“The NHS is safe in our hands. The elderly are safe in our hands. The sick are safe in our hands. The surgeons are safe in our hands. The nurses are safe in our hands. The doctors are safe in our hands. The dentists are safe in our hands.” - Margaret Thatcher.
As the wall to wall Thatcher coverage continues I have noticed that, so far, there has been little or no mention of her NHS reforms. I think there is a fairly obvious reason for this; simply that she started a process which gathered speed under Tony Blair, and which has now culminated in the Health & Social Care Act which is the biggest and most complex reform of the NHS in its history, and I suspect probably its biggest disaster.
The NHS was (and still is) completely incapable of controlling spending. Thatcher decided that what was needed to sort out these spendthrift doctors was a man with a cool business head. So the grocer’s daughter commissioned a grocer (Roy Griffiths, deputy chairman of Sainsbury) to investigate and report on NHS management. I am old enough the remember it, but to the new generation of doctors this is ancient history.
After a six month consultation period his report (October 1983) came in the form of a letter to the Secretary of State listing the changes he believed were necessary to get the NHS functioning properly. He blamed inefficient management and managerial structures for the financial chaos, and unsurprisingly he came up with a managerial solution to the problem.
His most famous sound bite was, “If Florence Nightingale were (sic) carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge”. As a result so-called Griffiths managers were appointed to run the hospitals and power shifted away from clinicians into the hands of the managers.
The arguments for and against Griffiths rumble on. Most doctors of my generation blame his report for the start of the rot – a process by which doctors became more and more distanced from strategic clinical decision making. To be fair if you read the report it is clear that Griffiths actually wanted quite the opposite, namely that doctors should be increasingly involved in management. However once CEOs were made legally accountable for balancing the hospital finances, control was taken more and more centrally. This became the defining feature of the NHS in the Blair years.
In 1989 and 1990 Thatcher introduced two more Acts which had profound effects on the NHS. These allowed the setting up if the “internal market” and created the purchaser provider split. Health authorities ceased to run hospitals but were able to “purchase” healthcare from hospitals. It also allowed the setting up of GP Fund Holding and hospitals to become “trusts” to encourage open competition in health care provision.
The Labour Party opposed all the changes until they got into power. Then, other than abolishing GP Fund Holding, they embraced the new order like a hungry python with a pie. Blair took competition to heights undreamed of by the Tories, involving the independent sector and wasting £millions on inefficient contracts.
But to return to the start of it all, I am fairly neutral about Griffiths. The NHS needs to be managed properly and in many cases I think we are under rather than over managed. My own radiology department is a highly complex £20 million p.a. business yet we run on just a handful of fairly junior managers.
My colleagues and I know exactly what to do in order to transform our business into a modern thriving service delivering high quality timely clinical imaging and intervention. But our managers and clinical director have neither the ability nor the authority to make the necessary strategic decisions to initiate change which is what Griffiths wanted. All we can do is stand at the edge of the playing field, waving our arms and shouting “please listen to us”, but fairly confident that no body will! I emphasise that this is not a critique of our trust executive who are as much strangled by system as we are.
So now Thatcher’s vision reaches its conclusion in the Health & Social Care Act. Already our local CCGs are contracting with the independent sector to provide some primary care based imaging with no reference to us, and the Act has barely got going. If a sizable chunk of primary care imaging is outsourced our income will plummet and our ability to deliver will become even more constrained. I would not mind so much if I had any confidence in the CCGs ability to commission imaging or the independent sector’s ability to provide it – but I haven’t! My experience so far is that GP commissioners have little understanding of what constitutes a good imaging service or of the essential interaction between clinicians and radiologists.
So Mrs Thatcher rest in peace. But the NHS “safe in your hands” – I think not!