Gill Morgan: We need to manage Griffiths' unintended consequences

I was something of an unusual creature in the early 1980s. Although I was working as a registrar and senior registrar in public health, I was interested in the leadership and management of the health service.

‘An interest in the leadership and management of the health service was enough to make you stand out’

At that time, such an interest was enough to make you stand out.

The administrators of the organisation were delighted to have discovered a doctor who was curious about what they did, and so I was soon invited to shadow very senior administrators at both district and regional levels.

Consequently, I was a regular fly on the wall for meetings at which important decisions were made – or, sometimes, not made.

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A whole picture view

The “sometimes” is important. My memory of consensus management is that, when it worked, it worked fantastically.

If a team was aligned, good decisions were made quickly and effectively.

The problem was that for every organisation like that which I observed I saw another where the picture was very different.

If there were problems in the personal relationships among the group, the outcome was often stalemate.

‘Individuals were protecting their personal freedoms and there was no one looking at the whole picture’

This was particularly common if the conversation was about the clinical process or finance.

Individuals were protecting their personal freedoms and there was quite simply no one looking at the whole picture.

Griffiths unlocked transformation

It was a big change, then, when the Griffiths recommendations were implemented and one individual was clearly identified as being in charge.

During the transition period, the best of the general managers regarded themselves at first among equals.

‘The best managers made clear that protectionism simply could not continue and, as a result, many decisions were unlocked’

They made clear that protectionism simply could not continue and, as a result, many decisions were unlocked. That was transformational.

My memory is that it was not easy – particularly for clinicians, who often felt distanced from the decision making process.

I was fortunate to work alongside an excellent district administrator who became a general manager. In spite of his role change, the way he viewed his role did not vary. He saw himself as serving the clinicians, helping them deliver the most effective care possible.

The unintended consequences

Unfortunately, not all saw the role change in the same way. I observed some general managers who, particularly as their financial responsibilities increased, adopted a degree of arrogance.

In these places in particular, I witnessed doctors withdrawing from the leadership process. They felt out of place in an environment where the talk seemed to be more about money than about patient care.

‘Some general managers who, particularly as their financial responsibilities increased, adopted a degree of arrogance’

They also sometimes felt outnumbered. At district meetings post-Griffiths, the general managers were the majority. I saw some clinicians turn negative and hostile to general management as a result.

I was reflecting on those big local meetings recently, and the unified local patient systems they represent.

It is ironic that we are now looking for ways to put such systems back together. But it speaks to one of the most interesting aspects of the Griffiths report: its unintended consequences.

I have little doubt that these will be one of the biggest topics of conversations for the HSJ Future of NHS Leadership inquiry.

Dame Gill Morgan is chair of the Foundation Trust Network, and a member of the HSJ Future of NHS Leadership Inquiry