Table Of ContentPower and Influence
in the NHS
oceans without continents
Geoff Meads
Professor of Health Services Development
Health Management Group, City University, London
Foreword by
Peter Dickson
Professor Emeritus of Early Modern History
University of Oxford
CRC Press
Taylor & Francis Group
Boca Raton London New York
CRC Press is an imprint of the
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First published 1997 by Radcliffe Publishing
Published 2016 by CRC Press
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© 1997 Geoff Meads
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ISBN-13: 978-1-85775-270-0 (pbk)
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Contents
Foreword v
Preface vii
Abbreviations ix
1 Introduction: manifesto 1
From planning to political processes of development
Translation of contemporary NHS into wider UK health
care environment
2 The Balance of Power 7
Devolution and difference - impact of general practice
fundholding
Scale of NHS internal change
Achieving a new balance of powe^
3 Revolution 15
Impact of choice
Implications for public accountability of NHS structural
change
Subsidiarity and development
4 The Dark Ages 23
Decline in NHS standards of behaviour and morale
iv • Contents
A new paradigm of public accountability
The spiritual dimension
5 Counter Revolution 33
European influences
Consumerist influences
Demand pressures
6 Renaissance 41
Leadership by participant observers in the NHS
Modern UK health care leaders and their methods
7 Reformation and Enlightenment 49
The subjective reality of the modern NHS
Creating a new orthodoxy for the NHS
Future hopes
Index 57
Foreword
I was Geoff Meads's college tutor from 1970 to 1973. It is flattering
a quarter of a century later to be asked by him to write the
Foreword to his expert study, and to find that he is a professor
too. His subject in this book, the modern NHS, seems to me every
bit as complex and as difficult to grasp as the periods of history to
which he refers.
He describes how the NHS has in the past decade moved away
from central direction and planning structures towards local control
centred on general practice fundholdings operating in an internal
market. In the process, political conflict and power contests have
been 'regionalized'. The underlying situation, which is outside the
scope of this book, is that the allocation of scarce resources
through a price-system responding to demand and supply, the
normal commercial situation, is absent in health care, for whose
consumers it is 'free at the point of sale'. Where there is no price
constraint on demand, it becomes infinite. But since supply is not,
demand is reined back by rationing, in the form of waiting lists and
other devices. The internal market, the devolution of health care to
local level, the importance of local initiatives, the variety of local
practices, all of which Meads emphasizes, are, as I understand it,
responses to this situation. They attempt to import enough of the
discipline of the market into health care to make it adequately
responsive to its consumers, while preventing escalation of its costs
from forcing it into bankruptcy.
Together with social security and pensions, health care expendi-
vi • Foreword
ture exerts a grip on the budgets of all western states similar to the
grip which defence exerted during the Cold War. Meads hints in
his interesting study that UK efforts to resolve this problem have
proved superior to those of other European governments; and
promise to do so in the future. The combination of effective admin-
istration and financial constraint which he describes is one of
which the great Sir Robert Walpole, to whom he refers in Chapter
2, would have firmly approved.
Peter Dickson
Oxford
April 1997
Preface
Much of the content of the chapters that follow is devoted to
identifying the changing interfaces of the NHS and the new oppor-
tunities for creativity that unexpected alliances, networks and coali-
tions can offer. This book owes its production to one such
opportunity. The Director roles of an NHS Executive regional office
and a university health management school are both new; arche-
typal spin offs of the contemporary NHS and clear evidence of the
range of participants now joined in the UK health care system.
Tony Laurance and Valerie lies occupy these roles, in the NHS
South and West Region and the Health Management Group of the
City University respectively. Their joint ability to read the times and
to supply the secondment opportunity through which this book
has been created seemed far sighted in the spring of 1996. A year
later I hope this foresight is still felt to have been worthwhile. This
publication is by way of repayment to Tony and Valerie, to both of
whom I owe a considerable debt.
I have enjoyed writing this book, and the refuge it represents
after seven years spent in senior NHS management. It has been like
learning to live again! The seven years mirror the seven chapters of
the book which seeks to trace the development of the NHS, and to
a lesser effect, the UK health care system, over this time. To
describe and interpret this development a mixture of personal
experiences and reflections, conceptual frameworks and parallels
from the great periods of change of the past are deployed. To
claim that the end result is multi-layered would be presumptuous.
It is certainly, however, a curious mixture and for readers, as a
viii • Preface
minimum benefit, the figures distributed around the text provide a
range of largely new change management methods and analytical
techniques for use in practice.
I hope the book communicates. The format with its grand
historic analogies, should not be taken too seriously; they have
been fun to toy with as a vehicle for some simple and, I hope, true
and striking assertions, albeit perhaps sometimes expressed too
simplistically. I have learnt a great deal along the way. The experi-
ence has been a catharsis; making sense of what has gone before,
finding a release to move on. I hope that at least for some readers
it helps provide a similar step forward.
The book has also been a team effort. I am delighted to be able
to acknowledge the crucial support I have received from Jane
Harding for her sympathetic understanding and secretarial
expertise; from Gillian Nineham and June Huntington whose
editorial guidance and feedback respectively has been that of real
friendship; and above all my gratitude goes to a partner whose
tolerance and patience over the years has been the key. It is to her
that I dedicate this book.
Geoff Meads
Winchester
April 1997
Abbreviations
AMGP Association of Managers in General Practice - nowadays
the main national organization for Practice Managers
which, over the past three years, has established itself as
a counterpart to the Institute of Health Services Manage-
ment.
BMJ British Medical Journal - the most widely read regular
medical publication in the UK, and the most influential.
BUPA British United Provident Association - the leading
private sector health care company in the UK.
CHC Community Health Council - consisting of local repre-
sentatives responsible for ensuring local health services
respond to the public interest.
CHS Community Health Services - include, for example,
district nurses, health visitors, community hospitals and
psychologists providing important specialist support to
general practices.
DGH District General Hospital - since 1962 the main unit of
NHS health care, usually providing for a population area
of at least 150000.
DHA District Health Authority - the pre-1996 tide given to the
170 organizations responsible for purchasing secondary
care services and promoting local health.
