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Commentary from WestminsterGriffiths under Scrutiny by Select Committee

IT is a relief to the Social Services Secretary, Mr NormanFowler, that the Commons Select Committee on SocialServices has accepted the general thrust of the Griffithsreport on management reorganisation in the NHS. TheGriffiths inquiry had already stirred up sufficient distrustamong doctors and administrators to give Mr Fowler pausefor thought. Implementing the proposals as they stand wouldplainly cause great disruption while there is no guarantee thatreal benefits would ensue. But conditional approval from theSocial Services Committee-amounting indeed to rejection ofsome of the key Griffiths suggestions-means Mr Fowler willhave some valuable support in his attempts to implement themore promising of the changes proposed in the reportprepared by a group led by Sainsbury’s chief executive.The Select Committee made its own appraisal of the

Griffiths plan, concluding that it commanded generalagreement, inasmuch as it could lead to "more efficient,effective, and coordinated management". But with past NHSreorganisations in mind the committee, in its report on thesubject, warned that: "The potential is considerable; as is thescale of damage which a botched reorganisation at the centrecould cause". The NHS may not, after all, be susceptible tocommercial management theory and practice in the same wayas a grocery store. "The NHS may suffer more in side-effectsfrom the wonder drug of general managers than it gains inbetter management", the committee added ominously.Those side-effects could manifest themselves at the heart ofNHS administration and at unit level, in individual hospitals.There is approval, for instance, for the idea of the Secretary ofState running the NHS through a supervisory boardand-one step below-an NHS management board. But the

proposal is criticised for its vagueness (a recurring complaintagainst the whole of the Griffiths study), which has led tofears among health authority chairmen and members thatthey could simply be bypassed by such a structure. There wasan inherent contradiction between regional chairmen

continuing to be responsible to the Secretary of State, and theprojected role of the management board and its chairman.This would have to be resolved, the committee declared.Although regional chairmen would not be directlyresponsible to the management board, it would be from theboard that directives would come to health authorities.Doubts have been more widely and fervently expressed

about the Griffiths scheme for appointing general managersto regional and district authorities and at unit level. Theprinciple was quite acceptable to the Select Committee, whobelieve in devolution of responsibility and accountability.But the change should extend no lower than districts, thecommittee insisted. Its imposition on units would end theconsensus management which, though the past ten years haveshown it to have weaknesses, is more effective thanalternatives. The most serious criticism of consensus, thecommittee acknowledged, is that fundamental issues anddifficult decisions are "avoided, fudged, or delayed".According to Griffiths future constraints on funding willemphasise these drawbacks to consensus. The BMA’s fearthat general managers at unit level would impose decisionsdetrimental to patient care (to the extent that doctors mightrefuse to cooperate) were, in the committee’s view,exaggerated but "by no means wholly imaginary". The mostsensitive decisions which may have to be made at unit

level-restrictions on investigations, limitation of post-operative convalescent time in hospital, changes of use orclosure of wards-would be likely to cause much frictionbetween medical staff and a general manager. "The potentialfor conflict at unit level is greater than at any other. We arenot convinced that the full consequences ... were

appreciated", the Select Committee concluded.The committee was also sceptical about the financial

advisability of a system of general managers. Although MrFowler told the committee’s inquiry that he expected theappointment of general managers to cost no more than thepresent system, the committee’s report believes that hisassurance is open to further interpretation. The changeovercould, at worst, cost the NHS an extra L3 million to 4million, the committee feared.

In spite of all these reservations, Mr Fowler was quick tothank the committee for its "helpful suggestions" and its"useful contribution". He singled out the SelectCommittee’s acceptance of the broad Griffiths message that"we need to improve the management in the NHS, and thatthis cannot be done fully within the existing managementsystem". In the light of the committee’s report Mr Fowlerwill announce, probably before the end of March, what heintends to do next. Originally he hoped to implement most ofthe Griffiths proposals from this April. The DHSS has beensearching since January for chairmen for the proposedmanagement and supervisory boards. On March 21 MrFowler was to meet all 14 RHA chairman, in the normalcourse of the Department’s annual accountability review.The Griffiths proposals were a major item on the agenda. Butit is more or less certain that the scheme for general managersat unit level will now be abandoned-as the price Mr Fowleris prepared to pay for acceptance of the principle that

management change is necessary in the NHS. It is a

climbdown for which hospital doctors will be thankful.

Deputising Arrangements in General Practice

Meanwhile, Mr Fowler’s deputy, the Health Minister, MrKenneth Clarke, is loudly insisting that he has not climbeddown from his position over another contentiousissue—the extent to which GPs use deputising agencies tolook after their patients at night and at weekends. In responseto broad-based and persistent Parliamentary backbenchpressure, Mr Clarke recently issued a consultation documentwhich proposed drastic reductions in the hours for whichGPs would be allowed to use deputies. The document alsosuggested there should be more lay members on the FPCsubcommittee which control GPs’ permission to use

deputies; and it proposed that random night-time telephonecheck calls should be made by the DHSS to ensure that GPswere complying with new restrictions on deputising. Boththe proposed restrictions and the telephone checks provokeda furious and highly organised response from GPs. Therestrictions were too rigid and unrealistic, the checks wereinsulting and counterproductive, the doctors complained.Mr Clarke has bowed to this pressure on both matters. In a

new circular, he proposed merely that FPCs should lay downthe extent of deputising restrictions "in the light of local andindividual circumstances". Checks on compliance will, it isnow planned, be made only through statistics compiled byFPCs and information provided on request to the DHSS bythe deputising agencies themselves. This is in fact only aclarification of what was alwavs the DHSS’s position, Mr

1. Deitch R. Outcry about Mr Clarke’s proposals on GP deputising services. Lancet 1984,i. 60-61

2 Editorial. Deputising services in NHS general practice. Lancet 1984; i: 377.