Leadership and management

Pre-1970s

Initially the NHS was organised in three parts, which separated GPs (with dentists, pharmacists and opticians) from services provided by local government (which included preventive services such as health visiting and child welfare) from hospital authorities. Individual hospitals were normally administered by consensus, by a hospital secretary, matron and medical superintendent. The need for better administration in the NHS was recognised soon after it was established, driven primarily by concern about costs rising much faster than had been predicted.

Guillebaud Report 1956

Established in 1953 to investigate the cost of the NHS, while the report made it clear that there was no financial crisis, it did call in very general terms for more emphasis on oversight and supervision of the service.

Ministry of Health and Scottish Home and Health Department. Report of the committee of enquiry into the cost of the National Health Service. (Chairman: C W Guillebaud). London, HMSO, 1956. Cmd 9663

Porritt Report 1962

Sir Arthur Porritt, President of the Royal College of Surgeons chaired a BMA’s Committee of Inquiry into the NHS which suggested that tripartite services should be brought together under a single area board, with boundaries determined by the health needs of the community, on which the profession was adequately represented and whose chief officer was a doctor. Comprehensive area general hospitals were desirable and should be the basis of long-term as well as acute care.

Porritt, A (1962) Report of the Medical Services Review Committee. British Medical Journal. 1962; 2: 1178-86

Farquharson-Lang Report 1966

Published in Scotland, suggested that regional health boards and local boards should employ a chief executive, who need not necessarily be medically qualified.

Administrative Practice of Hospitals Boards in Scotland (Chairman: Mr WM Farquharson-Lang). Edinburgh: HMSO

The King’s Fund/Institute of Hospital Administrators Joint Working Party 1967

Criticised previous reports that had ‘failed to grasp the nettle that someone had to be in command…with authority over all the rest of the staff’ (p24). The report stated that a hospital board was required to safeguard public interest and public accountability, but that there should be a clear chain of command with a general manager supported by medical and nursing directors, a director of finance and statistical services, and a director of general services.

Howard G (1967) The shape of hospital management in 1980? : the report of a Joint Working Party set up by the King's Fund and the Institute of Hospital Administrators. London: King Edward’s Hospital Fund for London and the Institute of Hospital Administrators

Salmon Report 1966

Aimed to raise the profile of the nursing profession in hospital management, recommending a new hospital nursing structure under the direction of a chief nursing officer.

Ministry of Health and Scottish Home and Health Departments (1966) `Report of the Committee on Senior Nursing Staff Structure' (the Salmon Report). London: HMSO

Cogwheel Report 1967

Encouraged the involvement of clinicians in management, recommending the creation of clinical divisions to ensure efficient deployment of resources and to cope with the management issues that arose within clinical fields.

Ministry of Health (1967) First Report of the Joint Working Party on the Organisation of Medical Work in Hospitals' (the Cogwheel Report). London: HMSO

By the end of the 1960s a consensus was developing that the tripartite structure of the NHS, established in 1948, was a source of problems.

Crossman Green Paper 1970

Announced a reorganisation which proposed that health services should be administered in 90 area health authorities, sharing boundaries with local authorities who would be responsible for social services

Department of Health and Social Security (1970) The Future Structure of the National Health Service (The Crossman Green Paper). London: HMSO

The Grey Book 1972

Recommended a system of consensus management by multi-disciplinary management teams consisting of an administrator, treasurer, nurse and doctors.

Department of Health and Social Security (1972). Management Arrangements for the Re-organised Health Service: The Grey Book. London: HMSO

NHS Reorganisation Act 1973

Created 14 regional health authorities (RHAs) in England which were responsible for planning local health services. Under them, 90 area health authorities were established, with a chair appointed by the Secretary of State and non-executive members appointed by the RHA and by local authorities. An area team of officers was established, made up of an administrator, a nurse, a public health doctor and a finance officer. General Practitioners remained independent contractors.

Royal Commission 1979

The new structure was quickly criticised, with a Royal Commission established to investigate it, but the report of the Commission, published in 1979 explicitly rejected general (as opposed to consensus) management in the NHS

Royal Commission on the National Health Service (1979) Report. Cmnd 7615, London: HMSO

Health Services Act 1980

The 1980 Act created 192 new district health authorities in England. Within districts, an emphasis was placed upon devolving management down to smaller units of management.

In the early 1980s, driven in part by financial challenges, a number of management initiatives were implemented to improve accountability in the NHS. This series of initiatives culminated in the establishment of an independent management inquiry into the effective use of manpower and related resources in the NHS, led by Roy Griffiths.

Griffiths Report 1983

The report found that the NHS had no coherent system of management at a local level and lacked any continuous evaluation of its performance against normal business criteria. In the report, Roy Griffiths famously said, ‘If Florence Nightingale were carrying her lamp through the NHS today she would be searching for the people in charge.’ Key among its recommendations was that general managers be introduced into the NHS and that clinical doctors should become more involved in local management. The government’s response to the Inquiry accepted this shift from consensus management: 'We do not undervalue the importance of consensus in a multi-professional organisation like the NHS. But we share the Report’s view that consensus, as a management style, will not alone secure effective and timely management action, nor does it necessarily initiate the kind of dynamic approach needed in the health service to ensure the best quality of care and value for money for patients.'

NHS Management Inquiry (1983) Report (The Griffiths Report). London: HMSO
Department of Health and Social Security (1984) Griffiths Report: Health Authorities to Identify General Managers. Press Release no. 84/173, 4 June

Working for patients 1989  and the NHS and Community Care Act 1990

Due to concern about health service funding in the late 1980s, the Prime Minister announced a fundamental review of the NHS, which was published as the White Paper, Working for Patients, proposing an internal market in the NHS by separating purchasers from providers. GPs also would be offered the option of becoming fundholders, able to purchase most services on behalf of their patients. The subsequent act created the necessary structures and introduced greater local diversity, competition and choice.

Department of Health (1989) Working for Patients. London: HMSO, Cm 555

Managing the New NHS 1993 and the Health Authorities Act 1995

This White Paper and subsequent act of parliament introduced another restructuring, abolishing the regional health authorities and creating eight regional offices and the merger of district health authorities and family health services authorities.

Department of Health (1993) Managing the New NHS. London: HMSO, Cm 555

The election of the Labour government in 1997 saw a series of widespread reforms and investment in the NHS.

The New NHS, Modern, Dependable 1997

Set out how the internal market would be replaced by a system called 'integrated care', based on partnership and driven by performance.

Department of Health (1997) The New NHS. Modern. Dependable. London: HMSO, Cm 3807

Health Act 1999

Replaced GP fundholding with primary care groups and established the Commission for Health Improvement (later the Healthcare Commission) which looked at the quality, governance and financial management of health trusts. It also introduced the National Institute for Clinical Effectiveness.

The NHS Plan 2000

The NHS Plan (2000) proposed significant new investment, together with large numbers of performance targets and standards with annual assessment of NHS organisations and publication of results.

Department of Health (2000) The NHS Plan. London: HMSO, Cm 4818-I

NHS Next Stage Review 2008

Lord Darzi’s next stage review, published in 2008, placed renewed emphasis on clinical leadership, and a national Leadership Council was established by the NHS Chief Executive in 2009.

Department of Health (2008) The NHS Next Stage Review: High Quality Care for All. London: HMSO

The end of the first decade of the 21st century has seen an increasing focus on leadership rather than management, with a desire expressed by all political parties to move away from ‘command and control’ management and a need for an increasingly shared agenda between managers and clinicians.

Liberating the NHS 2010

The newly-elected coalition government set out some of the most radical plans for reforming the NHS since its inception, removing strategic health authorities and primary care trusts, and establishing a National Commissioning Board, with local commissioning carried out by consortia of GPs.

Department of Health (2010) Equity and Excellence: Liberating the NHS. London: HMSO