Central accountability and local decision making: towards a new NHS.

Abstract

It was unfortunate perhaps for Mr Victor Paige that the first time that many people in Britain read about his activities in their newspapers was when they learnt that the chairman of the new National Health Service Management Board had sanctioned plans for 2250 extra maternity cases in the Trent region in 1985-6. ' It was a story that, in the form that it appeared, implied a somewhat excessive degree of control by the Department of Health and Social Security over the lives of the population. If the story suggested some misleading conclusions it also reflected the emergence of a more directive and interventionist style of management in the NHS. It is not a style that Mr Paige and his board have created. On the contrary, the appointment of Mr Paige and his board simply represents the last, logical step in a process that is gradually transforming the style of management in the NHS and the relationship between the DHSS and the health authorities: a process crystallised but not caused by the Griffiths report.2 And it is a transformation that has profound long term implications for the way in which health care policies are defined and implemented, and perhaps also for the structure of the NHS. Mr Paige's startlingly precise prediction of the number of maternity cases in the Trent region provides a good starting point to explore these implications. The source for the news about Mr Paige's decision was a DHSS press handout setting out details of the plans for next year agreed between the DHSS and the regional health authorities': an annual process linked to the system perform? ance reviews that started in 1983.4 Under this system DHSS ministers meet the regional chairmen annually to discuss and agree action plans; in turn, the regional chairmen then are expected to carry out a similar exercise with their district health authorities. The targets agreed between the DHSS and the regions do not therefore necessarily represent a departmental diktat, but are the product of a process of negotiation. In effect, the DHSS responds to, modifies, and sometimes imposes its own priorities on the plans put forward by the regions. The plans are the product of negotiation and bargaining. But it is clear that the two partners do not bargain on equal terms. The regions may propose but it is the DHSS that disposes. This emerges clearly from the manpower targets announced by Mr Paige: in other words, the inputs into the NHS. This concern with inputs as distinct from outputs?that is, the resources going into the services as distinct from the number of patients treated, etc, coming out of it?is longstanding. For example, control over consultant posts has been one of the Department's most effective instruments for achieving a better distribution of resources, both geographically and between specialties, almost since the start of the NHS. The latest round of manpower targets shows that the Depart? ment's long term concern with inputs is undiminished by its more recent interest in outputs. And, in this instance, it is the DHSS's decision that is final. Thus, five regions will have to settle for fewer staff than they asked for. The DHSS's insistence on determining the precise number of people to be employed in each region, and therefore indirectly in each district, is all the more remarkable given that the Department is in firm control of budgetary allocation. So, in effect, the Department is laying down how the money should be spent, as well as the total. There would seem to be little scope for local decisions about the appropriate mix of manpower, possibly substituting a larger number of cheaper workers for more expensive professionals.