making general remarks in relation to the Griffiths report and how it applies to a community hospital in my constituency. I have every right to speak about the Griffiths report in its denotation and not merely in its connotation.
We all know that there has been a small shift of 1 or 2 per cent. of NHS resources away from the four Thames regions towards the poorer districts in the north. I do not complain about that, but I find it impossible to accept that money cannot be found, in accordance with Griffiths principles, to create enough revenue resources to pay for the vital services which St. John's provides for patients. In that connection, and in accordance with the Griffiths report, I have six suggestions to make.
The first suggestion is entirely new and I have not yet put it to my right hon. Friend. Griffiths says that doctorsmust accept the management responsibility which goes with clinical freedom. This implies active involvement in securing the most effective use and management of all resources.I can illustrate that by describing how in Twickenham local doctors are offering to take over and run St. John's. They would be given an annual budget — perhaps slightly reduced from the present level—and run the hospital themselves. They have the management ability, to which Griffiths refers extensively, because they are self-employed and are used to budgeting. It could be seen as a pilot scheme. The case is set out in a letter which the chairman of the medical committee has sent to the Prime Minister. It will land on the desk of my right hon. and learned Friend in the near future. I hope that he will consider the idea carefully and sympathetically and give it a fair wind.
684 The second suggestion, which is also in line with the Griffiths report, is made by the medical committee at the hospital, which says that economies could be achieved by better management of drugs. It says that drug overspending at the Ashford hospital has been reduced by £55,000 and with similar action at the West Middlesex hospital the bill could be reduced by £105,000.
The third suggestion relates to economies on heating. Again, that could be achieved by better management. Patients could be kept sufficiently warm if heating were used more efficiently with a better use of thermostats.
The fourth suggestion to which I wish personally to draw attention concerns laundry, cleaning and catering at the two district general hospitals, West Middlesex and Ashford. Last year, the Secretary of State said that substantial economies could be made, but the local health authority has dragged its feet. If it followed Griffiths and had proper management, it would not drag its feet and substantial economies could be made. The authority put the services out to tender only recently, but it could have put them out last year. As a result, the tender figures are not in the hands of those making the decisions. It must be wrong to cause a small local hospital to close, perhaps for ever, for financial reasons without waiting to see whether better management along Griffiths lines could produce savings.
The fifth suggestion deals with capital resources. Again, management is involved according to the Griffiths principles. In February, the North-West Thames regional health authority asked all its districts to have their spare land valued. That could be done in a matter of weeks. I am told that Hounslow and Spelthorne has obtained valuations for spare acres of land at the West Middlesex hospital which could realise several millions of pounds. I have heard £6 million mentioned. The figures have not been published. I cannot help wondering why the authority is keeping quiet about the figures for the time being. Perhaps it wants to keep the figures quiet until after a decision has been reached about St. John's hospital.
I have asked the regional administrator if he will obtain the figures, and he has agreed to do so. I would add that the district received an offer last year from one of the most famous firms of estate agents—Cluttons—to do a free valuation of its surplus land. It is inexcusable that it turned down that offer.
Sixthly, there are empty properties of which I shall send details to my right hon. and learned Friend. I shall not detain the House by giving details of them now.
When my right hon. Friend announced publication of the Griffiths report on 25 October, he said in reply to a question from me that districts could keep, and would not have to yield up to the region, the proceeds of land sales. North-West Thames has since confirmed that that is its policy. As it can show a yield of several million pounds, even though we know that capital sums cannot be spent on annual revenue outgoings, it could be spent on projects that could save revenue. Again, I shall send details of that to my right hon. and learned Friend.
I wish briefly to refer to an important article in the British Medical Journal on 21 April, written by three medical authors, T. North, D. J. Hall and W. E. Kearns. It shows that in 70 per cent. of cases hospital patients do not need high technology treatment. It is, therefore, quite wasteful for a large proportion of patients to go to district general hospitals where high technology treatment is available. They should go to a local community hospital 685 where the cost per bed per day is far lower. In that way money could be saved so that hospitals such as St. John's, which is of enormous value to the community, could be saved.
I ask my right hon. and learned Friend to be kind enough to take fully into account the points that I have made today when I call to see him on 24 May.
§ Mr.Stuart Bell (Middlesbrough)
I congratulate the Secretary of State on his cogent exposition of the Griffiths report and the first report of the Select Committee. I welcome his statement that while this debate is on a motion for the Adjournment of the House, there will be a debate on a substantive motion once he is in a position to make known which recommendations he proposes to accept.
The Secretary of State lauded the emphasis that the Griffiths report places on concern for the individual patient, on the securing of the best motivation of staff for a caring, quality service and on the balancing of the interests of the patient, the community, the taxpayer and the employee. I am concerned that the report places emphasis on the measurement of quantity rather than quality. My hon. Friend the Member for Oldham, West (Mr. Meacher) has been the only speaker to refer to "Patients First". We feel that reform, if it is to be about anything at all, must be about the obligation to make the Health Service more sensitive to patients' needs. Somehow, the patient as a representative of his own interest is diminished in this report. We are anxious to ensure that the patient and his interests cannot be crowded out in a competition for balance between Health Service workers and budgetary requirements.
Reform has to be about discussion at local level. Lip-service is paid in the report to the local level discussion, and the first report of the Select Committee, on page 15, welcomes the Secretary of State's assurances thatnothing in the report is intended to diminish the role of authorities and authority members.Even that statement was belied by evidence given to the Select Committee by the chairman of Newcastle district health authority. One of my reasons for intervening in the debate is that I was a member of that authority when I was a member of Newcastle city council. The chairman of the health authority said:
Griffiths does not dismount the authority member any more than he has already been dismounted.That reflects the frustration already felt by members of health authorities at district level and locally.
The hon. Member for Twickenham (Mr. Jessel) in a timely intervention in the speech of the Secretary of State, sought to draw a distinction between the words clinicians and doctors. As he pointed out, the word used by the Griffiths report is doctors. He also said then, and again later in his own speech, that general practitioners had a say in the management of local community hospitals.
I do not wish to widen the debate into constituency matters, but on Teesside there has recently been a conflict between general practitioners and the consultant physicians over the best way to reduce the resources of the South Tees area health authority by £500,000, in line with Government spending proposals. The clinicians wanted to close a local community hospital, albeit temporarily, for three years. The general practitioners were able to point out the benefits of the hospital to the local community. In the end, the health authority had to make a decision 686 between the two and we were glad to see that the hospital was kept open, as the health authority came down on the side of the general practitioners.
There is a concern that if more authority is given to the clinicians, and they involve themselves more in management decisions, that will lead to conflict and to empire building, which in the end will not necessarily be to the benefit of the local health service or the local community. We note that the proposed management committee will cover all existing NHS responsibilities in the DHSS, including regional and district health authorities, family practitioner committees, special health authorities and other centrally financed services. However, those involved in health services want to know the implications of trying to rationalise the use of resources.
We have already discussed the fact that consultants' contracts are with the regional, and not the district, authorities. That in itself is a source of conflict. There are many in the Health Service at local level who feel that they do not take part in the selection process of clinicians, and that sometimes the interests of clinicians are incompatible with the development of the service. I have already mentioned the particular case of Teesside, but there may be conflict between the clinicians' and the general management committee's view of the needs for the level of practice locally.
We have heard a great deal of the phrase in the report, "maximum devolution of responsibility". In the report and the recommendations that will be taken up by the Secretary of State, we shall be hoping for maximum devolution of accountability. It was brought out by my hon. Friend the Member for Oldham, West, and taken up by other hon. Members, that although there is accountability, it appears to be going upwards towards the Secretary of State. rather than downwards to the district authorities. In our view that is not a desirable development in our democracy. It is the antithesis of local democracy. In a sense it is centralism. The Labour party has always been criticised for supporting the concept of democratic centralism, yet from the present Government we are getting a great deal of centralisation. If these recommendations are given the force of law, we believe that they will add to that upward thrust.
My hon. Friend the Member for Oldham, West asked whether there was not a fundamental contradiction between commercial attitudes and the function of professional freedom of action which would not be tolerated in the private sector. Although I am not anxious to widen the debate by going into the methods of doing business in the private sector, it must be said that my hon. Friend touched on a fear, which extends over a wide political spectrum, that the drift is towards central authority and away from local democracy.
In my view this is part and parcel of Government policy and of the logic behind that policy. The Government see in the years ahead in their general economic overview that North sea oil revenues will begin to diminish, that the productive base of the country will yield less in taxation, that unemployment will still have to be paid for to the tune of £17,000 million, that defence costs will have to be paid to the tune of £10,000 million and that there will be a further £13,000 million by way of tax handouts to those who have as opposed to those who have not.
Because of these tenets of our economy, and because we have built into the equation 3.5 million unemployed, it is only logical that the Government wish to tighten as 687 best they can the purse strings round the National Health Service, especially when, as the Secretary of State acknowledged, health care is on the basis of need, availability to all and financed by direct taxation. Given that the Government insist that direct taxation should be reduced, the fear must be that embarking on the reform of management in the NHS is but a cloak for the accretion of more power to the state, a diminution of the power of local democracy and an attempt to limit the resources available for the NHS.
The Secretary of State referred to the balance that must be struck between patients, the community and employees of the NHS. In our view that balance is likely to be disturbed not towards the patient, not towards the community and not towards the employees, but towards the state.
I have mentioned already my own involvement in health matters as a member of the Newcastle health authority. There I had to live through the consequences of the first reorganisation of the health authorities brought about by the right hon. Member for Leeds, North-East (Sir. K. Joseph) when he was Secretary of State for Health and Social Services. I also lived through the second reform of the structures of the NHS. I understand the ripples of uncertainty and anxiety that pass like a current through all grades of the staff of the Health Service. I understand the frustration that they feel when decisions about their livelihoods and work destinies are taken so far away from local level. The report and its recommendations are hardly likely to diminish that sense of frustration and insecurity.
We read in the Griffiths report that speed is of the essence and that somehow we have to come to terms with management. In my view, the more that these matters are debated in the House, the more that they are discussed throughout the Health Service, and the more that we seek to preserve consensus management, the more likely we are to continue with a National Health Service the principles and concepts of which were universally approved and acknowledged 40 years ago and still have the outstanding support of the British public.
§ 1 pm
§ Mr.James Couchman (Gillingham)
I am pleased to take part in this debate because I spent much of the Easter recess re-reading the Select Committee report, the oral evidence which we took and the many memoranda of written evidence which we received. I re-read yet again the Griffiths report. With the exception of the latter, my overwhelming reaction was one of disappointment.
The Select Committee received much evidence that was confusing and, in some cases, confused. We received evidence from the doctors, represented by the BMA, which I found deeply worrying in its arrogance. That attitude was typified in responses which suggested that undoubtedly autocrats would be put into the position of general managers but that doctors would feel at liberty to ignore the decisions of general managers which the doctors construed to be against the interests of their patients' welfare. That seemed in itself to be something of an inverted autocracy on the part of doctors.
From the nurses, represented by the several royal colleges, we had something of a history lesson in how hard they won the right to manage themselves, and they called 688 attention to the discrepancies between the status of their existing management and the managers of other disciplines.
COHSE, in its bitter attack on the Griffiths report, raised the spectre of the pre-Salmon report days when nurses had subordinate management to others. Those representing nurses generally were the most angry witnesses we saw. The nursing profession seems to believe that the implementation of the Griffiths report in all its aspects, particularly concerning the appointment of general managers, would pose a threat to the quality, quantity and integrity of nurse training. I fail utterly to understand that fear, for I am sure that anyone who has had anything to do with the NHS recognises the value — indeed, the essential nature—of nurse training.
It might just be that the hostility of the clinical professions to the Griffiths report and its recommendations stems from a suspicion that few doctors and few nurses will aspire to positions as general managers. That sells short those two professions. I prefer to believe that those representing nurses and doctors have simply failed to understand the driving force of the Griffiths report.
They have chosen to see the essential dynamism of Griffiths as malign and mischievous rather than benign and beneficial. That is sad, for it is essential to persuade the clinical professions of the considerable benefits that can accrue to the NHS from a more dynamic management regime. The alternative to co-operation from clinicians would, surely, be failure of any implementation.
Unsurprisingly, the administrators and treasurers whom we saw, perhaps with a slight hint of expectation, have proved more enthusiastic in their reception of Griffiths. The reservations of those two professions tended to centre around the likely job descriptions of any general managers who were appointed and the remuneration, scales and grades of those proposed general managers.
They have also expressed a belief, along with many hon. Members in this debate, that the new posts, if implemented, will have to be more than a nominal reclassification of the existing chief officer's role and support. One of the most thoughtful and positive contributions to the debate has come from the Association of Chief Administrators of Health Authorities, whose perception of Griffiths clearly respects the need for a new momentum.
The training of the disciplines of administrators and treasurers tends to mean that they will probably be better equipped for general management than some of the clinicians. However, it has become a cliché to suggest that the NHS is overadministered and undermanaged. The truth in that proposition suggests that not all administrators make good managers, and they must not presume that the beneficence of Griffiths will fall exclusively on administrators and treasurers.
Of the other evidence that the Select Committee heard, the offering of the TUC health services committee was more or less uniformly hostile, preferring to castigate the Government for an imagined starving of the NHS of resources. That is patently false in view of the Government's record. I was, therefore, unable to place any great weight on the written and oral evidence submitted from that quarter. The written evidence of the general secretary of NUPE contained a glorious sentence, in which he offered:
By any indicator you want to use, the British NHS is exceedingly, almost unbelievably, efficient.689 He exhorted us to accept the NHS for what it is—an extremely efficient scheme for the delivery of health care.
When I sought to tax Mr. Jones, the NUPE national officer for the NHS, with major examples of inefficiency, he accused me of taking the particular against a general statement. He went on to say that general management within the NHS would probably lead to greater inefficiency rather than efficiency. I fear that I may have listened to the remainder of the evidence from the TUC with less than rapt attention.
Of the written evidence that was not published, I was especially amused by the offering of one or two societies representing paramedicals which seized the opportunity of writing to my right hon. Friend the Secretary of State to promote district functional management for their skills without ever mentioning the recommendations of the Griffiths report. I found myself most in tune with the evidence of the National Association of Health Authorities and the regional chairmen. That is natural, given my recent experience of chairing a district health authority and serving previously on an area health authority. Clearly, the NAHA and the regional chairmen have looked, from the point of view of the employing authority, at the proposition for general management and Roy Griffiths' prescription for sharpening general management within the Health Service. They appear to like what they see. They perceive the potential for increased effectiveness of senior management, which the report discusses.
It is my experience that already, where consensus is difficult or impossible to achieve, primus inter pares appears on the scene to take the circumstances by the scruff of the neck. The implementation of the Griffiths report will frequently rationalise a de facto status and legitimise it. The weakness of consensus management is not something new or startling. It is a fact of life that horses designed by committees turn out to be camels. Decisions taken by committee are either bland and uncontentious or bound to involve the lowest common denominator when something more incisive is needed.
§ Mr.Frank Dobson (Holborn and St. Pancras)
Does not the hon. Gentleman accept that the Normandy landings in 1944, which are generally regarded as having been successful, were organised, planned and decided upon by a committee?
I take the hon. Gentleman's point. I am not sure that it is entirely relevant to a consideration of management in the NHS.
I included the Select Committee's report among my opening list of disappointments. That report offers the best and the worst of consensus. Perhaps that consensus is less evident among Members of the Select Committee who have spoken in the debate. My right hon. and learned Friend the Minister for Health, perhaps in a jocular moment, has suggested that the Select Committee's report offers something for everyone. My right hon. Friend the Secretary of State was able to welcome the report. The Royal College of Nursing and other nursing colleges hailed the report as a vindication of their position. Those three harmonious salutes from disparate quarters speak volumes about a report that should either have endorsed or rejected the most contentious recommendation of the Griffiths inquiry—the appointment of general managers. The Select Committee, to avoid a split which would probably have been down party lines, produced a report 690 that welcomed the general spirit of the Griffiths report, and then damned the report with faint praise with a set of slightly wishy-washy recommendations. I wish that the Select Committee had given my right hon. Friend the Secretary of State a firm lead to implement the Griffiths' recommendations.
§ Mr.Tony Lloyd
I am a little surprised that the hon. Gentleman is making those remarks now, because he was a member of the Select Committee. I understand that there is some desire to produce a productive report, which may mean that we need to curb our viewpoints. If the hon. Gentleman feels as strongly as he does, I point out that it was always open to him to put forward alternative recommendations. He could have put his name to those alternatives instead of to the major report, as I and other Committee members did.
I am at pains to say that I do not disagree with the Select Committee's report, but it does not go far enough in its recommendations. I am pleased that we could produce a report that went as far as it does, but it does not go as far as I should like. I suspect that if it had gone further there would have been a split. which would have necessitated more than one report. That would have been entirely regrettable.
I stand four square behind Griffiths with regard to his prescription for firmer, sharper and more dynamic management. I spent a good deal of time on the contentious issue of general management. Incidentally, is it not interesting how everyone suggests that general management is a good thing but then rejects the concept of general managers? I am well aware that Griffiths goes into various other points. I must restrain myself as I know that other hon. Members are waiting to speak, so I shall confine myself to this subject which is one of the most radical of Griffiths' suggestions.
However, I should like to say a word or two about one opportunity that I feel the Griffiths team almost missed. That was to offer some constructive criticism on how the process of consultation in the NHS might be streamlined and simplified. In one delicious paragraph on page 14 of the report, Mr. Griffiths spoke of the process of consultation beingso labyrinthine and the rights of veto so considerable that the result in many cases is institutionalised stagnation.There is no doubt that the labyrinth—consisting as it does of cogwheel committees, medical staff committees, local medical committees, district medical committees, family practitioner committees, unit joint staff committees, Uncle Tom Cobbleigh and all—is so tortuous that implementation of any decisions that are taken is almost impossible. The obsession with consultation, even on comparatively minor matters, stultifies progress so much that there is a reluctance even to embark on the redeployment of resources that is so necessary within the service. The process of consultation, combined with the weak and faltering style of consensus management, is a perfect recipe for the monumental inertia that afflicts the NHS. The introduction of general management will have to be accompanied by a considerable simplification and speeding up of the consultation process if the maximum impact on improving dynamism within the service is to be achieved.
The Government should prescribe and demand general management for all regional and district authorities, arid at the appropriate time, which may be later rather than 691 sooner, for all units. However, as the thoughtful and helpful papers of chief administrators and the King's Fund suggest, there is more than one way of skinning a cat. There is more than one model for general management. I should like to urge my right hon. Friend the Secretary of State to leave authorities some flexibility in the form of general management that they adopt while ensuring, by careful monitoring, that they accept and adopt the spirit of Griffiths.
I repeat that I support whole-heartedly the spirit of Griffiths, although I have no illusions that general management is a panacea. I acknowledge that flesh needs to be put on the bones of the report by the Griffiths team. However, the enthusiastic but flexible implementation of Griffiths can mean that 1984–85 heralds a completely new era of dynamic management within the NHS. That is a goal that few who are interested in the care of patients would forsake.
§ Mr.Kevin Barron (Rother Valley)
First, I thank the Select Committee for producing its report on the Griffiths report. I am also grateful for the opportunity that we have to hold this debate, although, like the members of the Select Committee, I feel that it would have been better if it had taken place not on the Adjournment of the House but in different circumstances.
The first recommendation of the Select Committee was, in effect, that the Government should lay before the House the responses of the health authorities to the consultation letter sent out by the Secretary of State for Social Services last November. Since I became a Member of the House last June, I have been in touch with the area health authority through the district management team meetings. Before that date, my only contact with the NHS had been consultations with my GP or visits to my local hospital as an outpatient.
The problems experienced in running the NHS need to be debated in the House. In particular, we ought to debate the problems of the district management team and of management at local level.
The report sent by the Rotherham district health authority to the Secretary of State was not allowed to be published, but I have a copy. Having read the Griffiths report and the evidence in the Select Committee report, it is interesting to see what my district health authority was saying last November.
When giving evidence to the Select Committee, Griffiths said that the heart of his report concerned the question of general management within the NHS. My district health authority, in its response to the Griffiths report last year, emphasised the same aspect.
The Rotherham district health authority believes that inadequate attention had been given to recent developments in the NHS. The annual review process and the union-management groups were the result of the 1982 reorganisation in 10 years. It was difficult to assess the results of the 1982 reorganisation last autumn, because insufficient time had elapsed. Some of the management arrangements recommended in the 1982 reorganisation had not been set up when the Griffiths inquiry was started. It is remarkable that hon. Members can talk about the need for change in the management of the NHS when we have not seen the results of the changes required in 1982.
692 The Rotherham district health authority also commented that the appointment of general managers at regional, district and unit level could create considerable communications problems if they had not been subject to the same discipline in other areas before their appointment. However, the authority's major concern was that the appointment of general management could lead to a major change in the relationship between members, the chairman and the officers of the health authority. The authority feared that the general management function would interfere with the role of the chief officers of the health authority and the exercise of professional judgment, and that there could be a major change in the existing situation in the health authorities.
When the Minister for Health replies to the debate, will he tell us how the Government view the possibility of conflict between general management at district and area level about how best to spend money? What would happen if someone's professional judgment conflicted with the general manager's idea of where the money should be spent?
The only occasion on which I went to see the Select Committee at work was when it was taking evidence from Mr. Roy Griffiths. Halfway through the proceedings he started talking about moving things into the general practitioner territory or into the hospital to give better value. The Chairman asked:
By 'things' do you mean patients? They are what doctors treat.Mr. Griffiths replied: "Yes, indeed." It worries me that general management in my area might talk in terms of moving things around. My health authority should not be shuffling goods along supermarket shelves, but ensuring the best possible care and protection for patients. My authority believes, as do I, that successful management is based on the consent of those being managed. It believes that general management could be counter-productive.
Conservative Members have argued that consensus management has failed. If there has been such a failure in my area, it has been not because the management does not know where to go but because the authority has been funded insufficiently to enable it to follow through its decisions. My health authority has been one of the most poorly funded per head of population in the country. Through cuts it is trying to redress the imbalance. It is not true that consensus management has failed. I have worked with my health authority since being elected and do not stand to gain from saying that.
In recommendation 13 the Select Committee says that the Secretary of State should make his intentions about the future role of consensus management clear. We should define clearly what we mean by consensus management. I should like there to be much broader decision taking. I am worried that general management might diminish the role of many people in health authorities and elsewhere who make decisions on health provisions. In recommendation 14, the Select Committee suggests that appointment of general management at unit level should be considered separately from general management at district and regional levels. That should be done. As is suggested in recommendation 15, the appointment of general management at unit level should be postponed until we see how it develops at regional and district levels.
As my health authority's report is not to be published, I shall mention what it says here. It says that if any area health authority believes that the Griffiths report is right 693 and that appointment of general management throughout the NHS is right to achieve efficient and dynamic management, it should proceed. However, it does not believe that such general management will be beneficial. It is trying to make consensus management work, but it has been constrained by a chronic lack of funding.
I hope that the Secretary of State will take into consideration those four recommendations of the Select Committee's report before he finally makes his decision.
§ Mr.Steve Norris (Oxford, East)
I, in common with several hon. Members, have a particular interest in the management of the NHS, being a vice-chairman of a district health authority. That is why my instant reaction to the Griffiths report was to look at how it would affect detailed implementation at a district health authority level. I read the Select Committee's report with great interest and, unlike some of my hon. Friends, found it generally a constructive report which made a number of interesting and important observations.
I must start by nailing certain colours to the mast. One that I must nail most firmly is that I believe that the principle of general management can, will and ought to work in the NHS. Of course it is wrong to blame, as I have heard it done, consensus management for all the problems of the NHS. I agree with those who point out that it is a misleading diagnosis and ignores the complexity of the service, and what has already been referred to today as the pluralism of responsibility in the NHS which necessarily demands a more sophisticated management technique than might be appropriate elsewhere. Therefore, I do not accept that one should replace the present consensus arrangement with the sort of entrepreneurial management which might have proved extraordinarily successful in the commercial context, but which I once saw described on a small sign on a chief executive's wall which said, "Be reasonable, do it my way." That may be—many would argue it should be—the thrust of real entrepreneurial management in the private sector, but it is not necessarily the technique one would wish to bring to bear on the NHS.
If one accepts — as the Select Committee's report does—that consensus management has some defects in terms of speed of implementation, ability to take quick decisions and to respond as quickly as might be desirable, and if one equally accepts that full-blooded entrepreneurial single-minded authoritarian management is inappropriate, one must ask whether the two can be reconciled and reproduced in a form which is appropriate to running a body such as the NHS.
I gain much comfort from two salient points. One is that the Health Service, while complex and individual, is not unique in being concerned with people, in having to respond to people's problems — in being a people-oriented service. The education service and social services committees are equally concerned with individual problems and the complexity of family and personal relationships. Yet, as has already been pointed out, they are all characterised by individual leadership. We should draw a lesson from that as to the appropriateness of leadership and management in the provision of hospital services.
I also take much comfort from, and see much common sense in, the conclusion of the Select Committee in paragraph 64, which says: 694No general manager would press ahead with policies universally opposed by medical advice unless he had the full backing of his Authority.That should be pointed out to the BMA and others who have raised objections to the principle of general management.
As I understand the report, the BMA accepts that an authority's decision will have to be implemented. Therefore, one sees the thread of common sense far imposing leadership. That is a word which I much prefer to management and therefore, to that entrepreneurial and autocratic definition of management which can be so unhelpful to us in this context.
It is ironic that, as a result of that, the question whether consultants' contracts should be held at regional or district level is irrelevant. The implication behind the argument that the consultant's contract should be held at district level is that once an authority has a consultant under contract it can throw clinical freedom out of the window. That is patently not the case. One inevitably concludes that, whether or not a consultant is directly under contract to the health authority, the general manager will be obliged to take the clinicians with him in his decisions arid objectives. We are talking, not about big stick management, but about intelligent management.
Despite my earlier example of autocratic management, private enterprise also recognises that intelligent managers manage with sympathy and with more carrot than stick. That is how I see management in the NHS proceeding.
I was glad to hear my right hon. Friend the Secretary of State say that he favoured the almost universal application of full-time appointments for general managers. It was a shame that the Select Committee emphasised the cost of general managers and said that the House should be told that the potential cost was £3 million and perhaps four times as much if unit administrators were included.
I believe that the report was right in saying that any general manager who would could not save at least his own salary would not be worth employing under any circumstances. There is a crucial difference between such management appointments and the simple administrative reorganisations of 1974 and 1982. Some of us were not surprised that the 1982 reorganisation became more expensive than was originally contemplated. That was largely because it was an administrative reorganisation and not a regeneration of management within the service.
Parliament can be reassured that the concept of a general manager must be based on the fact that his first duty is to earn his money. I regard that as the first duty of each member of the staff in my business, and I believe that the general managers will be capable of doing a great deal more than that.
I hope that my right hon. Friend the Secretary of State will come to a firm conclusion on limited contracts. In the pure environment of management, one wants to put managers under pressure to achieve the objectives set out for them. It has been suggested that that should involve limitation of contracts, but I see many difficulties in that. What would we do if an administrator wre appointed general manager and his results were not impressive? Would he be fired? Would he take voluntary retirement? What sort of option would that be for a man in his early 40s? Would he be returned, in parliamentary terminology, to the Back Benches or shoved sideways into another authority?
695 The matter is exposed by the Griffiths report, and I do not suggest that the problem is insoluble, but, as one who will be working with an administrator, I believe that we must think the matter through an come to a definitive conclusion. On balance, I am against the limitation of contracts. That would be undesirable.
Should the whole report be implemented straight away? More than one hon. Member has mentioned that it might be desirable to postpone the appointment of unit general managers. I do not think that it would be appropriate to postpone those appointments simply, as the hon. Member for Rother Valley (Mr. Barron) suggested, to see how the original appointments work. However, I think that it would be desirable to postpone them, because, without clear policy lines being laid down for district general managers by regional district managers, and without a framework in which unit general managers can be accountable, it would be almost impossible for authorities to control the simultaneous launching of unit and district general managers, who may not be able to fulfil their objectives without the benefit of serious consultation with the district health authority if they are to achieve a coherent programme of work. Thus, there is a strong case for putting the system into effect on a pyramid basis and for leaving the unit appointments until we are sure that the district appointments are working satisfactorily and, most importantly, that they have criteria and objectives that unit managers can then interpret.
I have a personal plea to make. As an authority member, I wanted to enter into the spirit of the 1982 reorganisation and allow units of management as much autonomy as possible under the present system. I have always felt that that is highly desirable, and that all health authorities should be doing that. However, there has been an unfortunate repercussion from that. The very notion of delegating responsibility can mean that the authority is the last to know of a development that it might have wanted to discuss before its implementation at unit level. I have direct experience of that, but I shall not bore the House with the details. However, it points to the fact that if the Griffiths report is fully implemented without some thought as to the role of authority members, there is a danger that only the chairmen will have the ability to respond instantly to the decisions of unit and district managers.
That, in turn, will only serve to emphasise the gulf that already exists between chairmen — who are part-time paid appointments — and the other members of the authority, who will come to be seen even more as mere laymen, who do not have the ability to respond to, or command the policy for which they are notionally responsible. There is a danger that the authority's role may be misunderstood. People may ask us why we cannot change policy at a unit level, and I doubt whether they will be very impressed with the response that we have delegated responsibility down the line. They will reply that we are the authority and it is our responsibility.
I was delighted that my right hon. Friend the Secretary of State made it clear that he wanted this debate to be held before he came to a final conclusion. I agree with the philosophy of looking at the evidence of the Select Committee and this debate before embarking on a definitive programme. I am also delighted to reiterate his point that we are at least discussing how, and not whether. I look forward to the implementation of the Griffiths 696 report, because it can lead to a more effective, more responsive and better managed service. We shall then be able to devote the greatest possible proportion of the huge resources given to the NHS to the direct care of patients.
§ Mr.Roy Galley (Halifax)
It is interesting to note that in the evidence to the Select Committee and in this debate no one has significantly challenged the diagnosis of the problems facing the Health Service given by Mr. Roy Griffiths and his team. The diagnosis is not in question. Indeed, as the debate has progressed the prescription in generic terms does not seem to have been significantly challenged. The only point at issue is the branded item which will be administered to the patient.
Let us keep well in focus the ethos behind the Griffiths report. There must be a final, responsible, accountable decision taker at each stage. Much has been made of consensus management. I believe that we are misleading ourselves. Management is based on consultation. One consults and then one decides. There is no stark dichotomy between the two processes. Somebody must take the final decision.
Some people came to the Select Committee fearful of autocracy. They pleaded for consensus because they believed that the alternative was autocracy. I believe that such people—including some hon. Members who have spoken today — deeply misunderstand and misinterpret the concept of management if they see a division between consensus and autocracy.
The hon. Member for Oldham, West (Mr. Meacher) said that the Select Committee's report was balanced. Despite some of the controversy this morning, the spirit, ethos and generic prescription of the Griffiths report was welcomed by the Select Committee. Not enough emphasis has been placed on the Select Committee's welcome of the report, although the mechanisms suggested may not be fully agreed. Mechanisms have tended to cloud some of the basic principles which we need to discuss.
Let us discuss the management ethos of Griffiths—that there must be a clear decision-making procedure, that every manager needs to know what his responsibilities are, that budgets need to be controlled, and that people need to be accountable and have devolved authority. Any organisation of the size of the Health Service needs commonly accepted performance criteria against which units and managers may be measured. That basic prescription has not been challenged today. Everyone who came to the Select Committee said that he saw a need for a more coherent and effective management of the Health Service. There was no disagreement on that whatsoever.
Only the appointment of a general manager is at issue. From the basic prescription that conclusion follows as a natural corollary. There has been much debate about whether in a service-related organisation one can employ the criteria which I have just mentioned. I came to the House from a large organisation which provides a good nationwide service and in which such principles are applied. I see no difficulty in applying them to an organisation which provides services to patients on a nationwide basis.
Doctors who gave evidence to the Select Committee were deeply concerned about clinical freedom. There is no way in which management based upon consultation could, would or should conflict with clinical freedom. The managers of the NHS will have enormous problems of 697 resources and staffing without wishing to interfere with the clinical freedom of doctors. They will have problems of transport, property, procurement of equipment and so on. Those are the areas that have been under-managed until now. They will be neither able nor competent to interfere with clinical judgment.
The days are passing when doctors can stand completely aside from management. Indeed, GPs and consultants have to manage their own practices. To involve them in a wider management process is but a logical next step. They and the nurses may need a great deal more training in management techniques, and I hope that my right hon. Friend will take on board the point about training made by the Select Committee. Under the Griffiths concept of the NHS, the role of doctors will be an extension of what they are already doing.
I have found it disappointing that some organisations that represent doctors have come to the Select Committee and issued documents that have tended to take a prima donna approach. The days when doctors can be allowed to take such an approach are passing — and, indeed, should have passed. Many doctors within the NHS agree that they need to know the cost effects of the decisions that they make. They need to evaluate options both clinically and financially in the interests of their patients.
My right hon. Friend is well advanced in establishing central management machinery. I ask him to ensure that that machinery keeps to the essentials of policies and does not interfere generally. I know that that is implicit in Griffiths, but it is important that Parliament and my right hon. Friend should take that point on board. They must allow the regions, districts and units to get on with the job of day-to-day management.
I hope that my right hon. Friend will move quickly to appoint general managers in regions and districts. Many of those who gave evidence to the Select Committee were fearful of another major reorganisation and upheaval in the Health Service. Providing that job descriptions are sensibly set, and relationships are clearly defined, there appears to be no need to shy away from the plea in the Griffiths report for speedy implementation. Nothing could be worse than either a long-drawn-out process or one where people, having been appointed, do not know clearly what their role is within the new set-up.
In setting out those relationships — which is a necessary prerequisite of any appointment—there will be no conflict with professional criteria and judgment. The role, objectives, projects and responsibilities of medical officers, nursing officers, managers and personnel in finance, supply and so on—all reporting to a general manager —can be readily defined, as they are in practically every other large organisation whether it provides services, sausage rolls, or whatever.
I urge my right hon. Friend to proceed with caution on units. Some units are still in the midst of change and to superimpose quickly another change upon them could undermine their effectiveness in the short term. That need not deter the establishment of management objectives and budgets and, at a later stage, the extension of general management principles. Many people have suggested to my right hon. Friend that there should be a considerable degree of flexibility. A degree may be right, but in the regions and districts he must appoint full-time, full-blooded general managers.It may be that for the smaller 698 units a part-timer could be considered, but I plead with him to shy away from the nominalist approach. We need a clear leader and not the concept of a primus inter pares.
Within that, there is the possibility that there could be either an executive board or varying structures on a supernumerary basis. I hope that, having decided on the principle of a general manager for regions and the districts, my right hon. Friend will allow the details of the structure beneath that general manager to be set by the appropriate authority and that he will give them that degree of flexibility.
There has been much concern about personnel management. It is inconceivable that an organisation as large as the Health Service should not have a committed and specialised personnel management function. One can no longer leave this function, which is increasingly complex, to the amateur. To establish personnel management throughout the Health Service would bring no conflict with national agreements on pay, hours and working conditions or with parliamentary accountability. Nor is there any conflict, although many people have expressed concern about it, with continuing code review board procedures.
There has already been mention of the cost aspect, and there will undoubtedly be, in terms of more accountancy and personnel involvement and the appointment of general managers, some additional cost. However, in view of the fact that in 10 years the staff in the Health Service has doubled, and that there has been an enormous increase in administrative, clerical and ancillary costs, it must be possible to accommodate that transition within the existing budgets. There may be some temporary readjustments of funds. It is vital that we do not allow patient care to suffer instead of administration. If we are to have a streamlined management, the costs must come from administration.
We have been largely speaking about management systems, but no management system is a panacea. The appointment of general managers per se will not solve the Health Service problems. The quality of managers will be vitally important, and the best managers are those who are on the factory floor, the shop floor—the ward. We have to ensure that the managers in the Health Service are in touch with the wards and the detailed day-to-day working of the hospitals and do not hide behind a smoke-screen bureaucracy.
One of the besetting sins of the Health Service over the past 10 years has been that the report has become more important than the patient. The dynamic, the whole basis, of Griffiths is that the consumer, the customer, the patient comes first. To appoint general managers will not achieve that. There must be much impetus to come after we have gone through the initial stage.
§ Mr.Tim Eggar (Enfield, North)
Few hon. Members have challenged the theory of Griffiths. Most of the discussion has been about whether the theory will work in practice, and there are a number of pre-conditions to ensure this. The first is that districts and regions must be able to go outside the Health Service to recruit general managers. That means specifically that they must have control over the salary levels of the general managers. I trust that the Department will not try to set down grades and supplements for pay.
The second pre-condition is that, while it is right that the Department insists on general managers at district and 699 regional level, I hope, together with other hon. Members, that it will not insist on general managers at unit level. That must be left to the discretion of individual district health authorities. As a general rule there should be unit managers, but it may not be appropriate for all units in all districts.
The third major pre-condition is that the functional reporting must be directed to the general manager at both district health authority and regional health authority level. The general managers must have responsibility for what is going on.
The first consequence of that is that there is no need for functional officers at regional level. They can be done away with. There is no need for functional activities there. The second implication of that is that the present DMT members and the heads of the other professional bodies must report direct to the general manager. They can have no right to go direct to the district health authority. They must go through the general manager.
The third implication is that I, together with the hon. Member for Oldham, West (Mr. Meacher), regret very much that consultants' contracts rest at the moment with the region rather than with the district. I accept that my right hon. Friend the Secretary of State is unlikely to change that. That being so, he must make it clear that responsibility for the budgeting is direct to the general manager at district level, even though the contract lies with the regional level. Consultants are prima donnaish enough, anyway. We cannot have them having the right of appeal to regional level over and above the district. They must report on budgetary matters to the general manager at district level.
The fourth pre-condition is that the DHSS must set the example. It must be prepared to lay down the policy and to devolve the decisions on its implementation first to regional level and then to ensure that the region gives as much discretion as possible to district, in the implementation of the policy. We must have it flowing down. If we go on having the present amount of control from the centre, by which I mean both from the Department to the region and from the region to the district, Griffiths will be stillborn.
Griffiths is a major opportunity. We must seize it. But we must give the general manager real powers of implementation.
§ Mr.Roger Sims (Chislehurst)
I am grateful to my hon. Friend the Member for Enfield, North (Mr. Eggar) for speaking more briefly than he would have liked to give me an opportunity to make a brief contribution.
I do not intend to dilate on a definition of "management", but it seems to me that at the end of the day management is essentially providing leadership and drive. It might even be said to be jollying people along.
The in word is "consensus", but it means taking decisions about what needs to be done and ensuring that those decisions are carried out. However, even if the manager does not often have to impose his decisions, it is important that he has specific authority and responsibility. I endorse what my hon. Friend the Member for Oxford, East (Mr. Norris) said. The manager's relationship at district level with the chairman, the health authority, chief officers, unit officers, and not least the consultant medical 700 staff, should be clarified beyond doubt. I also endorse what has been said about where the responsibility for consultant staff lies. In turn, the authority must define its objectives clearly so that management knows where it is going.
All that having been established, the management and the authority must be left to get on with the job. I remind my right hon. Friend of paragraph 12 of the Griffiths report, which suggests that his Department should to some degree withdraw from involvement and let the managers and the authority get on with the job.
As for who should be the managers, my experience in business is that those who could provide the leadership and the drive, given some training, are to be found in many disciplines — accountants, marketing men, engineers, and so on. All can become first-class managers. Similarly, there must be potential managers in the many disciplines available in the Health Service.
I do not rule out the possibility of part-time managers. There are those involved in medicine who may have the management qualities but who may be reluctant to withdraw from the work for which they are qualified and may have a vocation to follow. It is not possible to draw a precise parallel with the Health Service, but, for example, it has always seemed to me unfortunate that a good social worker could promote his career prospects only by going into administration, thereby no longer performing the day-to-day social work for which he was well suited. That is rather different from the position in the probation service. A senior probation officer has what might be described as managerial responsibilities but retains a case load, albeit a reduced one.
There are few who are natural managers and who cannot benefit from some training. It is particularly important, therefore, that as Griffiths is implemented there are adequate facilities for training. The need for management cannot be doubted. I need not go into the figures that have been produced by the increasing use of performance indicators on the administration side. One appreciates that one immediately gets into difficulties when asking consultants, say, why one consultant keeps his hernia operation cases in hospital for two days and another for seven days. We then get into the whole realm of clinical independence.
But this area cannot be sacred. A balance must be struck between staff costs—which, after all, represent 75 per cent. of expenses — the costs of cleaning, laundry, catering, and so on, and the cost of drugs and equipment and the scale and types particularly of the more sophisticated types of operation.
I have been talking of general management at the district level. It should not be introduced on a rigid timetable, because local circumstances vary. At this time, with the problems of limited resources and increasing costs, with more and more sophisticated equipment and drugs, the emphasis must be on the desirability of implementing the management concept so as to make the best use of the limited resources.
I invite my right hon. Friend to consider whether general managers are so urgently needed at the unit level. Unit management teams often consist of small groups which meet to resolve day-to-day problems. If there is s case for general management at that level—it could lead to administrative and financial complications—I suggest that it should wait until the district general management structure has been well established.
701 There seems to be general acceptance of the Griffiths analysis. The need now is to develop in the NHS what Mr. Tom Evans, the director of King's Fund college, has described as "a management culture". There will be doubts about exactly how it is to be implemented, and it is inevitable that there will be concern, particularly among the professional bodies. I hope, however, that my right hon. Friend, having studied the responses that he has received and having heard this debate, will take the bull by the horns and go ahead.
§ 2.3 pm
§ Mr.Frank Dobson (Holborn and St. Pancras)
This has been an interesting and thoughtful debate. I hope that not too many people will consider that I am lowering the tone. I do not have time to go through the list of hon. Members who contributed, and I hope that my fellow males present will not object if I single out for special attention the speeches of the two hon. Ladies.
In particular, I must mention that of my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short), who has chaired the Social Services Committee in a most distinguished fashion, and we owe her a great deal on all matters to do with health and social services. She has the respect of all the members of the Select Committee, and she added to our respect by her presentation today of the Committee's views.
In fariness to the hon. Member for Derbyshire, South (Mrs. Currie), who is not now in her place and who was the butt of a joke of mine last week, I must say that I differed little from most of what she said in her well-informed speech, and even on those matters with which I did not agree her remarks were well delivered and thoughtful. I understand that she has left to have a crown fitted, not because of her speech today, but because, regrettably, she must pay another visit to the dentist.
The problem for the Government when proposing anything to do with the NHS is that people in the service are wary of any further propositions for change. They approach any such proposition, in Wordsworth's words, "not in entire forgetfulness." They cannot forget the track record of the reorganisations to which they have been subjected repeatedly.
In 1973 the right hon. Member for Leeds, North-East (Sir K. Joseph) reorganised the Health Service wholesale. He was advised in that matter, at great profit to the advisers, by McKinsey and Co., the American management consultants. Those consultants and the right hon. Gentleman said that there would be a massive improvement in the efficiency of the NHS. By 1977, some of the partners of McKinsey and Co. were saying, according to the Daily Telegraph, that the reorganisation of the NHS, in which they had played a major part, had been a failure. That was the view of the experts who helped to plan the NHS. The consultant's report said:
Something has clearly gone wrong.It went wrong for many people in the NHS. I suspect that none of the McKinsey consultants suffered in any way. Indeed, their bank balances were probably supplemented by the further work that they did proving that their original work was wrong.
The Tory Government who came into office in 1979 did not take long before wanting a further go at reorganising the NHS. In 1982, the right hon. Member for Wanstead and Woodford (Mr. Jenkin), who is now the Secretary of State for the Environment, reorganised the Health Service.
702 He is now trying to persuade everyone that English and Welsh local government should be reorganisd. The aim was that major structural change would immediately make the NHS more efficient. The right hon. Gentleman said that it would be necessary to abolish one tier. He may have been right. The right hon. Gentleman also said that the measure would save on administration. The immediate effect of the abolition of that tier of administration was an increase in the proportion and number of administrators in the NHS.
It is interesting to note that, in the consultation document issued in the process of that reorganisation, the Government specifically rejected the idea of appointing a chief executive. The Government said that that action was irreconcilable with the proper relationships of the professions in the NHS. Apparently, that was a conviction. We are told that this is a "conviction Government". It would appear that the convictions about which the Government talk are similar to those in the Rehabilitation of Offenders Act 1974—they are wiped from the record after the passage of time.
We are faced with yet another reorganisation. It is no good Ministers pretending that this is a small technical adjustment or a piece of fine tuning. A substantial change is proposed. I am worried that this measure is being undertaken against the background of a desire to further the impression that the NHS is in some way spectacularly inefficient. That is —I am not attributing this to any hon. Member, Mr. Deputy Speaker—a downright lie.
Britain spends only 5.6 per cent. of its national wealth on health; France and West Germany spend 8 per cent. on health; and, according to some estimates, the United States spends no less than 10 per cent. on health. People in those countries are no healthier than we are and are no better served than we are. The NHS spends 4.7p in the pound on administration; France spends 12p in the pound, or so many centimes in the franc; and the United States spends 20p in the pound, or so many cents in the dollar. The United States spends so much because it has commercialised medicine. Because many people cannot afford to pay for their operations, the United States runs the largest group of debt collecting agencies the world has ever known. We want to reject that sort of "efficiency", as the Tories regard it.
Conservative Members should remember that if British private industry had been as comparatively efficient in international terms as the NHS the country would be much better off. British car and motor cycle manufacturers would be planning to build in Japan, instead of having to go with a begging bowl to get. Nissan into county Durham. Some Conservative Members say, "Manufacturing is passé. Finance is our forte." Let us examine the point about finance being our forte. The Midland bank was probably helped by a general manager when it decided to buy the Crocker bank of California. Up to now, it has lost only £75 million on that transaction. Therefore, the NHS does not have a lot to learn from people in private management in banking or manufacturing.
Mr. Griffiths is from Sainsburys. We should not be prejudiced against grocers, not in a nation of shopkeepers, even if some Opposition Members are prejudiced against grocer's daughters. I have a particular prejudice against Sainsburys, because, contrary to popular belief, it does not expand in all directions. I used to habituate a branch of Sainsburys in Drury lane, Covent Garden, but the 703 company withdrew from trading there. It must be the only company in Britain that felt that there was no future in trading in Covent Garden. Somebody else took over the shop and seems to be making quite a profit out of it. Therefore, even in Mr. Griffiths' own sphere I am dubious about his proposals and am not impressed by what he has said.
One of the things that bothers me about the Griffiths report is that in many ways it seems superficial and approaches things from a view which I do not recognise. This is the report's view of the NHS:
Above all, of course, lack of a general management process means that it is extremely difficult to achieve change. To the outsider, it appears that when change of any kind is required, the NHS is so structured as to resemble a 'mobile': designed to move with any breath of air, but which in fact never changes its position and gives no clear indication of direction.To people working in the NHS, or those who are dependent on and interested in it, the idea that it is an unchanging body seems utterly remarkable and quite loony. One of the biggest problems that the NHS faces, from the point of view of both the patients and those working in it, is that it never stops changing. It is said that it is infantile if, after one has planted something and it grows a bit, one pulls it up to have a look to see how it is getting on. That is what is happening all the time in the NHS. When there has been a change, before people have had the time to settle down, before there is stability and before those people have re-established their relationships with colleagues in their own and other professions or started to exercise the skills in which they were trained and in which they rightly take pride, someone shifts the whole scene and they do not know what they are doing.
There has been a great falling off of morale in the NHS. There is confusion and depression, and the Griffiths report has contributed to it. Its most famous and best quoted sentence is:
In short if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge.If Florence Nightingale did carry her lamp through the corridors of the NHS and the hospitals she would find professionalism, a high standard of care, dedication and commitment in skill. She would not find what she found in Scutari—cheap Jack profiteers and parasites. Today she would also find people who are sick to death of being criticised and not being able to settle down and do their job properly.
I am still not clear whether the Secretary of State intends to appoint what might be called a director general of the Health Service—
I am glad that the right hon. Gentleman is not doing that. The Minister for Health said earlier this week that central interference would not be possible because the Department of Health and Social Security did not have the staff and competence for it. At least we will be spared that. It is proposed that general managers will be introduced at district and unit level. At the time of the Soviet revolution, the motto was,All power to the Soviets".The motto of the Griffiths report—
I am afraid that I do not have time to give way.
The motto of the Griffiths report is "All power to the district chair and the general manager." If I were a member of a district health authority, I should be perturbed. Many of the people with whom I am in contact already feel that they are left out too much from the decision-making process and that they will be left out further by the proposals.
I am sorry; I do not have time.
Relations between the professionals and a general manager have raised problems to which neither Griffiths nor the Government have given adequate attention. It is fair to say that both the medical and nursing professions are, to say the least, dubious about the whole thing. They are dubious about the principle of the general management supervisor. Over the years they have become used to the consensus style of management. Like other styles of management, consensus has its problems, but over the years people have begun to learn how to cope with the problems that arise from consensus. Consensus has its advantages, too. In so far as the Government left the DHAs and the units alone, better relations are being developed and improvements are being made.
People are committed to exercising their skills, not just severally, but jointly to improve the service. The best thing that the Government could do would be simply to help those who are moving in the right direction in improving the management of their areas and their units, and to encourage those who are not moving as far as the Government would like. That would be legitimate. The Secretary of State has told us today that, in the case of the unit level general managers, he will issue guidance. What will be the status of that guidance? Will it be an instrument in writing which the districts have to obey, or will it be genuine guidance which they can reject? If one does not agree with one's guide, one is free to go the other way. If the Secretary of State is to issue instructions, I believe that the imposition of general managers—at unit level in particular—will be a hammer blow to those who work in the NHS. Those people have many reservations which have not been dealt with by those who are in favour of general management. If the Government cannot make out a case that will convince the professionals in the NHS that the replacement of consensus management by general management principles is a good thing, that will demonstrate, not that there is anything wrong with those who work in the Health Service, but that there has been a failure on the part of the Government to produce any good ideas or any arguments that can convince people who are always on the lookout for ways to improve their performance.
There is an element of irresponsibility in the NHS. There is buck-passing. Most of it is done by Ministers. When any hon. Member or any citizen makes a complaint about his local health service or district health authority, Ministers always say that under the present system it is nothing to do with them. They say that, after they have allocated the money, all the decisions are made within the Health Service. We need a clearer identification of the responsibility of Ministers for their own decisions.
I am not in favour of increased centralisation. We have had plenty of the worst form of centralisation, which enables men and women to take a decision and then hide behind someone else. It is the Pontius Pilate principle in practice, and that is what we want to get away from.
I intend to keep my promise about the length of my speech. My final point is that the National Health Service was founded on two basic principles expressed in the Labour party's 1945 election manifesto: that the best health services should be available to all, and that money should no longer be the passport to the best treatment. The present Government seek to undermine those unimpeachable principles. Few people support them, and the Labour party is dedicated to protecting the NHS from cuts and threats and from changes in its organisation which are likely to damage the service which all the dedicated professionals in the NHS want to provide. If the Government decide to go ahead by fiat and impose general managers on the units, they will have a fight on their hands, not just with the Labour party, but with the whole of the National Health Service and with everyone who treasures that service as the Tories have never treasured it.
§ The Minister for Health (Mr. Kenneth Clarke)
The hon. Member for Holborn and St. Pancras (Mr. Dobson) and I are always in danger of lowering the tone of debates such as this as we are not always averse to a little combative political debating. If I were to give in to the temptation, as I fear he rather did in his peroration, I might take up with him the implications of what he said about the extra spending engaged upon in other countries that do not produce better health care than we enjoy. It might follow on from what the hon. Member for Oldham, West (Mr. Meacher) finally conceded — that there must be some limit to the resources available to the NHS.
I should like to tease the hon. Member for Oldham, West about his admission, at last, in the clearest terms that I recall that better management has a contribution to make to the NHS, but this has not been that type of debate. As I predicted, it has not been well attended but those who have come have an interest in the Health Service and have something to say. We have practically run out of time and it requires self-discipline to enable everyone to have the opportunity to speak. The debate will be widely read outside as there is enormous interest in the subject. This is an important stage in the process of debate and consultation that we have engaged upon now that we have the Griffiths report.
The hon. Member for Oldham, West was being mischievous when he kept going on about our six weeks' consultation. One of the steps that we took was to send a letter to chairmen, asking for a response within six weeks. We extended that time.
There has been extremely wide debate and discussion throughout the service about the Griffiths report ever since its publication. My right hon. Friend and I have tried to take part in that discussion and regard consideration of the Select Committee report, the evidence that it took and today's debate as important stages before producing final decisions and the required guidance.
Another thing which has come out of the debate, as several hon. Members have said, is general agreement that better management has something to contribute and that the Griffiths analysis is right. Bearing in mind what has 706 been said today, we all ought to join in paying tribute to the Griffiths team. With respect to right hon. and hon. Members on both sides of the House, it is time that the Sainsbury jokes were dropped. Three business men, from a wide variety of industries, were involved in the team with a fourth business man who is an ex-trade union official and longstanding chairman of a health authority. It was a team of wide experience that produced an analysis of the way in which management in the service might be improved. That analysis is scarcely challenged by anyone who knows anything about the Health Service.
As we have accepted the broad direction of Griffiths' recommendations, the issue is how to implement what is proposed and how to get the best out of it by improvement of existing management. I understand that people fear that the report will lead to the upheavals of a fresh reorganisation. I entirely agree with those who say that they do not want the turmoil of full reorganisation again. I took on this job when the process of the last reorganisation was under way. The last reorganisation was desirable as it took out a tier of administration and got more responsibility down to the districts, nearer to patients. The process of implementation was extremely difficult and put great strain on the staff. I watched with horror for almost two years as nobody knew whether they still occupied their jobs, jobs were being advertised and authorities that wanted to get on with appointing their officers were told that they could not until other slower ones got in line. That was not because of Ministers—it was consensus management and the staff side agreeing through Whitley councils to go through that extraordinary process which harmed the service.
I wanted to stop it, but I was told that I could not as there was a Whitley council agreement and that Ministers should not interfere in such matters that were widely accepted in the Health Service. That is a feature of how we have done things which might be avoided in future.
We need decisions on Griffiths and therefore we need a reasonably concise process of discussion and debate. People in the service want decisions from my right hon. Friend and a reasonable and sensible way in which to implement them. They do not want further uncertainty or the types of problems that we have experienced before. That is attacked and criticised as part of a process of centralisation. I shall not be drawn into that debate with the hon. Member for Holborn and St. Pancras. When he wants Ministers to say why a given number of beds are not available for a particular specialty in Gateshead, he seems to be asking for rather a lot of centralisation rather than the other round.
Centralisation is definitely what we do not want. The Griffiths' proposal is a logical next step from what has been done in the past four or five years to stop things being run from the centre and to give day-to-day responsibility not only to the districts but preferably to the units—the people near to the patient who are best able to take decisions.
What is required at the centre is not detailed supervision but the necessary strategic guidance, the holding to account, the management, in order to keep up standards of performance and to enable those in the locality to define their objectives and then to make sure that they keep to them.
707 We cannot be accused of centralisation when we now have 20 per cent. fewer staff at headquarters working on this. The Griffiths report suggests that that number could fall further. Moreover, we are trying to strengthen our strategic role while dispensing with a great deal of functional supervision, which I accept is unnecessary. To improve our relationships with the districts an administrator from the Health Service, Mike Fairey, who is well known to many people in the Health Service, is helping us to reduce the lines of communication with the districts and regions. We are also trying to reduce the amount of paper as well as telephone calls and contacts that flow backwards and forwards between the Health Service and the outside world. We have reduced the number of DHSS circulars to 600 a year from about 2,000 a year when we started the process. My right hon. Friend the Secretary of State and I do not think that 600 a year is few enough and we also want to consider the "dear administrator" letters.
Much of that is in response to requests from the Health Service. The culture of the Health Service induces local managers and officials to telephone and pursue the Department asking for detailed guidance rather than taking on themselves the kind of management responsibility which, as Griffiths says, should be taken on at the local level.
The hon. Member for Stretford (Mr. Lloyd) and others have asked us about changes in the Department. They are already under way. My right hon. Friend showed his acceptance of the broad principles of Griffiths by setting up the supervisory board and the management board. We have given to the Select Committee details of the interim arrangements. Someone asked why we have not given more details.
The next step is to appoint the general manager. That post is now being advertised. When that appointment has been made, we can begin to appoint the management board. At that stage, we shall settle the final arrangements within the Department and then report to the Select Committee about those arrangements. The hon. Member for Wolverhampton, North-East (Mrs. Short) will get those details. The objective is to strengthen our strategic control and to enable us to hold to account properly the regions and the districts in the service, not to increase the centralised detailed control of day-to-day decisions.
Many hon. Members have expressed interest about the position and role of the chairmen and members of authorities. I must emphasise that not only is the statutory position not altered but nor is the factual position of those 708 authorities. They are the people responsible to my right hon. Friend for the Health Service. They are the policy makers. The chairman of the authority, supported by his members, will provide leadership to the authority.
The management, however we organise it, is answerable in the first place to the authority in the way in which it performs. It is answerable for the delivery of the policy objectives which the authority shall set and the authority will review the procedure and, in the case of a district, is answerable to the region—the chairmen and the members of that region—for the way in which they are performing and achieving their objectives. My hon. Friends the Members for Oxford, East (Mr. Norris) and for Gillingham (Mr. Couchman), experienced chairmen and vice chairmen of district health authorities, will appreciate the clear accountability of officers to an authority. They will see no threat in what is proposed to the role of members of an authority.
I was asked whether authorities would have flexibility in their arrangements. The hon. Member for Leeds, West (Mr. Meadowcroft) said that we do not want one uniform national solution. We agree with that. With respect to my hon. Friend the Member for Derbyshire, South (Mrs. Currie), I must say that I do not know who said that general management would solve everything or who prescribed a univeral national system.
Flexibility must not mean that people are allowed to go through the motions of general management. They must make sure that the general management function is carried out in their regions, districts or units in the way that is most appropriate to deliver the objectives that Roy Griffiths and his team have identified. We need that sort of flexibility, along with flexibility on time to allow units to take a little longer in reaching their decisions.
The debate has shown that improvements can be made in management. The Select Committee report also suggested that. The NHS is not perfect, and defining the general management function is one improvement that could be made. We need clear guidance and help to enable us to make—
It being half-past Two o'clock, the motion for the Adjournment of the House lapsed, without Question put.