Abstract
Griffiths R. (Chair). The NHS Management Inquiry. London: Department of Health and Social Security, 1983
2013 marks the 30th anniversary of what has become one of the most influential reports in the history of the English National Health Service. The Griffiths Report introduced a new approach to organizing health care based less on political planning or the expertise of the clinical professions, and more on the capabilities and authority of dedicated managers to administer, coordinate and transform health services in line with the aspirations of policy makers. General management laid the foundations for successive waves of reform and their influence can arguably be felt now in all aspects of care organization. Despite the potential for managers to offer more rational and accountable ways of organizing health care, they remain the subject of critical debate, especially where they are seen as wasting resources or undermining clinical quality. Today, this can be seen in reforms that aim to substitute clinical leaders for general managers and also in the findings of the Francis Report which point to the potential for management priorities to undermine patient safety.1 It is therefore timely to reflect on the origins of general management and to consider the continuing contributions that managers can make.
The substantive contribution of the Griffiths Report was the introduction of general management. Reflecting upon the existing system of consensus management, 2 the report argued that decision making was too slow, involving layers of consultation and committee, but with no individual responsible for driving change. This was powerfully articulated in the now famous line … ‘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’. The report called for a new form of general management, with ‘responsibility drawn together in one person, at different levels of the organization, for planning, implementation and control of performance’.
Arguably, the Griffiths Report was not simply about creating new lines of accountability within the NHS, but also a more fundamental shift in the culture and ethos of health care organization. Rather than relying on bureaucratic planning and professional control, the Griffiths report called for more responsive and devolved management to motivate staff, assure performance and implement strategic priorities in areas previously dominated by professionals, including the use of management techniques more commonly found in retail whence came Sir Roy Griffiths, the Report’s author. As is often the case, the NHS was at the forefront of a wider reform agenda associated with the transfer of private business and management practices into newly decentralized and disaggregated public services, which is now associated with New Public Management. 3 This laid the foundations for subsequent, more dramatic reforms. For example, the purchaser/provider split, introduced in 1991, relied upon the emerging responsibilities and capabilities of NHS managers to govern semi-autonomous Trusts operating within an increasingly competitive internal market. 4 Further changes in health care commissioning and regulation have cemented the role of managers in liaising with external stakeholders, implementing strategic change and transforming day-to-day practices. This not only includes senior managers but also those working at middle-levels with clinicians. It is also the case that, like other health care workers, health care managers have sought to ‘professionalize’ through formalizing their specialist education programmes and developing new accreditation mechanisms. Reflecting this, health care organizations now depend upon a myriad of specialist managerial positions. The proliferation of management roles might suggest the growing influence of management thinking, but also a process of sub-specialization as managers seek to legitimize their distinct contributions to service organization and governance.
General management heralded a shift from ‘professional bureaucracy’, where administrators largely supported clinicians to an era where managers proactively supervise specialist labour. An earlier analysis of US health care reforms highlighted the growth of ‘corporate rationalizers’ as challenging the monopoly interests of doctors. 5 In a similar vein, commentators have described the general manager as challenging the power and ‘clinical freedoms’ of doctors in the pursuit for service reconfiguration. 6,7 This research testifies to the complex political struggles that managers have faced, which were possibly under-estimated by the Griffiths Report. Illustrating this, research shows how attempts by managers to engender organizational change have been stymied by the continuing power of health professionals to resist change. 8
In recent years, health care managers have been castigated within public and political discourse, especially in the current climate of austerity and spending cuts. Reflecting this, politicians often describe contemporary NHS reforms as reallocating resources from the ‘back office’ to the clinical ‘frontline’ and returning power to clinicians. 9 Managers are associated with ‘red-tape’, ‘bureaucracy’ and ‘waste’, which is something of a volte-face for policy-makers who once saw general management as a means of reducing bureaucracy and curbing the power of professionals. Along similar lines, the recent Francis Report reveals how management priorities can degrade professional standards and fail to serve the interests of patients and the community.11 Like similar inquiries, it speaks of managerial strategy as dominated by institutional pressures and performance targets, as creating a culture that alienates the professional workforce, as undermining clinical standards and as lacking in accountability to patients and the public. It might be argued, therefore, that managers now find themselves the culprits, not the saviours of NHS performance. Perhaps, if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be asking the people in charge if they know what they are doing?
In contrast to the mid-1980s, policy-makers now place greater emphasis on health care professionals as taking an active role in service administration and leadership. Although the Griffiths Report anticipated that clinicians might take up the new management roles, and experience suggests that many senior and middle managers do indeed have clinical backgrounds, contemporary policy speaks less of ‘management’ and more of ‘leadership’. Clinical leaders are seen as close to the action, better understanding the needs of patients and better placed to lead change. In some ways, clinical leadership suggests a return to an era of health care organization before general management, where doctors and matrons held responsibility for ward level administration. Yet, the contemporary language of clinical leadership owes much more to Griffiths than policy-makers might suggest. Like the Darzi Report,11 the Francis Report 1 calls for enhanced professional training in leadership, the creation of a code of conduct and the development of competency frameworks against which leaders can be assessed. These ‘hybrid’ professional–managerial roles reveal how clinical practices are becoming infused with the principles, priorities and practices of management, while at the same time negating the need for managers. 8 This offers the possibility of management-inspired reforms, but without costly or wasteful ‘managers’. However, it also raises the possibility that the demands of management might overtake those of clinical practice and put at risk the very values and standards that professionals are said to bring to management. At a time when policy-makers are engaged in further structural reforms, it is instructive to reflect upon the Griffiths Report and the recent history of health care management; in particular, how social and political attitudes towards managers have changed, how clinician–managers are becoming more significant, but also how difficult it might be for them to balance professional and managerial imperatives as they take on more responsibility.