Final Report > Chapter 15: The Culture and Management at the UBH/T > Conclusion
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18 The UBHT was not unusual in having problems. It was, after all, managing the transition from the known (the old NHS) to the unknown (trust status). We understand that problems arise in all institutions. But it is incumbent on senior management to devise systems which respond quickly and effectively to these problems. What was unusual about the UBHT was that the systems and culture in place were such as to make open discussion and review more difficult rather than more easy. As we have said, we were told by Mrs Rachel Ferris, General Manager, Directorate of Cardiac Services, UBHT, that Dr Roylance told his staff: `don't give me your problems, give me your solutions'.  This approach was generally unhelpful. It was counterproductive as a means for securing improvements in the quality of care. It ignored the growing realisation that problems are better understood as offering valuable opportunities for learning. It failed to encourage staff and patients to share their problems and to speak openly. The most dangerous management style of all is that of the exercise of power without strategic vision, accompanied by `divide and rule'. Dr Roylance's style of management could be so characterised.
19 We accept that Dr Roylance was both thoughtful and principled in his development of a management system for what was one of the newest and largest trusts in England, and that he succeeded in putting in place stringent financial controls and in balancing the books. Sadly, a system of separate and virtually independent clinical directorates, combined with a powerful message that problems were not to be brought to the centre for discussion and resolution, meant that there was power but no leadership. An environment was created in which problems, which we repeat are likely to arise in all institutions, were not adequately identified or addressed in Bristol.
20 Nor were there effective measures outside Bristol to monitor or change the style or system of management adopted by Dr Roylance. This was a feature of the NHS reforms in 1989-1991. Trusts were to be allowed to get on with things. Senior managers were invited to take control, but little or no system existed to monitor what they did in the exercise of that control. Indeed, it did not really exist inside the Trust either, as Bristol suggested. The Chair and the Trust Board were either part of the `club' or treated as outsiders. Referring to information about the outcome of care, Mr Robert McKinlay, the Chair of UBHT from 1994 onwards, told us that: `there was no tradition or culture in UBHT that the Board or the committees of the Board should be involved. ... I thought that was something that was wrong. I thought the Board should have some knowledge of statistical outcome, but there was a tightrope to be trod to find a way of easing it into place.' 
21 Thus, in our view, there were a number of elements in the system and culture of management in Bristol which were conducive to the provision of less than adequate care. It may be true, as Mr Wisheart argued in his evidence to the Inquiry, that the fact that the managerial system was less than adequate may not have affected directly the adequacy of care received by any particular patient. Nevertheless, contrary to Mr Wisheart's view, the inadequacies of management were an underlying factor which adversely affected the quality and adequacy of care which children received.
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 WIT 0089 0032 Mrs Ferris