Scot. med. J., 1977, 22: 267
A CRITICISM OF THE ORGANISATION OF THE NATIONAL HEALTH SERVICE A. I. Packt Hospital of the University of Pennsylvania, Philadelphia, U.S.A. *
highly personalised account of the organisation of the Health Service has T been stimulated and coloured by the process HI S
of transferring my vantage point temporarily from the Eastern District of the Greater Glasgow Health Board Area to the other side of the Atlantic. The Health Service discussed is that in Scotland, which has one less administrative tier (Regional Authorities) than that in England. Reorganisation - the need The current problems of the Health Service are largely related to administrative reorganisation and to economic failure of the United Kingdom. Reorganisation was suggested originally (Report, 1962)to abolish the tripartite structure of the Health Service, thereby increasing its efficiency. The objective of Whitehall, however, was to 'increase political content of decisions and to demote professional decisions' to quote a distinguished analyst of the British Health Service (Klein, 1975). That the DHSS should have this objective is hardly surprising. Ministers, such as Crossman (1972), felt powerless at the centre and if there were major iniquities, e.g, the small amount of money spent on food for mentally handicapped patients, they could not correct them.
The principle upon which the Conservative reorganisation of the Health Service was based was accountability upwards and decision making downwards (H.M. Stationery Office, 1971). What does this mean? The evidence is that Area Board administrators and District administrators would givedifferent interpretations (Lewis & Weiner, 1975). The central group are supposed to be planners, to decide objectives and to monitor progress. The lower management level get on with the job.
Role of the area board This task is new to many of the administrators at Area Board level and the evidence is that they may attempt to manage the Districts directly rather than monitor their progress (Lewis & Weiner, 1975). This has led to conflict. Each level fights for control of particular areas since there is no stated policy. The rules seem to be determined largely by the relative strengths of the District and Area personnel, and are flexible as the following example illustrates. In my limited experience of administrative matters I became involved in planning a computer project in the Eastern District, Greater Glasgow Health Board (GGHB). After extensive reading I became convinced that if such a project were to have a chance of Reorganisation - the principle success, there would need to be significant One of the weaknesses of our over-centralised form of government, however, is that control and involvement at a district level ministers take decisions relatively hurriedly (see Barber & Abbott, 1972; Medinfo and in broad principle. Thus the working out Conference, 1974). I was advised by the Area of details of policy are left to the army of Board computer officials that this was against civil servants. Principles are vague and open the principles of reorganisation and was not to interpretation; details are concrete. Power the stated Area Board policy. This prompted is devolved to the bureaucrats who are questions: What principle did it offend? largely unanswerable to Department ministers Where is the stated Area Board policy? and certainly not answerable to the populace. Who decided the Area Board policy? The This is the major lesson to be learned from only reply was an assurance that this was indeed the policy of the Area Board. In the 'The Crossman Diaries' (Crossman, 1975). event, hostility in the District to the concept *Formerly Centre for Respiratory Investigation, of a project completely controlled by Area Royal Infirmary, Glasgow. tWinner of Editor's Prize 1976. became so strong that the 'stated policy'
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changed in the course of an hour. These discussions were inordinately time-consuming, and during them I wondered what the political architects of reorganisation would have thought. The Area Board may also intervene in relatively minor matters at District level. Thus, the Greater Glasgow Health Board prevented the Glasgow Royal Infirmary from producing its annual report with endowment money bequeathed to the Infirmary. This is hardly monitoring progress. The effect of this irrational decision was to solidify resistance to the Area Board and to lead to the medical staff of the Royal Infirmary producing its own report. Role of the district
While the Area Board seems distant to the clinician the District is more immediate. There was in the District in which I worked, a strong relationship between clinicians and administrators built on mutual respect and trust and a belief that both groups had common objectives, i.e. to improve health care. Unfortunately the District concept is based on a false premise, the District being defined as a population served by community health services supported by the specialised services of a district general hospital. This would suggest that all Districts should be medically complete and little thought has been given to 'special centres'. It is evident that not all districts, nor indeed all areas in Scotland, can have cardiac surgery, plastic surgery, renal dialysis, respiratory investigation, cardiac catheterisation etc. Thus many patients are referred across district and area boundaries without increased monies being paid to the district which treats them. In the unit in which I worked 60 per cent of the patients came from outwith the district and 30 per cent outwith the area. Thus it is evident that district budget allocations cannot be decided equitably by a simple formula, since special centres are usually costly in terms ofpersonnel etc., and place an increased burden on support services in their district. Futhermore, budget allocations can be affected detrimentally if the District succeeds in attracting a particularly able consultant. Thus if a District has a surgeon who, because of his 268
excellence at a particular operation, has patients referred to him from a wide area, District budgets will have to pay for the costly treatment of many patients who do not 'belong' to it. The extreme effect of this policy would be for districts not to attempt to attract such able consultants, nor to develop their services. There is, furthermore, an additional policy which will downgrade centres of excellence - the current reallocation ofresources (Working Party Report, 1975). Whilst it has been argued reasonably for some time that existing allocations were historical accidents, previous Health Ministers (Crossman, 1972) saw that re-allocation could only be achieved by levelling up rather than down. Thus the current levelling down policy must lead to a significant drop in standards. Role of the Department
Standing apart from the jungle of District/ Area activities is the Department. The Department seems to issue guidelines and advice to lower authorities. Lower authorities seem to believe that the Department thinks in idealistic rather than practical terms (Forsythe, 1975). In particular, the Department does not make available new funds to allow its advice to be implemented. For example, if it points out to Area Boards the importance of developing Clinical Immunology, what are the Area Boards supposed to do? They are already battling to maintain existing services. The Department might argue that it is a virtue not to interfere directly in affairs at Area Board level. This relationship is, I believe, wrong. Firstly, there could be a large amount of time wasted at Department level in preparing plans which are never implemented. Since these plans are formulated by the most able in the Health Care professions, this is a waste of one of our most valuable resources. Plans, once formulated, raise expectations, and if never implemented have a deleterious effect on morale. It is in the nature of things that the advice available at Area Board level must be less good than that at the Department. Thus the dissociation of planning from practical considerations on implementation is not in the best interests of the service.
A Criticism of the Organisation of the National Health Service
Decision making in the reorganised health service Faced with such an awesome structure, the average clinician will be inhibited from taking initiatives to improve services. Indeed in my limited experience as chairman of a subcommittee, an opportunity was identified within the computer-orientated field to get a necessary task done using the Government Job Creation Scheme." This would cost minimal monies which would have to be obtained from the Department as a project grant. An estimated cost for the same task using conventional labour would be £60,000. The computer advisers (Area Board) indicated that the following steps would need to be taken: (a) Obtain approval of the Eastern District Computer Committee; (b) Obtain approval of the Eastern District Medical Committee; (c) Obtain approval of the Eastern District Executive Group; (d) Submit request to Area Board; (e) Obtain approval of an Information Planning Committee (or similar title at Area Board level); (f) Obtain approval of a Consortium committee who looked after the large Health Service computer installation at Park Circus, Glasgow (a small amount of computer processing was necessary); (g) Submit to Central Services Agency (C.S.A.); (h) Obtain approval of an Information Planning Committee at C.S.A. level. Since the job creation scheme was political in origin and, therefore, possibly transient, it seemed that if use were to be made of this labour there was need for an early decision. The Area Board officials suggested that the likely time scale of the process outlined above was 6 to 9 months. Since the Consortium Committee had not met since reorganisation and it was not known when they would meet, this seemed an optimistic estimate. t Thus it has to be argued that reorganisation has not simplified the decision-making process; it has rather created an infinite capacity for stalling and avoiding decisions (see Fig. I). Planning in the reorganised health service Since increased planning of health care delivery is envisaged in the reorganised health service there has been further development of Information Services, the lynch-pin
of which is SMRI returns.] SMRI returns are filled up reluctantly by clinicians and processed equally reluctantly and with difficulty by records office staff. This is hardly surprising since both groups have more immediate tasks and question their relevance. Thus the accuracy of the data on these returns is highly suspect. It was argued in a departmental report (Bodenham & Wellman, 1972) commissioned from outwith the Health Service that the problem would be alleviated if the returns could be processed quickly. Thus clinicians, once they were able to make use of the information from the returns, would be motivated to fill them up. It is not clear what benefit clinicians would obtain if the list of the patients who had been treated were available more quickly. Nevertheless the system is now in operation and there is an expensive computer system in one district which carries out this activity-processing SMRI returns. Within medical circles it is well known that to collect large amounts of limited inaccurate data for some as yet undefined research project will lead nowhere. One assumes that a similar principle applies in planning. The questions first should be formulated, the relevant data collected, and decisions made. Apart from the question of information there is the question of objectives. These are laid out for the Scottish Health Service in the recent document, The Way Ahead (1976). They are: (1) The need to operate the services within the budgets available, which allow for a limited measure of growth: (2) The need to promote health care in the community through the progressive improvement of primary care services and community health services: (3) More positive development of health services for families in areas of multiple deprivation: (4) Lessening the growth rate of the acute sector of the hospital service *This scheme was set up to provide funds for employing out-of-work teenagers. There was no direct cost to the employing authority. [In the event by pressure from the District, and after some difficult meetings with Computer advisers, the project was initiated. tSMRl returns are filled up for each patient discharged, or transferred from a ward following admission. They contain a small amount of information, e.g, name, diagnosis, etc.
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j-----------
---LINEal AUTHORITY -------- MAJOR ADVISORY LINK
I
Health Service Planning Council
I I I I I
I
EiJ
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r
r
r
I I I I r
I I I I It
Advisory Panel on Information Services &
Processing
I I I I I r r
I I
I I
_
- - -----1 --------------------------1
I I
r r
A9 I
GGHB Information
MEDICAL GG",
Services and
COMMITTEE
Computing
Ad Hoc Committee
EASTERN DISRICT MEDICAL ADVISORY COMMITTEE
EASTERN DISTRICT '--_ _-r-:-_ _--J-------- STAFF COMMITTEE ON COMPUTERS
Organisation suggested
by Area Boord for the computer
project in the Eastern District.
Certain committees are
indicated by initials only. The author does not pretend to understand what each of these committees is or does.
Fig. 1. Eastern District project machinery for control.
in order to finance essential developments in other sections: (5) Continued improvements in hospital and community health services for the elderly, the mentally ill, the mentally handicapped and the physically handicapped. (6) Encouragement of preventive measures and the development of a fully responsible attitude to health on the part of the individual and the community. These objectives are socio-political iand not specifically orientated to alleviating the major diseases of our time. Indeed one of the few mentions of disease in the document is in Section 2.10. To 270
quote-'In addition, high mortality rates from bronchitis, lung cancer, and ischaemic heart disease persist. These diseases like the increasing spread of dental disease, largely reflect cultural and behavioural patterns; little impact will be made on them until the attitudes of the public are changed.' Whilst it is admitted that we have major problems in Scotland in ischaemic heart disease, bronchitis and lung cancer, no specific programme has been developed to attack them. We now know more about the basic biochemical abnormalities, e.g. lipo-
A Criticism of the Organisation of the National Health Service
protein disorders (Fredrickson & Levy, 1972) and are in a position both to recognise and treat them at a pre-symptomatic stage. The importance of smoking in causation of such diseases has been accepted for about 2 decades, and there is increasing evidence of the value of anti-smoking programmes (Hunt & Bespalec, 1974). Thus there are these and other areas of activity which could modify the morbidity and mortality of these diseases. Indeed it is arguable that in a planned Health Service, we should question which diseases are the most important and then assess the means available to us to control them. Programmes would include better facilities for treatment of patients with these diseases, and preventive measures related to their causation. While a medical approach, based on scientific evidence, may change disease patterns, it is not immediately obvious that a political approach will. For example, although infant mortality is unacceptably high in deprived areas, this may not be related to inadequate medical services. In this area, as in others, there is a need for more research into aetiology, careful consideration of more detailed objectives, and institution of properly financed, carefully planned, imaginative programmes, the results of which are available to future generations of planners. It seems pointless to spend money on a 'good intent' basis without this information and without methods being available to assess the return from investments. The depressing fact is that this document (The Way Ahead) is vague, if not frankly amateurish. It also foresees contraction of the hospital service with expansion of community services and argues that the former has grown out of proportion in the last decade. It does not, however, consider why it has grown or whether the growth has been associated with improvements in health care. This aspect is discussed elegantly in a recent article by Professor W. B. Jennett (1976). The public are aware of the achievements of the hospital sector and value the service which it provides. Thus the major change in health care delivery which is envisaged in the document should be preceded by full public
debate. It is the profession's responsibility to insist on such a step, before allowing the present system to be dismantled. The public debate on education has come only after the large scale experiment with large comprehensives has proved a failure. During my time in Glasgow Royal Infirmary it appeared that the Health Service had too few hospital beds, not too many. Many receiving nights were spent attempting to find room for the admissions-decanting, transfers, etc. Wards were not infrequently overfull. Decisions were taken about admitting patients under the pressure of not having enough beds to put them in. Patients with central chest pain but not a definite myocardial infarction were a particular problem. Even though normally one would admit such patients, they were often sent home when beds were in short supply. Would the planners accept legal responsibility if such a forced decision proved to have disastrous consequences? Planners seem to fail to understand that medicine is not as controllable as a production line, and that demand on services is largely determined by the pattern of behaviour of patients. Thus it is not just the total number of beds that are important but rather their distribution in relation to origin of demand. During these difficult winters I argued with our consultants that it was wrong of them to make an inadequate system continue to function by artificial means. Certainly the reward for their effort has not been the praise of our political masters, but rather the promise of further reductions. Medical practitioners as decision makers Part of the administrative drive for some new forms of control of events must be related to their discontent with the previous system. They felt that consultants ('the barons') had too much say. A District Planning Administrator told me the story of his first planning meeting at the Glasgow Royal Infirmary about equipment for the new hospital. One item he had not heard of before. He asked innocently what this was. The chairman of the committee (a distinguished professor) replied, after a pause, that he didn't know, but his department needed 2! 271
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It may be that the profession didn't appreciate that it was managing. It certainly did not consider budgetary implications of decisions, believing that it was someone else's responsibility to provide the money. This philosophy is hardly unique to the medical profession as it has pervaded most of our publicly owned services and industries. Nevertheless, I am impressed by the consultants' tolerance rather than intransigence. The first Medical Division meeting which I attended was to assess the priorities for capital equipment requests (any article of equipment in excess of £50 is counted as capital equipment). There were 25 items requested. Each person requesting a piece of equipment gave a 3-minute presentation about the need for that item. There then followed a discussion on how to vote. It was agreed that each of the 30 people present should rank the items in priority (1-25), recording their votes on sheets of paper. The youngest consultant was nominated by the chairman to count the votes, which he did after the meeting. The meeting lasted from 4.30 p.m. until 7.00 p.m. In the event it was decided at a higher level that the monies were so limited that none of the items could be funded. The wastes in this dubious democratic process were: (1) The time of 30 very well qualified senior registrars or consultants (time-75 hours); (2) The time of 25 people preparing submissions; (3) The time of administrative assistants circulating copies of the documents to the Division. The fact that the Divisions continue to function speaks of the dedication of the consultants to the N.H.S. The general practice/hospital relationship Although in the administrative aspects of reorganisation there has been an excessive drive to create a complex structure, there is the general point that the service is now unified. At the committee levels, e.g. District Medical Committee, there is involvement of all branches of medicine. At a working level there is little sign of increased cooperation. One of the main sources of personal contact between hospital and general practitioners is when the general practitioner has to phone his hospital colleague to accept an emergency admission. The hospital colleague in this case is generally a 272
junior house officer who may cross-examine the general practitioner. My favourite story about this concerns a deputy doctor who 'phoned in' a patient who had taken an overdose of Valium. As he stood in a vandalised phone-box with no light or glass, in a deprived, if not frankly dangerous area of Lanarkshire, he was asked by the house physician if he had facilities for gastric lavage! A hindrance to progress in this area is lack of understanding by each group of the other's problems. The fundamental fact is that general practice and hospital specialisation are very different jobs. The general practitioner has to have a very broad and, therefore, relatively superficial knowledge, whereas the specialist must have an in-depth knowledge of a limited area. The major problem with general practice is that more than 90 per cent of time is spent treating minor illnesses. To many this is unsatisfying and not in the least intellectually challenging. (It has to be wondered whether it is in the best interests of a struggling nation to use some of the best products from its schoc I system to spend their lives treating verrucas, common cold, dysmenorrhoea, minor musculo-skeletal problems, etc.) This is not to deny that general practice provides an extremely useful function or to suggest that practitioners are second rate. It is to suggest that their intellectual talents are underemployed in the present mode of work. Current attempts to have the general practitioner act as a hospital specialist as well seem to be impractical. It is a difficult enough task to keep up-to-date as a specialist without also being a generalist. The danger is that general practitioners will be given the unpopular tasks in hospitals thereby further increasing their discontent and resentment of hospital colleagues. Equally, current attempts to equate general practice with a 'speciality' is a superficial analysis and does not in any way alter the basic problem. Thus there remains in the general practice area the problem of how to use the available talent properly. The Department seems to believe that this is achieved by the creation of health centres, but these do not in any way alter the fundamental problems of practice.
A Criticism of the Organisation of the National Health Service
Reorganisation/the opportunity Reorganisation does give the profession in Britain an opportunity to develop a new style of health care system with more emphasis on prevention. The major question is, however, who will implement this change? It is unlikely to be achieved solely by community physicians. Evidence from correspondence in journals would suggest that they are unclear about their role. Furthermore it is difficult to conceive of a single group who assume, in isolation, responsibilities for control of typhoid epidemics, investigation of inherited biochemical defects and screening of certain groups of workers for lung disease. Medical knowledge is now so extensive that specialisation is essential. Such specialisation is at present largely system-orientated. In the reorganised health service the specialist could assume responsibility for the control of diseases related to his speciality in his district. This envisages an expansion of his role from that of being a referral clinician. He could be responsible for implementing programmes of prevention with community physicians. In the pulmonary area, for example, there is a need for more active investigation including pulmonary function testing for groups of workers particularly at risk from industrial lung disease, more active pursuit of anti-smoking programmes and investigation of groups at risk from forms of allergic alveolitis, e.g. pigeon-fanciers. Tuberculosis remains a problem in certain groups. It will be a test of the Department's intentions to see whether it pursues actively a prevention policy or whether it views preventive medicine as a means to excuse downgrading the hospital sector. In addition, the specialist and general practitioners could develop joint programmes of care for particular clinical problems after fulI discussion. Such programmes will require initial investment but should be cost-effective. This could be facilitated by the specialist assuming an increased responsibility for post-graduate education, and a more active policy being implemented to ensure standards are maintained both in hospital and general practice. Case conferences at which general practitioners and specialists discuss cases are essential. Part of the problem with the current
British system is that hospital clinicians have little time for objective reflection since they are so close to the problems. Re-examination of one's activities always occurs on changing posts and it is a weakness in the British style of practice that consultants rarely change positions. The effect of change is also to revitalise. Financing the health service The Health Service has been under-resourced for at least the last decade. This would probably be agreed by all major participants including the politicians. The profession has continued to point out that there are major differences in expenditure in health care between Britain and the other countries of the Western world. An industrial nation must have as its main priority, however, the creation of a strong, successful industrial base. Thus such comparisons reflect different priorities which may be occasioned by different needs. It is at any rate an argument which has failed to impress the politicians. They seem to believe that no matter how much money is spent on the Health Service, the profession will demand more. This is probably true. Thus there may come a point in any society, no matter how successful economicalIy, where modern technological medicine may outstrip the available resources. Members of the profession must, therefore, be concerned with budgets and must attempt to maximise the delivery of health care for a given expenditure. There are possibly 3 aspects to such budgetary decisions: (a) Deciding the overalI expenditure on health care ; (b) Deciding the portioning of these monies between different parts of the service, e.g. geriatrics; (c) Use of monies at a local level, Part of the current problem is that the profession disagrees with the government both with respect to the overalI sum and also probably to its distribution. The government stresses the importance of geriatrics. They may fail to understand, however, that in many geriatric cases medicine has little to offer, and that training of health care staff is such that they tend not to want to see increased resources being expended in this direction, while patients who can be actively 273
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helped by modern medicine are denied such help because of lack of resources. At a local level there is a case for more decentralisation of budgetary control. For example each division could have its own budget. Most of the profession would undoubtedly dispute this but it would have the following advantages: (a) It would create more usable money since much of the inefficiency can only be dealt with at a local level; (b) It would simplify, accelerate and render decision making less costly. We would not have to fight through layers of administration to obtain even minor items of equipment. This should also improve morale; (c) We could obtain a more rational, cohesive policy for development of our Division. At the present time the Division contains a number of strong independent members. Its priorities may thus be overturned by the argument of one of its members at a higher committee; (d) We would have a united effort in our increasingly difficult fight with central administration. One member of the division should be able to devote himself full-time to this and other administrative matters; (e) We would act even more vigorously to force alternative solutions if we saw our budget being used inappropriately, e.g. long-stay admissions of geriatric patients in teaching hospitals on purely social grounds. I do not accept the argument that members of the medical profession are incapable of such management. Indeed, some heads of medical departments on the American side of the Atlantic seem capable of running IBM successfully!
private sector better than in the NHS? The answer to this is no, since there are, in general, less facilities in the private sector and less medical cover at non-consultant level. (4) Is it not desirable that every patient should be able to obtain a second opinion at reasonable cost, since he cannot demand such in the NHS, let alone choose his initial consultant? The real public debate, which the profession should encourage, is related to the overall funding of the NHS, to concepts of equality between regions as opposed to a strong centre but available to all, to priorities in terms of provision of facilities, to consideration of alternative systems of financing health care. The proximity of medicine to party politics is in neither the interest of the profession nor the politicians. It diverts the attention of the latter from more urgent matters, i.e. the economy, and leads to discussion on the Health Service becoming at times emotive. Hence irrational decisions (e.g. that of the Conservative Secretary for State on Reorganisation) are taken. There is a strong case for a non-political independent body with real power to administer the service. Conclusion
In this article I have attempted to layout the opinions which I have formulated during my period in the Health Service and the events which have led to formation of these opinions. I have also attempted to develop a number of theses: (a) The Health Service at the present time is leaderless. The centre advises: the areas are not listening but rather meddling Party politics in district affairs. Professional administrators Since the Health Service was largely a lack both imaginative drive (to quote Crosspolitical creation, medicine remains a matter man) and enough detailed knowledge of for intense partisan political debate. Unfortu- health care to fit them to lead. Leadership nately the current debate is largely irrelevant must be provided by the most able in the to current problems. The Labour Party is profession. It is an historical fact that at committed to total abolition of private the present time many of the most able practice. The profession has the responsibility senior members of the profession are in of opposing this. It has to be asked: (l ) Would clinical specialities (i.e. not in community abolishing private practice totally improve medicine). It would be in the interests of all the NHS and how? (2) Would attempting to if they could be recruited to key positions, abolish private practice in a free society not e.g. Chief Medical Officers. The current make it more expensive and, as in the case of balance of power in executive groups is too schools, make the private sector the preserve heavily weighted towards lay administrators. of the elite? (3) Is the standard of care in the (b) Clinicians must abandon the posture that 274
A Criticism of the Organisation of the National Health Service
they are divorced from consideration of cost efficiency. Health care can only advance if the profession optimises its use of scarce resources. While the problem may be alleviated by alternative systems of financing health care, it will not be cured. Thus the profession must accept some form of more direct managerial responsibility. An argument can be made for more decentralisation of budgetary control. (c) The current trends of policy in the use of resources may not all be in the best interests of the population. Since the profession is unlikely to convince the government, it should insist on a full public debate before allowing any major changes to be implemented and it must commit resources to education of the public on the real issues and facts. The public as consumers are dangerously ignorant. (d) Reorganisation in its current form is illconceived. Arguments that we are only witnessing the settling-down period are false since there are major conceptual flaws. The system has excessive decision-making layers, such that communication will always be a problem and decision-making slow. There is a large gulf between planning and implementation. The Health Service has traditionally made progress by harnessing the talents of able clinicians who initiated new developments. The present cumbersome structure stifles any such possibilities and this is to the detriment of the service and the frustration of the individual clinician. In the Scottish system the new Area Boards seem unclear about their role and have been spending much of their energies in fighting border skirmishes with districts to obtain more direct powers. They are too remote to achieve an identity with their employees, despite for example the circulation of excessive numbers of glossy newspapers. For proper planning (e.g. special centres) the areas are too small. Thus, unless there are convincing reasons with definite evidence of present and likely future achievements, a case can be made in Scotland for abolishing the Area Boards. (e) The responsibility for forging a new type of integrated care must fall on the major hospital-based specialities. General practitioners' training is too superficial to enable
them to carry out this role. Community medicine is weakened by being general and may take years to get off the ground. There is a case for a full discussion between the Royal Colleges on integrated care, and on the role of the specialist in the reorganised service. At some point we must face the problem of continued assessment following qualification. (f) The current policy of the Information Services Division is likely to be wrong. This is not to deny the importance of planning or information but to suggest that because of the current mode of collecting data, and the data collected, the information is unlikely to be very useful. It would be interesting to know the annual cost of processing the SMRI returns. (g) There remains a problem on how to utilise properly the intellectual capabilities of general practitioners. The equating of general practice with a speciality is not helpful in this regard. (h) The events during reorganisation of the Health Service indicate certain basic principles about the current style of government in Britain. In particular it shows that bureaucracy, presented with a set of principles, can turn these to any purpose they require. There is a need for a system of more active questioning of bureaucrats once details of policy have been developed. REFERENCES
Barber, B., Abbott, W. (1972). Computing and operational research at the London Hospital. London: Butterworth Bodenham, K. E., Wellman, F. (1972). Foundationsfor Health Service Management. Provincial Hospitals Trust. Oxford: Oxford University Press Crossman, R. H. S. (1972). A politician's view of health service planning. Maurice Bloch Lecture, University of Glasgow Crossman, R. H. S. (1975). The Diaries of a Cabinet Minister. Volume 1. 1964-1966. London: Hamish Hamilton Forsythe, J. M. (1975). In Discussion on reorganisation: the first year. British Medical Journal, 2, 736 Fredrickson, D. S., Levy, R. I. (1972). Familial hyperlipoproteinaemia. In Metabolic Basis of Inherited Disease, p.545. Eaited by J. B. Stanbury, J. B. Wyngaarden and D. S. Fredrickson. New York: McGraw-Hill 275
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H.M.S.D. (l971). Department of Health and Social Security. National Health Service Reorganisation, Consultative Document. London: H.M.S.O.
Medinfo Conference (1974). Several papers from proceedings.
Hunt, W. A., Bespalec, P. A. (l974). An evaluation of current methods of modifying smoking behaviour. Journal of Clinical Psychology, 30, 431
Report (1962). A review of the Medical Services in Great Britain. Report of the Medical Services Review Committee, London. Social Assay, 1962
Jennett, W. B. (l976). The way ahead for acute hospital services. Lancet, 2, 1235
The Way Ahead (1976). The Health Service in Scotland. Scottish Home and Health Department. Edinburgh: H.M.S.O.
Klein, R. (l975). In Discussion on Reorganisation: the First Year. British Medical Journal, 2, 737 Lewis, J., Weiner, S. (l975). Views from the Districts. British Medical Journal, 3, 22
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Working party report (l975). First Interim Report of the Resource Allocation Working Party. Department of Health and Social Security
A CRITICISM OF THE ORGANISATION OF THE NATIONAL HEALTH SERVICE A. I. Packt Hospital of the University of Pennsylvania, Philadelphia, U.S.A. *
highly personalised account of the organisation of the Health Service has T been stimulated and coloured by the process HI S
of transferring my vantage point temporarily from the Eastern District of the Greater Glasgow Health Board Area to the other side of the Atlantic. The Health Service discussed is that in Scotland, which has one less administrative tier (Regional Authorities) than that in England. Reorganisation - the need The current problems of the Health Service are largely related to administrative reorganisation and to economic failure of the United Kingdom. Reorganisation was suggested originally (Report, 1962)to abolish the tripartite structure of the Health Service, thereby increasing its efficiency. The objective of Whitehall, however, was to 'increase political content of decisions and to demote professional decisions' to quote a distinguished analyst of the British Health Service (Klein, 1975). That the DHSS should have this objective is hardly surprising. Ministers, such as Crossman (1972), felt powerless at the centre and if there were major iniquities, e.g, the small amount of money spent on food for mentally handicapped patients, they could not correct them.
The principle upon which the Conservative reorganisation of the Health Service was based was accountability upwards and decision making downwards (H.M. Stationery Office, 1971). What does this mean? The evidence is that Area Board administrators and District administrators would givedifferent interpretations (Lewis & Weiner, 1975). The central group are supposed to be planners, to decide objectives and to monitor progress. The lower management level get on with the job.
Role of the area board This task is new to many of the administrators at Area Board level and the evidence is that they may attempt to manage the Districts directly rather than monitor their progress (Lewis & Weiner, 1975). This has led to conflict. Each level fights for control of particular areas since there is no stated policy. The rules seem to be determined largely by the relative strengths of the District and Area personnel, and are flexible as the following example illustrates. In my limited experience of administrative matters I became involved in planning a computer project in the Eastern District, Greater Glasgow Health Board (GGHB). After extensive reading I became convinced that if such a project were to have a chance of Reorganisation - the principle success, there would need to be significant One of the weaknesses of our over-centralised form of government, however, is that control and involvement at a district level ministers take decisions relatively hurriedly (see Barber & Abbott, 1972; Medinfo and in broad principle. Thus the working out Conference, 1974). I was advised by the Area of details of policy are left to the army of Board computer officials that this was against civil servants. Principles are vague and open the principles of reorganisation and was not to interpretation; details are concrete. Power the stated Area Board policy. This prompted is devolved to the bureaucrats who are questions: What principle did it offend? largely unanswerable to Department ministers Where is the stated Area Board policy? and certainly not answerable to the populace. Who decided the Area Board policy? The This is the major lesson to be learned from only reply was an assurance that this was indeed the policy of the Area Board. In the 'The Crossman Diaries' (Crossman, 1975). event, hostility in the District to the concept *Formerly Centre for Respiratory Investigation, of a project completely controlled by Area Royal Infirmary, Glasgow. tWinner of Editor's Prize 1976. became so strong that the 'stated policy'
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changed in the course of an hour. These discussions were inordinately time-consuming, and during them I wondered what the political architects of reorganisation would have thought. The Area Board may also intervene in relatively minor matters at District level. Thus, the Greater Glasgow Health Board prevented the Glasgow Royal Infirmary from producing its annual report with endowment money bequeathed to the Infirmary. This is hardly monitoring progress. The effect of this irrational decision was to solidify resistance to the Area Board and to lead to the medical staff of the Royal Infirmary producing its own report. Role of the district
While the Area Board seems distant to the clinician the District is more immediate. There was in the District in which I worked, a strong relationship between clinicians and administrators built on mutual respect and trust and a belief that both groups had common objectives, i.e. to improve health care. Unfortunately the District concept is based on a false premise, the District being defined as a population served by community health services supported by the specialised services of a district general hospital. This would suggest that all Districts should be medically complete and little thought has been given to 'special centres'. It is evident that not all districts, nor indeed all areas in Scotland, can have cardiac surgery, plastic surgery, renal dialysis, respiratory investigation, cardiac catheterisation etc. Thus many patients are referred across district and area boundaries without increased monies being paid to the district which treats them. In the unit in which I worked 60 per cent of the patients came from outwith the district and 30 per cent outwith the area. Thus it is evident that district budget allocations cannot be decided equitably by a simple formula, since special centres are usually costly in terms ofpersonnel etc., and place an increased burden on support services in their district. Futhermore, budget allocations can be affected detrimentally if the District succeeds in attracting a particularly able consultant. Thus if a District has a surgeon who, because of his 268
excellence at a particular operation, has patients referred to him from a wide area, District budgets will have to pay for the costly treatment of many patients who do not 'belong' to it. The extreme effect of this policy would be for districts not to attempt to attract such able consultants, nor to develop their services. There is, furthermore, an additional policy which will downgrade centres of excellence - the current reallocation ofresources (Working Party Report, 1975). Whilst it has been argued reasonably for some time that existing allocations were historical accidents, previous Health Ministers (Crossman, 1972) saw that re-allocation could only be achieved by levelling up rather than down. Thus the current levelling down policy must lead to a significant drop in standards. Role of the Department
Standing apart from the jungle of District/ Area activities is the Department. The Department seems to issue guidelines and advice to lower authorities. Lower authorities seem to believe that the Department thinks in idealistic rather than practical terms (Forsythe, 1975). In particular, the Department does not make available new funds to allow its advice to be implemented. For example, if it points out to Area Boards the importance of developing Clinical Immunology, what are the Area Boards supposed to do? They are already battling to maintain existing services. The Department might argue that it is a virtue not to interfere directly in affairs at Area Board level. This relationship is, I believe, wrong. Firstly, there could be a large amount of time wasted at Department level in preparing plans which are never implemented. Since these plans are formulated by the most able in the Health Care professions, this is a waste of one of our most valuable resources. Plans, once formulated, raise expectations, and if never implemented have a deleterious effect on morale. It is in the nature of things that the advice available at Area Board level must be less good than that at the Department. Thus the dissociation of planning from practical considerations on implementation is not in the best interests of the service.
A Criticism of the Organisation of the National Health Service
Decision making in the reorganised health service Faced with such an awesome structure, the average clinician will be inhibited from taking initiatives to improve services. Indeed in my limited experience as chairman of a subcommittee, an opportunity was identified within the computer-orientated field to get a necessary task done using the Government Job Creation Scheme." This would cost minimal monies which would have to be obtained from the Department as a project grant. An estimated cost for the same task using conventional labour would be £60,000. The computer advisers (Area Board) indicated that the following steps would need to be taken: (a) Obtain approval of the Eastern District Computer Committee; (b) Obtain approval of the Eastern District Medical Committee; (c) Obtain approval of the Eastern District Executive Group; (d) Submit request to Area Board; (e) Obtain approval of an Information Planning Committee (or similar title at Area Board level); (f) Obtain approval of a Consortium committee who looked after the large Health Service computer installation at Park Circus, Glasgow (a small amount of computer processing was necessary); (g) Submit to Central Services Agency (C.S.A.); (h) Obtain approval of an Information Planning Committee at C.S.A. level. Since the job creation scheme was political in origin and, therefore, possibly transient, it seemed that if use were to be made of this labour there was need for an early decision. The Area Board officials suggested that the likely time scale of the process outlined above was 6 to 9 months. Since the Consortium Committee had not met since reorganisation and it was not known when they would meet, this seemed an optimistic estimate. t Thus it has to be argued that reorganisation has not simplified the decision-making process; it has rather created an infinite capacity for stalling and avoiding decisions (see Fig. I). Planning in the reorganised health service Since increased planning of health care delivery is envisaged in the reorganised health service there has been further development of Information Services, the lynch-pin
of which is SMRI returns.] SMRI returns are filled up reluctantly by clinicians and processed equally reluctantly and with difficulty by records office staff. This is hardly surprising since both groups have more immediate tasks and question their relevance. Thus the accuracy of the data on these returns is highly suspect. It was argued in a departmental report (Bodenham & Wellman, 1972) commissioned from outwith the Health Service that the problem would be alleviated if the returns could be processed quickly. Thus clinicians, once they were able to make use of the information from the returns, would be motivated to fill them up. It is not clear what benefit clinicians would obtain if the list of the patients who had been treated were available more quickly. Nevertheless the system is now in operation and there is an expensive computer system in one district which carries out this activity-processing SMRI returns. Within medical circles it is well known that to collect large amounts of limited inaccurate data for some as yet undefined research project will lead nowhere. One assumes that a similar principle applies in planning. The questions first should be formulated, the relevant data collected, and decisions made. Apart from the question of information there is the question of objectives. These are laid out for the Scottish Health Service in the recent document, The Way Ahead (1976). They are: (1) The need to operate the services within the budgets available, which allow for a limited measure of growth: (2) The need to promote health care in the community through the progressive improvement of primary care services and community health services: (3) More positive development of health services for families in areas of multiple deprivation: (4) Lessening the growth rate of the acute sector of the hospital service *This scheme was set up to provide funds for employing out-of-work teenagers. There was no direct cost to the employing authority. [In the event by pressure from the District, and after some difficult meetings with Computer advisers, the project was initiated. tSMRl returns are filled up for each patient discharged, or transferred from a ward following admission. They contain a small amount of information, e.g, name, diagnosis, etc.
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j-----------
---LINEal AUTHORITY -------- MAJOR ADVISORY LINK
I
Health Service Planning Council
I I I I I
I
EiJ
~ I~---l
r
r
r
I I I I r
I I I I It
Advisory Panel on Information Services &
Processing
I I I I I r r
I I
I I
_
- - -----1 --------------------------1
I I
r r
A9 I
GGHB Information
MEDICAL GG",
Services and
COMMITTEE
Computing
Ad Hoc Committee
EASTERN DISRICT MEDICAL ADVISORY COMMITTEE
EASTERN DISTRICT '--_ _-r-:-_ _--J-------- STAFF COMMITTEE ON COMPUTERS
Organisation suggested
by Area Boord for the computer
project in the Eastern District.
Certain committees are
indicated by initials only. The author does not pretend to understand what each of these committees is or does.
Fig. 1. Eastern District project machinery for control.
in order to finance essential developments in other sections: (5) Continued improvements in hospital and community health services for the elderly, the mentally ill, the mentally handicapped and the physically handicapped. (6) Encouragement of preventive measures and the development of a fully responsible attitude to health on the part of the individual and the community. These objectives are socio-political iand not specifically orientated to alleviating the major diseases of our time. Indeed one of the few mentions of disease in the document is in Section 2.10. To 270
quote-'In addition, high mortality rates from bronchitis, lung cancer, and ischaemic heart disease persist. These diseases like the increasing spread of dental disease, largely reflect cultural and behavioural patterns; little impact will be made on them until the attitudes of the public are changed.' Whilst it is admitted that we have major problems in Scotland in ischaemic heart disease, bronchitis and lung cancer, no specific programme has been developed to attack them. We now know more about the basic biochemical abnormalities, e.g. lipo-
A Criticism of the Organisation of the National Health Service
protein disorders (Fredrickson & Levy, 1972) and are in a position both to recognise and treat them at a pre-symptomatic stage. The importance of smoking in causation of such diseases has been accepted for about 2 decades, and there is increasing evidence of the value of anti-smoking programmes (Hunt & Bespalec, 1974). Thus there are these and other areas of activity which could modify the morbidity and mortality of these diseases. Indeed it is arguable that in a planned Health Service, we should question which diseases are the most important and then assess the means available to us to control them. Programmes would include better facilities for treatment of patients with these diseases, and preventive measures related to their causation. While a medical approach, based on scientific evidence, may change disease patterns, it is not immediately obvious that a political approach will. For example, although infant mortality is unacceptably high in deprived areas, this may not be related to inadequate medical services. In this area, as in others, there is a need for more research into aetiology, careful consideration of more detailed objectives, and institution of properly financed, carefully planned, imaginative programmes, the results of which are available to future generations of planners. It seems pointless to spend money on a 'good intent' basis without this information and without methods being available to assess the return from investments. The depressing fact is that this document (The Way Ahead) is vague, if not frankly amateurish. It also foresees contraction of the hospital service with expansion of community services and argues that the former has grown out of proportion in the last decade. It does not, however, consider why it has grown or whether the growth has been associated with improvements in health care. This aspect is discussed elegantly in a recent article by Professor W. B. Jennett (1976). The public are aware of the achievements of the hospital sector and value the service which it provides. Thus the major change in health care delivery which is envisaged in the document should be preceded by full public
debate. It is the profession's responsibility to insist on such a step, before allowing the present system to be dismantled. The public debate on education has come only after the large scale experiment with large comprehensives has proved a failure. During my time in Glasgow Royal Infirmary it appeared that the Health Service had too few hospital beds, not too many. Many receiving nights were spent attempting to find room for the admissions-decanting, transfers, etc. Wards were not infrequently overfull. Decisions were taken about admitting patients under the pressure of not having enough beds to put them in. Patients with central chest pain but not a definite myocardial infarction were a particular problem. Even though normally one would admit such patients, they were often sent home when beds were in short supply. Would the planners accept legal responsibility if such a forced decision proved to have disastrous consequences? Planners seem to fail to understand that medicine is not as controllable as a production line, and that demand on services is largely determined by the pattern of behaviour of patients. Thus it is not just the total number of beds that are important but rather their distribution in relation to origin of demand. During these difficult winters I argued with our consultants that it was wrong of them to make an inadequate system continue to function by artificial means. Certainly the reward for their effort has not been the praise of our political masters, but rather the promise of further reductions. Medical practitioners as decision makers Part of the administrative drive for some new forms of control of events must be related to their discontent with the previous system. They felt that consultants ('the barons') had too much say. A District Planning Administrator told me the story of his first planning meeting at the Glasgow Royal Infirmary about equipment for the new hospital. One item he had not heard of before. He asked innocently what this was. The chairman of the committee (a distinguished professor) replied, after a pause, that he didn't know, but his department needed 2! 271
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It may be that the profession didn't appreciate that it was managing. It certainly did not consider budgetary implications of decisions, believing that it was someone else's responsibility to provide the money. This philosophy is hardly unique to the medical profession as it has pervaded most of our publicly owned services and industries. Nevertheless, I am impressed by the consultants' tolerance rather than intransigence. The first Medical Division meeting which I attended was to assess the priorities for capital equipment requests (any article of equipment in excess of £50 is counted as capital equipment). There were 25 items requested. Each person requesting a piece of equipment gave a 3-minute presentation about the need for that item. There then followed a discussion on how to vote. It was agreed that each of the 30 people present should rank the items in priority (1-25), recording their votes on sheets of paper. The youngest consultant was nominated by the chairman to count the votes, which he did after the meeting. The meeting lasted from 4.30 p.m. until 7.00 p.m. In the event it was decided at a higher level that the monies were so limited that none of the items could be funded. The wastes in this dubious democratic process were: (1) The time of 30 very well qualified senior registrars or consultants (time-75 hours); (2) The time of 25 people preparing submissions; (3) The time of administrative assistants circulating copies of the documents to the Division. The fact that the Divisions continue to function speaks of the dedication of the consultants to the N.H.S. The general practice/hospital relationship Although in the administrative aspects of reorganisation there has been an excessive drive to create a complex structure, there is the general point that the service is now unified. At the committee levels, e.g. District Medical Committee, there is involvement of all branches of medicine. At a working level there is little sign of increased cooperation. One of the main sources of personal contact between hospital and general practitioners is when the general practitioner has to phone his hospital colleague to accept an emergency admission. The hospital colleague in this case is generally a 272
junior house officer who may cross-examine the general practitioner. My favourite story about this concerns a deputy doctor who 'phoned in' a patient who had taken an overdose of Valium. As he stood in a vandalised phone-box with no light or glass, in a deprived, if not frankly dangerous area of Lanarkshire, he was asked by the house physician if he had facilities for gastric lavage! A hindrance to progress in this area is lack of understanding by each group of the other's problems. The fundamental fact is that general practice and hospital specialisation are very different jobs. The general practitioner has to have a very broad and, therefore, relatively superficial knowledge, whereas the specialist must have an in-depth knowledge of a limited area. The major problem with general practice is that more than 90 per cent of time is spent treating minor illnesses. To many this is unsatisfying and not in the least intellectually challenging. (It has to be wondered whether it is in the best interests of a struggling nation to use some of the best products from its schoc I system to spend their lives treating verrucas, common cold, dysmenorrhoea, minor musculo-skeletal problems, etc.) This is not to deny that general practice provides an extremely useful function or to suggest that practitioners are second rate. It is to suggest that their intellectual talents are underemployed in the present mode of work. Current attempts to have the general practitioner act as a hospital specialist as well seem to be impractical. It is a difficult enough task to keep up-to-date as a specialist without also being a generalist. The danger is that general practitioners will be given the unpopular tasks in hospitals thereby further increasing their discontent and resentment of hospital colleagues. Equally, current attempts to equate general practice with a 'speciality' is a superficial analysis and does not in any way alter the basic problem. Thus there remains in the general practice area the problem of how to use the available talent properly. The Department seems to believe that this is achieved by the creation of health centres, but these do not in any way alter the fundamental problems of practice.
A Criticism of the Organisation of the National Health Service
Reorganisation/the opportunity Reorganisation does give the profession in Britain an opportunity to develop a new style of health care system with more emphasis on prevention. The major question is, however, who will implement this change? It is unlikely to be achieved solely by community physicians. Evidence from correspondence in journals would suggest that they are unclear about their role. Furthermore it is difficult to conceive of a single group who assume, in isolation, responsibilities for control of typhoid epidemics, investigation of inherited biochemical defects and screening of certain groups of workers for lung disease. Medical knowledge is now so extensive that specialisation is essential. Such specialisation is at present largely system-orientated. In the reorganised health service the specialist could assume responsibility for the control of diseases related to his speciality in his district. This envisages an expansion of his role from that of being a referral clinician. He could be responsible for implementing programmes of prevention with community physicians. In the pulmonary area, for example, there is a need for more active investigation including pulmonary function testing for groups of workers particularly at risk from industrial lung disease, more active pursuit of anti-smoking programmes and investigation of groups at risk from forms of allergic alveolitis, e.g. pigeon-fanciers. Tuberculosis remains a problem in certain groups. It will be a test of the Department's intentions to see whether it pursues actively a prevention policy or whether it views preventive medicine as a means to excuse downgrading the hospital sector. In addition, the specialist and general practitioners could develop joint programmes of care for particular clinical problems after fulI discussion. Such programmes will require initial investment but should be cost-effective. This could be facilitated by the specialist assuming an increased responsibility for post-graduate education, and a more active policy being implemented to ensure standards are maintained both in hospital and general practice. Case conferences at which general practitioners and specialists discuss cases are essential. Part of the problem with the current
British system is that hospital clinicians have little time for objective reflection since they are so close to the problems. Re-examination of one's activities always occurs on changing posts and it is a weakness in the British style of practice that consultants rarely change positions. The effect of change is also to revitalise. Financing the health service The Health Service has been under-resourced for at least the last decade. This would probably be agreed by all major participants including the politicians. The profession has continued to point out that there are major differences in expenditure in health care between Britain and the other countries of the Western world. An industrial nation must have as its main priority, however, the creation of a strong, successful industrial base. Thus such comparisons reflect different priorities which may be occasioned by different needs. It is at any rate an argument which has failed to impress the politicians. They seem to believe that no matter how much money is spent on the Health Service, the profession will demand more. This is probably true. Thus there may come a point in any society, no matter how successful economicalIy, where modern technological medicine may outstrip the available resources. Members of the profession must, therefore, be concerned with budgets and must attempt to maximise the delivery of health care for a given expenditure. There are possibly 3 aspects to such budgetary decisions: (a) Deciding the overalI expenditure on health care ; (b) Deciding the portioning of these monies between different parts of the service, e.g. geriatrics; (c) Use of monies at a local level, Part of the current problem is that the profession disagrees with the government both with respect to the overalI sum and also probably to its distribution. The government stresses the importance of geriatrics. They may fail to understand, however, that in many geriatric cases medicine has little to offer, and that training of health care staff is such that they tend not to want to see increased resources being expended in this direction, while patients who can be actively 273
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helped by modern medicine are denied such help because of lack of resources. At a local level there is a case for more decentralisation of budgetary control. For example each division could have its own budget. Most of the profession would undoubtedly dispute this but it would have the following advantages: (a) It would create more usable money since much of the inefficiency can only be dealt with at a local level; (b) It would simplify, accelerate and render decision making less costly. We would not have to fight through layers of administration to obtain even minor items of equipment. This should also improve morale; (c) We could obtain a more rational, cohesive policy for development of our Division. At the present time the Division contains a number of strong independent members. Its priorities may thus be overturned by the argument of one of its members at a higher committee; (d) We would have a united effort in our increasingly difficult fight with central administration. One member of the division should be able to devote himself full-time to this and other administrative matters; (e) We would act even more vigorously to force alternative solutions if we saw our budget being used inappropriately, e.g. long-stay admissions of geriatric patients in teaching hospitals on purely social grounds. I do not accept the argument that members of the medical profession are incapable of such management. Indeed, some heads of medical departments on the American side of the Atlantic seem capable of running IBM successfully!
private sector better than in the NHS? The answer to this is no, since there are, in general, less facilities in the private sector and less medical cover at non-consultant level. (4) Is it not desirable that every patient should be able to obtain a second opinion at reasonable cost, since he cannot demand such in the NHS, let alone choose his initial consultant? The real public debate, which the profession should encourage, is related to the overall funding of the NHS, to concepts of equality between regions as opposed to a strong centre but available to all, to priorities in terms of provision of facilities, to consideration of alternative systems of financing health care. The proximity of medicine to party politics is in neither the interest of the profession nor the politicians. It diverts the attention of the latter from more urgent matters, i.e. the economy, and leads to discussion on the Health Service becoming at times emotive. Hence irrational decisions (e.g. that of the Conservative Secretary for State on Reorganisation) are taken. There is a strong case for a non-political independent body with real power to administer the service. Conclusion
In this article I have attempted to layout the opinions which I have formulated during my period in the Health Service and the events which have led to formation of these opinions. I have also attempted to develop a number of theses: (a) The Health Service at the present time is leaderless. The centre advises: the areas are not listening but rather meddling Party politics in district affairs. Professional administrators Since the Health Service was largely a lack both imaginative drive (to quote Crosspolitical creation, medicine remains a matter man) and enough detailed knowledge of for intense partisan political debate. Unfortu- health care to fit them to lead. Leadership nately the current debate is largely irrelevant must be provided by the most able in the to current problems. The Labour Party is profession. It is an historical fact that at committed to total abolition of private the present time many of the most able practice. The profession has the responsibility senior members of the profession are in of opposing this. It has to be asked: (l ) Would clinical specialities (i.e. not in community abolishing private practice totally improve medicine). It would be in the interests of all the NHS and how? (2) Would attempting to if they could be recruited to key positions, abolish private practice in a free society not e.g. Chief Medical Officers. The current make it more expensive and, as in the case of balance of power in executive groups is too schools, make the private sector the preserve heavily weighted towards lay administrators. of the elite? (3) Is the standard of care in the (b) Clinicians must abandon the posture that 274
A Criticism of the Organisation of the National Health Service
they are divorced from consideration of cost efficiency. Health care can only advance if the profession optimises its use of scarce resources. While the problem may be alleviated by alternative systems of financing health care, it will not be cured. Thus the profession must accept some form of more direct managerial responsibility. An argument can be made for more decentralisation of budgetary control. (c) The current trends of policy in the use of resources may not all be in the best interests of the population. Since the profession is unlikely to convince the government, it should insist on a full public debate before allowing any major changes to be implemented and it must commit resources to education of the public on the real issues and facts. The public as consumers are dangerously ignorant. (d) Reorganisation in its current form is illconceived. Arguments that we are only witnessing the settling-down period are false since there are major conceptual flaws. The system has excessive decision-making layers, such that communication will always be a problem and decision-making slow. There is a large gulf between planning and implementation. The Health Service has traditionally made progress by harnessing the talents of able clinicians who initiated new developments. The present cumbersome structure stifles any such possibilities and this is to the detriment of the service and the frustration of the individual clinician. In the Scottish system the new Area Boards seem unclear about their role and have been spending much of their energies in fighting border skirmishes with districts to obtain more direct powers. They are too remote to achieve an identity with their employees, despite for example the circulation of excessive numbers of glossy newspapers. For proper planning (e.g. special centres) the areas are too small. Thus, unless there are convincing reasons with definite evidence of present and likely future achievements, a case can be made in Scotland for abolishing the Area Boards. (e) The responsibility for forging a new type of integrated care must fall on the major hospital-based specialities. General practitioners' training is too superficial to enable
them to carry out this role. Community medicine is weakened by being general and may take years to get off the ground. There is a case for a full discussion between the Royal Colleges on integrated care, and on the role of the specialist in the reorganised service. At some point we must face the problem of continued assessment following qualification. (f) The current policy of the Information Services Division is likely to be wrong. This is not to deny the importance of planning or information but to suggest that because of the current mode of collecting data, and the data collected, the information is unlikely to be very useful. It would be interesting to know the annual cost of processing the SMRI returns. (g) There remains a problem on how to utilise properly the intellectual capabilities of general practitioners. The equating of general practice with a speciality is not helpful in this regard. (h) The events during reorganisation of the Health Service indicate certain basic principles about the current style of government in Britain. In particular it shows that bureaucracy, presented with a set of principles, can turn these to any purpose they require. There is a need for a system of more active questioning of bureaucrats once details of policy have been developed. REFERENCES
Barber, B., Abbott, W. (1972). Computing and operational research at the London Hospital. London: Butterworth Bodenham, K. E., Wellman, F. (1972). Foundationsfor Health Service Management. Provincial Hospitals Trust. Oxford: Oxford University Press Crossman, R. H. S. (1972). A politician's view of health service planning. Maurice Bloch Lecture, University of Glasgow Crossman, R. H. S. (1975). The Diaries of a Cabinet Minister. Volume 1. 1964-1966. London: Hamish Hamilton Forsythe, J. M. (1975). In Discussion on reorganisation: the first year. British Medical Journal, 2, 736 Fredrickson, D. S., Levy, R. I. (1972). Familial hyperlipoproteinaemia. In Metabolic Basis of Inherited Disease, p.545. Eaited by J. B. Stanbury, J. B. Wyngaarden and D. S. Fredrickson. New York: McGraw-Hill 275
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H.M.S.D. (l971). Department of Health and Social Security. National Health Service Reorganisation, Consultative Document. London: H.M.S.O.
Medinfo Conference (1974). Several papers from proceedings.
Hunt, W. A., Bespalec, P. A. (l974). An evaluation of current methods of modifying smoking behaviour. Journal of Clinical Psychology, 30, 431
Report (1962). A review of the Medical Services in Great Britain. Report of the Medical Services Review Committee, London. Social Assay, 1962
Jennett, W. B. (l976). The way ahead for acute hospital services. Lancet, 2, 1235
The Way Ahead (1976). The Health Service in Scotland. Scottish Home and Health Department. Edinburgh: H.M.S.O.
Klein, R. (l975). In Discussion on Reorganisation: the First Year. British Medical Journal, 2, 737 Lewis, J., Weiner, S. (l975). Views from the Districts. British Medical Journal, 3, 22
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Working party report (l975). First Interim Report of the Resource Allocation Working Party. Department of Health and Social Security
