Introduction and methodology
Several commentators have pointed to significant variations in NHS
management in Scotland and England. These have been attributed to the differing pace and experience of clinical and other initiatives in Scotland;(1) the specific administrative and institutional structures in Scotland and England;(2) distinctive social and community values in Scotland, allied to the historical legacy stemming from the formidable position held by medical and public health professionals in the country in the nineteenth century.(3) ln part the Scottish devolution settlement was justified on the grounds that health (and other services notably education and legal services) could be more appropriately administered at Scottish rather than UK level due to traditionally separate arrangements for management and delivery in Scotland albeit within a UK framework.
Much has been written in UK terms on health service management and policy, though one of the key writers and researchers has little to say about Scotland.(4) While the NHS’s historian has included excellent Scottish material in both his volumes,(5) and a number of Scottish based researchers have made valuable contributions,(6) a comprehensive and systematic work on National Health Service management in Scotland from its creation in 1947 does not exist.
The research on which this paper is based has examined secondary source material on the Scottish health service. In addition, since the health service settlement after the war gave considerable executive responsibility to devolved area authorities, a fuller picture was obtained by researching primary archive material from a major area board, the Greater Glasgow Health Board (GGHB) and its predecessor the Western Regional Hospital Board (WRHB). Although it would be wrong to suppose that these geographical/managerial units were typical of hospital service management throughout Scotland as a whole, the proportion of Scotland’s population covered by these authorities was one third to one half, making them highly significant in terms of NHS management in Scotland. Obviously, a completely comprehensive picture awaits archival research of other major authorities. Nonetheless, from this research, a picture starts to emerge of both difference and congruence in the management of the health service in Scotland and England.
The NHS in Scotland: the first two decades
A key feature of this period was the centrality of the NHS in the Scottish political and social firmament. There were three dimensions to this. First, although there is now no doubt that in the UK there was a growing consensus for some form of ‘national’ health service in the decades prior to establishment,(7) developments in Scotland especially during the war years went further and could be almost said to foreshadow many of the NHS’s fundamental principles. As part of the UK wide Emergency Hospital Programme to meet the threat of civilian air raid casualties, the Scottish Department of Health built and directly administered seven new general hospitals supplying 7000 beds.(8) When Gleneagles hotel was not required for emergency hospital facilities it was diverted to an initiative involving the rehabilitation of workers from Clydeside.(9) Thomas Johnston, the war time Secretary of State for Scotland, concluded that this initiative unique in the UK "blazed the trail for the NHS".(10)
Second, there is considerable evidence that the political/institutional framework gave health a greater prominence in Scotland. At UK level during the early years of the NHS the Ministry of Health was one of the largest departments of government led by Anuerin Bevan. But when Bevan became Minister of Labour in 1951 the Department’s responsibility was reduced and the Ministry of Health lost cabinet status. It was not until Enoch Powell was promoted to cabinet in 1962 that cabinet status was restored, a situation that was not permanent: Harold Wilson’s first cabinet in 1964 excluded health and it was only in the late 1960s when the Ministries of Health and Social Security were merged under Richard Crossman that permanent cabinet membership was established. The absence from the cabinet denied health a political heavyweight presence which created difficulties in standing up to Treasury pressures. Scotland was different: here health had a strong champion in cabinet through the territorial remit of the Secretary of State for Scotland always a cabinet position.
This situation had knock on effects on the administration of health. Health was seen early on as a relatively unattractive proposition for a civil service career and was therefore avoided by the high fliers needed to take the new machinery forward and to negotiate strongly with the Treasury.(11) The evidence for this is strong: all permanent secretaries at the Department of Health prior to Sir Bruce Fraser’s appointment in the 1960s were occupying their last career posts. Fraser was exceptional in that he later transferred from health to a parallel civil service appointment. The firm career pattern which existed by the mid 1960s whereby the majority of Permanent Secretaries had spent time at the Treasury had not been replicated in Health until Fraser’s appointment. As one writer has put it:
" . . . the change from Hamilton [Sir John Hamilton, Fraser’s predecesor] to Fraser represented a major shift of culture within the Health Department and it was an important step towards bringing the Ministry of Health into the Whitehall mainstream." (12)
The contrast with Scotland was significant. The headship of the Department of Health for Scotland/Scottish Home and Health Department (SHHD) was usually seen as a staging post in the Scottish Office. John Anderson was recruited from the Scottish Home Department; served as Secretary of the Department of Health 1956-1959; then became Secretary of the Scottish Home Department and in 1963 became chairman of the Board of Customs and Excise. When Anderson left the Scottish Department of Health in 1959 he was succeeded by Douglas Haddow who had risen through the ranks of the Health Department; in 1962 he transferred to the Scottish Development Department; in 1965 he succeeded Sir Williarn Murie as Permanent Under Secretary at the Scottish Office. If Health was the place for the most able to avoid in England, this was not so in Scotland. Third, medical professionals were incorporated into the management and delivery of health care throughout the UK, through the executive responsibilities given to Regional Health Boards (RHBs): these boards contained senior medical professionals. One authority has stated that this in effect amounted to government compliance with professional control of the system and led to "professionals being turned into the state’s agents for rationing scarce resources".(13)
In Scotland the importance of senior medical figures in this structure was even clearer cut than in England. Perhaps due to the contrast in size and scale of English and Scottish operations, the direct line of communication in Scotland from the Department of Health to RHBs and from the RHBs to Hospital Boards of Management was clear; in England there were instances where the reporting lines were less clear with examples of Hospital Boards reporting directly with the Department of Health in Whitehall and Whitehall circumventing the Regional Boards and communicating directly with hospitals. This had the effect of fragmenting or obscuring the executive responsibility role of medical professionals (and others) on the Regional Boards. The position of teaching hospitals in Scotland was different too. Here they were part of the RHB network not separately administered, again giving clearer control and power to RHBs in Scotland. This administrative-management structure helped reinforce a historically greater interest in Scotland (in relative terms) in medical education (eg, more undergraduates, and for postgraduate education three of the five ancient Royal medical corporations were based in Scotland): in England and Wales the existence of separate hospital Boards of Governors in all regions tended to exclude the RHBs there from a role in medical education especially undergraduates.(14)
More generally, correspondence between SHHD and the Western Regional Hospital Board (WRHB) reinforce the considerable respect (and often deference) to the medical profession per se throughout the period. There are indications of SHHD ‘gently’ pressuring RHBs themselves to broaden involvement with doctors: in 1962 the SHHD ". . . asked the Board[WRHB] to reconsider arrangements for consultation with the medical profession with a view to more regular consultation . . ." and also asked the senior administrative medical officer " . . . to broaden the scope of his consultations to include hospital services as well as hospital staffing matters where appropriate."(15)
A lengthy correspondence between the Secretary of State for Scotland and WRHB chairman J Dunlop from 1965 to 1966 over the disciplining of a consultant at Glasgow Royal Infirmary indicated the SHHD’s unwillingness to move without the appropriate medical professional body’s agreement on disciplinary proceedings.(16) Indeed on some occasions, considerable chagrin was displayed at the position sometimes accorded to senior medical professionals. In the run up to the 1970s reforms at a series of consultations and briefings held by the Scottish Office which senior representatives of the medical profession were( apparently) given access to and others not:
"Mr Stevenson [Chairman of GGHB] drew the Department’s attention to the disquiet being felt generally in the service over unofficial reports on meetings of medical staff held periodically outside Edinburgh (convened by the Chief Medical Officer) at which it seemed that information was given and conclusions reached on the future administrative structure of the service. The status of the meetings was unknown, papers circulated were said to be confidential: but it was made clear that information was made available for them before it was communicated to Regional Board Chairmen."(17)
In the absence of parallel research on health authorities in England it is difficult to assess Scottish-English difference, and any difference is likely to be of shade and degree given the institutional responsibility of the profession in both countries. Such evidence as does exist indicates a stronger medical-professional focus in Scotland.(18) Institutional arrangements also indicate a greater role for doctors in the general running of hospitals, for example in the continuation post NHS creation of whole time medical superintendents in general hospitals until 1974 and (with a different title) after this date in some major teaching hospitals.
The 1970s reforms
The outcome of the major structural reform in 1974 saw different institutional patterns in England and Scotland. In the former a three tier structure was put in place (District, Regional Health Authority, Area Health Authority - this latter tier abolished in 1982) which in effect gave England an additional layer of bureaucracy. Scotland had local Health Boards subdivided into area management structures. The GP service was integrated with the local boards in Scotland but in England was governed by another body, the Family Practitioner Committee. More important than the structural/organisational differences were the ideas and thinking driving and shaping this changed framework. In this area, irony abounds:
In England, there were managerial overtones to the pre reform discussions and initiatives, but also a particularly strong rationalistic/planning ethos with its genesis in the Salmon Report (19) recommending hierarchical structures for nurses; the Coghill Reports (20) urging physicians to recognise interdependence with each other and the organisation; the Zuckerman and Hall Reports on career structures for scientists and technicians, and pharmacists respectively.(21) The ‘Grey Book’(22) on management arrangements emphasised prescription of structures and roles; consensus; management and planning processes; role clarity. It has been defined as consistent with key thinking of the time in its stress on planning, integration, professional specialisation and large scale institutional operations.(23)
However, in Scotland, a key report - the Farquarson Lang Report (24) - was much more managerialist in tone, advocating the widespread adoption of chief executives. The thinking behind Farquarson Lang has been considered as 20 years ahead of Griffiths in all main aspects.(25) Yet ironically, while managerial thinking did influence the policy process in England, with Keith Joseph the Health Secretary appointing McKinsey consultants and academics such as Elliot Jaques at Brunel University,(26) the Scottish Office response to Farquarson Lang was somewhat different (and in fact management consultants were not appointed in Scotland at all):
Para 14 [of Farquarson Lang] - ". . . there are more fundamental difficulties in the use of chief executives to administer affairs of a health board " other officers must be able to advise the board; it remains to be determined whether the executive of the board’s functions is most appropriately performed through a hierarchy in which relationships are essentially those of superiors to subordinates . . .
. . . the rationale of the executive group is that a service pursuing a wide range of objectives with the help of a number of professions can be administered better by a multi disciplinary group than by a single chief executive . . . an executive group may provide a more suitable point of contact and communication with clinical divisions"(27)
Keith Joseph attempted to alter some of the particularistic Scottish provisions outlined in the draft Scottish White Paper, a key one being his wish to avoid professional advisory committees gaining a statutory right to consultation. The SHHD declined to make these changes and the right was eventually conceded in England.(28) One area though of very important English/Scottish similarity was the consensus principle whereby unanimity was required at executive group level before a decision could be enshrined in health board policy.
The very distinctively Scottish feature which emerged from the reform was the idea of a Scottish Health Service Planning Council(SHSPC). This idea was driven strongly by Scotland’s Chief Medical Officer. No equivalent existed in England. The SHSPC was to contain representatives of regional boards and had a range of specialist committees, so institutionalising the importance of medical professional representation . The important role played by this body will be assessed below.
The 1970s after the reforms
After the reformed structures were in place, the latter years of the 1970s saw conflict in the NHS in two broad areas, industrial relations and pay beds. Again, divergence between Scotland and England was apparent. Industrial relations problems were severe in the years 1976-1977 and again in 1979-1980 when the NHS suffered severe cash limits. Scotland too was affected but much less so, perhaps ‘cushioned’ to the extent that health was more generously funded on a per capita basis.(29) The issue of pay beds saw the medical profession and the Labour Government (especially 1974-1976) locked in ideological conflict. A compromise was reached in 1976 under legislation designed to phase out pay beds (the decision to be taken by an independent board with half of its members from the profession). Four years later the number of pay beds in England had been reduced from 3444 to 2533. Yet in Scotland this dispute was peripheral: in the entire GGHB area covering over one third of Scotland’s population there were only 50 pay beds in total.(30) However the continuation of this aspect of Scottish particularism was questioned within the GGHB:
"The existing level of private practice carried out in Glasgow hospitals is comparatively small - only 40 beds can be used at any one time. The implication of [the government’s] Consultative Statement will not result in any major problems in the Glasgow area. It would however be wrong to assume that the demand for private treatment will not increase as more professional and trade union groups are being covered by private insurance and it may well be that Scotland will follow the trend in the rest of Britain." (31)
1980-1987
Many of the NHS reforms in the Thatcher era have been described as ad hoc, disconnected and a series of accidents.(32) However it is also recognised that there was an ideological thread running through the reforms, an attempt to change the governance arrangements in the NHS, the instruments used being managerialism (‘the new managerialism’), an attempt to draw clinicians into resource management ( ‘medical managerialism’) and the creation of a mixed economy of health care.(33) Lest it was thought otherwise, central government made its intention quite clear (in a Parliamentary Statement by the Secretary of State for Scotland) that these arrangements and initiatives would apply to Scotland. The central administration of health in the Scottish Office was strengthened for this purpose.(34) Does the case evidence indicate that these policy instruments were applied in Scotland in congruence with the rest of the UK?
New managerialism
New managerialism was defined as a combination of devolved and decentralised responsibility for service delivery (including, critically, control of cost) with strategic and policy control coming from the centre ie central government.(35) There can be no doubt that decentralisation of cost control was tackled with vigour by GGHB in its various measures to combat a forecast shortfall of c.£9m in 1986-87: the Board achieved its objective in ‘ensuring that it did not exceed its projected cash limited allocation in that year’.(36) However the extent to which these control measures were accompanied by devolution of control and responsibility to unit managers is questionable. The following statement from the Board’s general manager was revealing:
". . . I have been asked several times on visits to unit management teams whether if they make savings in one area they can spend in another. This question reveals a totally niaive misunderstanding - all savings will be taken to the centre and used to reduce overall board deficit."(37)
The other pillar of the new managerialism - strategic control from the centre - seemed similarly flawed in practice: the Scottish Health Authorities’ Priorities for the Eighties(SHAPE) framework seemed to provide the machinery for this with the intention of framing policy and spending in key areas like geriatric care, care for the mentally ill and preventative primary care.(38) But the documentation on the monitoring of this indicates little in terms of strategic thinking, of programmes set against specifically measurable aims and objectives; concern was almost exclusively on cost and expenditure control.(39) The imperfect and rather one sided implementation of the new managerialism was no different from experience in England.
Medical managerialism
The attempt to draw clinicians into resource management was considered crucial by Griffiths in his 1983 review given that individual clinician decisions were at the core of health care decisions and resource use. The difficulties felt by many clinicians in moving into management is well documented in both England and Scotland - the main fear being the difficulty in returning to medical practice after a period of absence undertaking ‘managerial duties’. However any notion of medical-professional disengagement from management is surely misleading. Research in England has indicated professional accomodation to managerialism largely achieved through the creation of part time clinical director posts enabling managerial and clinical functions to coexist for the postholders.(40)
There is evidence too of such arrangements in the GGHB area. At the key interface of clinical autonomy and management of resources it appears Scotland was ‘ahead of the game’: the SHSPC (dominated by medical professionals) - there was no comparable body in England - undertook in depth studies of various sectors and services, a successful example being its study of the management of orthopaedic services in Scotland: this examined administrative procedures, case management , liaison between medical and para medical professions.(41)
Although the SHSPC ceased to function by 1978, this approach mirrored the situation post 1990 when many protocols on good practice were issued by the Royal Colleges thereby retaining medical audit within the boundaries of professional control.(42) Evidence suggests this process was more apparent earlier in Scotland perhaps accounting for the view taken in the 1997 White Paper that the country led the way with the creation since the late eighties of the Clinical Resource and Audit Group under the chairmanship of the Chief Medical Officer.(43) This of course should not be taken to mean that medical audit and management of resources are always comfortably coupled in Scotland or elsewhere.(44)
Mixed economy of health care
The establishment of a mixed economy of health care had two key aspects, market tendering of support services, and a greater emphasis on private care. First, privatisation and marketisation of support services, which despite some spirited opposition and representation to GGHB, did take place as elsewhere in Britain, with some in house tenderers winning contracts and on other occasions external private sector providers. Second, was the significant increase in private practice. In the 1980s doctors’ private earnings soared, though much skewed by specialism and most certainly by geography.(45) In the case studied (and in the rest of Scotland too) private care was relatively insignificant and there seems to have been little concerted enthusiasm among doctors in support of private care. The following example illustrates the point.
In 1982 the chairman of the Consultants Committee of the Institute of Neurological Sciences in Glasgow attempted to gain GGHB’s approval of private treatment in the Department of Neuroradiology at the Southern General Hospital. Approval was given by the Area Medical Committee of GGHB on the understanding that government guidelines were adhered to.(46) The key guideline was ‘principle 2’ of NHS guidelines: ‘subject to clinical considerations earlier private consultation should not lead to earlier NHS admission or to earlier access to NHS diagnostic procedures’. The main issue was the interpretation of the time to be ‘added on’ after a private patient had been diagnosed. Three of the seven consultants supported the application. One of the remaining four, Sam Galbraith, received clarification from the Scottish Office:
" . . . The effect of principle 2 is that a patient should not be admitted more quickly following a private consultation than if he or she had remained under NHS throughout, taking account of the patient’s relative urgency - I would agree with your interpretation that a private inpatient in the case you quote would also have to wait 6 months for admission."(47)
Clearly the GGHB had to rescind its earlier approval which it did. The key feature is that less than half of the consultants supported the initial application for private treatment, hardly a resounding endorsement though views were clearly split.
Yet the period closed with a very significant question: given a unitary UK political system, just how particularistic could Scotland be? When central government indicated its support for a private hospital in Clydebank run by a private for profit international health care organisation, Health Care International (HCI) the GGHB made known its opposition to this aspect of government policy:
" . . . It is generally accepted that more recruitment would be a problem in the 1990s . . . scepticism of the chairman that all HCI’s nursing staff will be met from overseas recruitment-medical staff required by HCI likely to be recruited from among top consultants creating considerable medical staffing problems in NHS hospitals. There is also a shortage of paramedical staff. The development was not seen as one which could be considered prestigious for the Glasgow area as it did not introduce facilities or techniques not already available . . . the Committee agreed to recommend to the Board that this development would significantly interface with the provision of NHS services or operate significantly to the disadvantage of NHS patients."(48)
The main board agreed with this recommendation. However the HCI development proceeded with considerable support from central government including derelict land grants, tax breaks and a range of other supports.
Summary and conclusion: What about the future?
The dimensions of the overlapping and layering of Scottish particularism and UK congruence are clear though a comprehensive history of Scottish NHS policy and management remains to be written. A reductionist or mono causal explanation is unsatisfactory. Several explanatory elements are important: in the early years the stature of Scottish medicine (" [Scotland] one of the great nurseries of modern medicine"49) contributed greatly to Scotland’s standing in health politics generally; perhaps linked to this, the clearly articulated status which health had in the Scottish civil service; an apparently deeper embeddedness of socialised medicine in Scotland. These multi faceted factors have been overlaid by UK wide policy sometimes ‘permitting’ a specific Scottish approach, at other times not.
Our understanding will become fuller when similar archival research can be undertaken for the 1990s when access to original material for these years becomes available.
To conclude by moving forward to the present and speculating into the early years of the new century, two areas of Scottish/English divergence can be identified. First, the Arbuthnott Report, not yet accepted by the Scottish Parliament, may lead to significant redistribution of health service resource based on socio-medical indicators. Such a (potentially) comprehensive approach appears some way off in England where initiatives like Health Action Zones important though they are, scarcely amount to a national programme. Second, if current public expenditure policy remains and the reformulated Barnet formula for distributing additional public expenditure is fully implemented, Scotland will receive less additional expenditure for health than England on an annual basis. This leaves the possibility of differential rates of growth, redistribution of the Scottish Executive’s block financial allocation and/or the Parliament using its tax raising powers to supplement health expenditure. NOTE: A full list of references and footnotes for this article is available from the author.