Since its inception in 1948, the NHS has continued to change and develop its structure to accommodate expectations from patients, medical advances, political pressures and financial demands. In 1983 the Griffiths report suggested that managers (some of whom could be doctors) should be appointed to have a more direct influence on the running of hospitals and community services. This was to end the previous multi-layered management structure which ran District Health Authorities (DHAs) by committees. Decisions relied on consensus and although doctors, particularly, had management responsibilities within their unit (hospital or community) through the so-called 'Cogwheel' system where various disciplines met to discuss management issues, the influence of the DHA meant that decision making was slow, clumsy, tended to exclude other professional groups, and was inefficient at coping with the increasing financial demands of units. In 1986, as an experiment, 6 hospitals established clinical directorates; management teams which were responsible for running distinct clinical services e.g. paediatrics, women's services, surgical services etc, and to do this were given responsibility for a budget to run that service. Subsequently, because of the success of the system, most units have adopted the Directorate model of management. The team is headed by the clinical director (CD) who is supported by a business manager and a nurse manager. The first CDs were consultants, and although senior members of other professional groups e.g. nurses, might be CDs, most are still consultants. Each directorate team usually consults and takes advice from other members of the department (and also delegates some responsi-