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‘I’ve Never Found Doctors to be a Difficult Bunch’: Doctors, Managers and NHS Reorganisations in Manchester and Salford, 1948–2007

  • Stephanie J. Snow (a1)
Abstract

Since 1974 the National Health Service (NHS) has been subject to successive reorganisations which have shaped and reshaped patterns of administration, clinical care and services. This paper uses two sources of oral evidence: a Witness Seminar with a group of administrators who attended the NHS National Administrators’ Training Scheme in the late 1950s and a collection of interviews with doctors and managers who have played key roles in the health services of Manchester and Salford between 1974 and 2007. It surveys the day-to-day interactions between doctors and administrators/managers in hospital settings and analyses what these reveal about relationships within the broader context of shifting organisational structures and management styles. It suggests that the evidence challenges the historical stereotyping of the two groups and that strong working relationships have been determined as much by the values of respect and association as by changes to structures or management styles.

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The online version of this article is published within an Open Access environment subject to the conditions of the Creative Commons Attribution licence .
Corresponding author
*Email address for correspondence: stephanie.snow@manchester.ac.uk
References
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1. Battistella, Roger M. and Chester, T.E., ‘Reorganisation of the National Health Service: Background and Issues in England’s Quest for a Comprehensive-Integrated Planning and Delivery Service’, The Milbank Memorial Fund Quarterly. Health and Society, 51 (1973), 489–530: 505.

2. See Charles Webster, The National Health Service: A Political History (Oxford: Oxford University Press, 2002), ch. 3; David J. Hunter, ‘The National Health Service 1980–2005’, Editorial, Public Money and Management, 25, 4 (2006), 209.

3. Committee of Enquiry into the Cost of the National Health Service, Cmnd.633 (London: HMSO, 1956), 211. See also Stephen Harrison, National Health Service Management in the 1980s (Avebury, 1994), 11–16.

4. Throughout this paper I use the common term for each period: ‘administrator’ until the introduction of General Management in 1983 and then ‘manager’ from 1983 onwards. It is, however, important to recognise that these semantic shifts, which are often assumed to be evolutionary and associated with changes in practice, are challenged by our witnesses’ testimonies as some described themselves as managers in the earlier period. Stewart has suggested that the terms ‘administration’, ‘management’ and ‘leadership’ operate as a hierarchy, R. Stewart, Leading in the NHS: A Practical Guide (London: Macmillan, 1999), but Grey draws attention to the way in which the choice of such terms is highly context-dependent: ‘the ascription of the term “management” to various kinds of activities is not a mere convenience but rather something which has certain effects. The use of words is not innocent, and in the case of management its use carries irrevocable implications and resonances which are associated with industrialism and modern Western forms of rationality and control’, C. Grey, “‘We are all Managers Now”; “We always were”: On the development and demise of management’, Journal of Management Studies, 36 (1999) 561–85: 577.

5. Quoted in Brian Watkin, Documents on Health and Social Services: 1834 to the Present Day (London: Methuen & Co Ltd, 1975), 167.

6. Pollitt, Christopher, Managerialism and the Public Services. Cuts or Cultural Change in the 1990s? (Oxford: Wiley-Blackwell, 1990), Stephen Harrison and Ruth McDonald, The Politics of Healthcare in Britain (London: SAGE Publications, 2008), 46.

7. Ham, Chris, The New National Health Service: Organisation and Management (Oxford: Radcliffe Medical Press, 1991), 26. Since 2002 Foundation Trusts have been progressively established; they are independently regulated by Monitor. Since 1997, the devolution of political power to Scotland and Wales has resulted in significant divergences in these countries in relation to NHS organisational arrangements and entitlement to services. See Harrison and McDonald, ibid., 156–61.

8. Stevens, Rosemary, ‘Hospital Administration: The Status Quo’, Medical Care, 2 (October–December, 1964), 208–13: 209. See also Mark Learmonth, ‘Kindly Technicians: Hospital Administrators Immediately Before the NHS’, Journal of Management in Medicine, 12, 6 (1998), 323–30.

9. Hunter, op. cit. (note 2), 209.

10. On doctor–manager relations see the special themed issue of the BMJ (22 March 2003) (Vol 326, Issue 7390) especially: N. Edwards, ‘Doctors and Managers: A Problem Without a Solution?’, 609–10, Huw T.O. Davies and Stephen Harrison, ‘Trends in Doctor–Manager Relationships’, 646–9; Pieter Degeling et al., ‘Medicine, Management and Modernisation: a “Danse Macabre”?’, 649–52; Antony Garelick and Leonard Fagin, ‘The Doctor–Manager Relationship’, Advances in Psychiatric Treatment, 11 (2005), 241–52.

11. See Stephen Harrison, ‘Clinical autonomy and health policy: past and future’, in Mark Exworthy and Susan Halford (eds), Professionals and the New Managerialism in the Public Sector (Buckingham: Open University, 1999), 50–64; Stephen Harrison and Waqar I.U. Ahmad, ‘Medical Autonomy and the UK State 1975–2025’, Sociology 34 (2000), 129–46.

12. Witness Seminar: National Administrators’ Training Scheme, 1958 Cohort, held at the University of Manchester, October 2008. Hereafter referred to as NATS WS. David Robson, one of the witnesses, donated his working papers spanning from 1958 to 1997 to the Centre for the History of Science, Technology & Medicine. Hereafter referred to as CHSTM/RA.

13. Our sixteen interviewees were made up of: managers who had worked in the NHS since the 1970s and at different levels – district, area, region and national; and doctors who had worked in hospitals, general practice and public health, and several who had taken up management posts as medical directors, directors of public health and chief executives (local and national).

14. Grele, R., Envelopes of Sound: The Art of Oral History (New York: Greenwood Press, 1991); Paul Thompson, The Voice of the Past (Oxford: Oxford University Press, 1990).

15. Smith, Graham and Nicholson, Malcolm, ‘Re-Expressing the Division of British Medicine Under the NHS: The Importance of Locality in General Practitioners’ Oral Histories’, Social Science and Medicine, 64 (2007), 93848.

16. Sennett, Richard, The Culture of the New Capitalism (Yale: Yale University Press, 2006).

17. Pollitt, Christopher, ‘Institutional Amnesia: A Paradox of the “Information Age”?’, Prometheus, 18 (2000), 516, this 6; Christopher Pollitt, Time, Policy, Management. Governing with the Past (Oxford: Oxford University Press, 2008).

18. Personal communication to author, 29 September 2009.

19. On the use of oral history in the history of policy making and networks of power see Virginia Berridge, ‘Hidden from History?: Oral History and the History of Health Policy’, Oral History, 38 (2010), 91–100.

20. Voluntary hospitals were originally established as charitable enterprises and were managed by boards with members drawn from local subscribers such as doctors, industrialists and philanthropists. Local authority hospitals had their origins in the 1834 Poor Law and from the late nineteenth century were central to state initiatives around public health, especially the spread of epidemic disease. See Brian Abel-Smith, The Hospitals 1800–1948: A Study in Social Administration in England and Wales (London, 1964); Martin Gorsky, ‘Hospital governance and community involvement in Britain: evidence from before the National Health Service’. Available online at http://www.historyandpolicy.org/papers/policy-paper-40.html (accessed 9 December 2011).

21. Stevens, op. cit. (note 8).

22. Chester, T.E., Organisation for Change: The British National Health Service, Centre for Educational Research and Innovation (Paris: Organisation for Economic Cooperation and Development, 1975), 8. Available online at http://eric.ed.gov:80/ERICDocs/data/ericdocs2sql/content_storage_01/0000019b/80/31/58/20.pdf (accessed 17 May 2010).

23. The Acton Society Trust, Hospitals and the State: Hospital Organisation and Administration under the National Health Service: The Impact of Change (London: Acton Society Trust, 1956–59) 6 volumes, vol. 1, 43; Stevens, op. cit. (note 8), 208.

24. Acton, ibid., vol. 2, 51. The medical superintendent post was retained in Scotland and in mental hospitals. Some commentators have argued that this shift pinpoints the beginning of a weakening of medical control of hospitals and it is worth noting that Greer’s comparative analysis of England, Scotland and Wales shows that in Scotland, where the medical superintendent post was retained, the medical profession retained significant power in the health system. Scott Greer, Territorial Politics and Health Policy: UK Health Policy in Comparative Perspective (Manchester: Manchester University Press, 2004).

25. Stevens, op. cit. (note 8).

26. Acton, op. cit. (note 23), vol. 2, 39.

27. Stevens, op. cit. (note 8).

28. Acton, op. cit. (note 23), vol. 2, 17.

29. Acton, op. cit. (note 23), vol. 2, 25.

30. Central Health Services Council, Report of the Committee on the Internal Administration of Hospitals (London: HMSO, 1954), paras 196–7, quoted in Watkin, op. cit. (note 5), 184. In 1961 the Department of Social Administration at the University of Manchester undertook an analysis of medical committees, reviewing their functions and working practices. It noted that the different lengths of experience between the hospital administrator and the local medical committee chairman could create tensions: ‘In these days, when the hospital secretary is becoming a sort of administrative registrar, moving on fairly quickly to higher posts, it must be difficult for him to meet on even terms a spokesman of the medical staff who was a senior member of the hospital staff when the hospital secretary was still a schoolboy’. It also noted communication difficulties associated with the hierarchical structures. In one instance, all three officers of a hospital group had been asked to report ‘independently’ to the Group Secretary on a Health Circular on Hospital Catering which created the risk of ‘inconsistent recommendations’ about the services in a particular hospital. In other localities the hospital administrator was by-passed by the Group Secretary liaising directly with the catering officer or matron. CHSTM/RA, op. cit. (note 12), file 3.

31. Freidson, Eliot, Profession of Medicine (Chicago: University of Chicago Press, 1988).

32. Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982).

33. Stevens, op. cit. (note 8), 209.

34. Webster, Charles, The Health Services since the War Volume II. Government and Health Care: the National Health Service 1958–1979 (London: HMSO, 1996), 17.

35. Harrison, Stephen, ‘Consensus Decision-Making in the National Health Service – A Review’, Journal of Management Studies, 19 (1982), 377–94: 379; Webster, ibid., 92–109.

36. Wilson, John F., The Manchester Experiment: A History of Manchester Business School, 1965–1990 (London: Paul Chapman Publishing, 1992), 8.

37. History of the Institute of Healthcare Management, http://www.ihm.org.uk/About_Us/history/history (accessed 19 October 2011).

38. Acton, op. cit. (note 23), vol. 2, 38.

39. Stevens, op. cit. (note 8), 208.

41. Acton, op. cit. (note 23), vol. 2, 46–7.

42. Stevens, op. cit. (note 8), 210.

43. Note from David Robson to Stephanie Snow, October 2010.

44. Chester, T.E., ‘A New Recruitment and Training Scheme for Senior Hospital Administrators’, Public Administration, Winter (1956), 4259.

45. Acton, op. cit. (note 23).

46. Our witnesses joined NATS from a variety of backgrounds such as the Civil Service and banking; they were all graduates bar one in-service member. Nicknamed ‘the sobersides’ by contemporaries, they shared a keen belief in the value and purpose of public service and most were practising Christians. Collegiality amongst this cohort may have been exceptional; the group has maintained strong social links including wives and families over the fifty years or so since they first met in Manchester.

47. NATS WS, op. cit. (note 12).

48. Battistella, Roger M. and Chester, T.E., ‘Role of Management in Health Services in Britain and the United States’, The Lancet (18 March 1972), 626–30. Note the use of the terms ‘management’ and ‘leadership’, see note 4.

49. NATS WS, op. cit. (note 12).

50. NATS WS, op. cit. (note 12). See note 4.

51. Nuffield Trust Symposium in Administrative Training: Paper II, Management and Training Problems, P.A. Steele and G.S. Evans, 18 March 1963, CHSTM/RA, op. cit. (note 12).

52. Nuffield Trust Symposium, ibid.

53. The October Club File, CHSTM/RA, op. cit. (note 12).

54. Letter to the Rt. Hon. Sir Keith Joseph, 30 July 1971, CHSTM/RA, op. cit. (note 12).

55. Memorandum on National Health Service Re-organisation, para 1.2, CHSTM/RA, op. cit. (note 12).

56. The Farquharson–Lang Report was published in Scotland in 1965 and recommended that Chief Executives should head regional health boards and local boards but disagreed, albeit ‘reluctantly’ with the British Medical Association’s view that the emphasis should be on medical qualifications: the decisive factor should be the individual’s ‘ability and experience as a manager not his professional qualifications’, quoted in Watkin, op. cit. (note 5), 318; see also Webster, op. cit. (note 34), 312.

57. Letter to the Rt. Hon. Sir Keith Joseph, 30 July 1971, CHSTM/RA, op. cit. (note 12).

58. Letter from D.M. Robson to John Sully, 16 October 1972: ‘Integration and improvement is not going to occur by everyone hanging grimly onto what they can. If we as representatives of the age group that will make or break this reorganisation present ourselves to Sir Keith Joseph in the same sort of terms that might be used by the hard core BMA or IHSA council member, I do not think that we will commend ourselves as imaginative, farsighted coordinators of all aspects of the service’, CHSTM/RA, op. cit. (note 12).

59. Harrison, op. cit. (note 35).

60. Harrison, op. cit. (note 35), 379–80.

61. Battistella and Chester, op. cit. (note 1), 519.

62. Letter to the Rt. Hon. Sir Keith Joseph, 30 October 1972, attaching a Memorandum on Management Arrangements from a group of eight NHS administrators, CHSTM/RA, op. cit. (note 12).

63. NATS WS, op. cit. (note 12).

64. Note from David Robson to Stephanie Snow, October 2010. See also Stephanie J. Snow (ed.), The Recent History of Guy’s and St Thomas’, 1970s to 2000s, held 16 June 2011 at Guy’s and St Thomas’ Foundation Trust (University of Manchester: Centre for the History of Science, Technology & Medicine, 2011), 11. Hereafter referred to as GST WS. Available online at http://www.chstm.manchester.ac.uk/downloads/guys-thomas-witness-seminar-2011-06.pdf (accessed 10 December 2012).

65. Undated draft of letter from David Robson c.1973. Robson was then the Assistant Clerk of Management Services at St Thomas’ Hospital, London. Other references in working notes included reference to a planning team at a Regional Health Authority where a multi-disciplinary team was ‘practising consensus without knowing it’ as a means to overcoming differences in opinion between hospital and local authority members, CHSTM/RA, op. cit. (note 12).

66. Chester, op. cit. (note 22), 8.

67. Chester, op. cit. (note 22), 19.

68. Chester, op. cit. (note 22), 26.

69. For a detailed account of mental health services in Salford and Manchester see Valerie Harrington, ‘Voices Beyond the Asylum: A Post-War History of Mental Health Services in Manchester and Salford’ (unpublished PhD thesis: University of Manchester, 2008).

70. Ibid., ch. 2.

71. Interview with Bill Sang, 24 April 2006.

72. Harrison, op. cit. (note 35), 381.

73. Harrison, op. cit. (note 35), 391.

74. See Gorsky in this volume on the various judgments made on the success or failure of consensus management as a management model.

75. Harrison, op. cit. (note 3); and Stephen Harrison and J. Lim, ‘The Frontier of Control: Doctors and Managers in the NHS 1966–1997’, Clinical Governance, 8, 1 (2003), 13–18. See Gorsky in this volume for the details of the circumstances surrounding the Griffiths’ report and its implementation.

76. Stephen Harrison et al., Just Managing: Power and Culture in the NHS (Basingstoke: Macmillan Press, 1992), 95–117.

77. Interview with Lois Willis, 17 March 2006. Around fifty-six per cent of the new general managers were appointed from within the same authority or another authority within the same region; just under ten per cent of appointments were from the private sector and the armed forces. Brian Edwards, The National Health Service: A Manager’s Tale, 1946–1992 (Nuffield Provincial Hospitals Trust, 1993), 83.

78. NATS WS, op. cit. (note 12).

79. NATS WS, op. cit. (note 12).

80. NATS WS, op. cit. (note 12).

81. NATS WS, op. cit. (note 12).

82. Quoted in Edwards, op. cit. (note 77), 86.

83. Sang, op. cit. (note 71).

84. Sang, op. cit. (note 71). The Griffiths Report intended that the role of regional authorities who would hold the districts, hospitals and units to account for performance and achievement should be strengthened. Edwards, op. cit. (note 77), 83.

85. Edwards, op. cit. (note 77), 83.

86. Sang, op. cit. (note 71).

87. Christie, Sophia, ‘Being on Speaking Terms with Doctors’, Health Services Management, 84 (1988), 323.

88. Ibid., 32–3.

89. Chawner, John, ‘The consultant’s role in NHS management’, BMJ, 287 (10 December 1983), 1816–8: 1817.

90. Chantler, Cyril, ‘Historical background: where have clinical directorates come from and what is their purpose?’, The Role of Hospital Consultants in Clinical Directorates (London: Royal College of Physicians, 1993), 1103.

91. Ibid., 10.

92. Interview with Peter Barnes, 21 June 2007.

93. Quoted in Philip Strong and Jane Robinson, The NHS Under New Management (Buckingham: Open University Press, 1990), 33.

94. Barnes, op. cit. (note 92).

95. Barnes, op. cit. (note 92). On clinical directorates see also Gordon Marnoch, Doctors and Management in the National Health Service (Buckingham: Open University Press, 1996), 48; on the inherent tensions of the clinician-manager role see Gorsky’s discussion elsewhere in this volume.

96. Barnes, op. cit. (note 92).

97. Strong and Robinson, op. cit. (note 93), 50.

98. Simpson, Jenny, ‘Whither or wither medical management?’, BMJ http://careers.bmj.com/careers/advice/view-article.html?id=20001287# (accessed 21 March 2012).

99. Ibid.

100. Barnes, op. cit. (note 92).

101. Barnes, op. cit. (note 92).

102. Interview with David Warrell, 16 May 2007.

103. A major study comprising more than 300 interviews concluded that most consultants during the 1980s were ‘perfectly prepared to acknowledge the need for efficiency and economy’. Christopher Pollitt et al., ‘General Management in the NHS: The Initial Impact, 1983–88’, Public Administration, 69 (1991), 61–83: 74.

104. Ibid., 69.

105. Warrell, op. cit. (note 102); GST WS, op. cit. (note 64), 54.

106. For a detailed account see H.K. Valier and J.V. Pickstone, Community, Professions and Business: A History of the Central Manchester Teaching Hospitals and the NHS (Lancaster: Carnegie Press, 2007), 76–93.

107. Community Health Councils which existed between 1974 and 2003 were statutory bodies to ‘represent the public interest in the local provision of health services, and to be the channel for consumer concerns’. There was generally one Council for every District Health Authority. See Ham, op. cit. (note 7), 27.

108. Warrell, op. cit. (note 102).

109. NATS WS, op. cit. (note 12).

110. Warrell, op. cit. (note 102).

111. Sang, op. cit. (note 71).

112. Audit Commission and Healthcare Commission, Is the Treatment Working? Progress with the NHS System Reform Programme (London: Audit Commission, 2008).

113. Interview with Peter Mount, 6 June 2007.

114. Sang, op. cit. (note 71).

115. Mount, op. cit. (note 113).

116. Sang, op. cit. (note 71).

117. Barnes, op. cit. (note 92).

118. Barnes, op. cit. (note 92).

119. Klein, Rudolf, The New Politics of the NHS: From Creation to Reinvention (Oxford: Oxford University Press, 2006), 105.

120. Gorsky, Martin, ‘“Searching for the People in Charge”: Appraising the 1983 Griffiths NHS Management Inquiry’, Medical History, 57, 1 (2013), 87107.

121. Department of Health, Equity and Excellence (2010).

122. Interview with Margaret Morris, 21 February 2008.

This paper evolved out of a pilot study on ‘The Recent History of the NHS in Manchester and Salford, 1980–2007’, which was funded by a Wellcome Trust Strategic Award to the Centre for the History of Science, Technology & Medicine (Grant No. 079984). The author gratefully acknowledges the contribution of her co-investigators John Pickstone, Stephen Harrison and Kath Checkland, and thanks them, Naomi Chambers, Martin Gorsky, David Robson, Rosemary Stevens and the external reviewers for their helpful comments on this paper.

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