Clin Radiol. (1978) 29, 473-478 A D V I C E TO T H E R O Y A L C O M M I S S I O N ON T H E T A S K AS T H E Y S E E IT THE RT. HON. LORD ROBENS OF WOLDINGHAM, PC, DCL, LLD, DUNIV The 22nd Crookshank Lecture delivered to the Royal College o f Radiologists in London on 19May 1978
It gives me great personal pleasure to be invited to deliver the Crookshank Lecture this year, for I shared 16 years of Harry Crookshank's 32 years' membership of the House of Commons. As these were the six years of the Attlee Government, before the return of the Conservative Government in 1951, I saw him as a leading light on the Opposition Front Bench and subsequently as a stout defender of Government policies. One could not help but have a high regard for his intellectual abilities and his reverence for Parliamentary tradition and usage. His personal friendship, which I enjoyed, was marked by a geniality and warm-heartedness which, because of his sensitivity, was largely hidden from the public at large. He was well regarded by the House and much respected by Labour members. He was a master of the complex subject of Parliamentary procedure, which made him a formidable parliamentary opponent of the post-war Attlee Government of which I was a member and this mastery stood him in good stead when he subsequently became Leader of the House. He served with distinction in many high offices of State and when the Attlee Government was defeated in 1951, Crookshank was made Minister of Health, combining this office with Leader of the House. Some 8 months later, he resigned as Minister of Health and concentrated upon his task as Leader of the House and a member of Churchill's Cabinet. As a matter of interest, his place as Minister of Health was filled by Iain Macleod, now regrettably passed from us. I often contemplate that the early demise of Iain Macleod and Hugh Gaitskell made a most significant change in British politics. They were both a grievous loss to the country. Harry Crookshank was Leader of the House for 4 years and performed that exacting task with great skill. He was never flurried, never lost his poise, seldom raised his voice. I shall never forget that delicately chiselled countenance with the high domed forehead, which strangely enough always put me in mind o f the portrait of William Shakespeare. Because I enjoyed his personal friendship it makes this occasion a very special one for me. 36
Harry Crookshank's short tenure of office as Minister of Health, was not marked by any special event. He was a good administrator and well liked in the Department. No problem of reorganisation faced him, but had it been the case, I think he would have made a much better job of it than his long-term successor in 1974. He established this lecture as a tribute to his mother, but it has now become also a tribute to an outstanding man, who combined great ability with charm and grace and whose main object in life was to render public service. It seems hard to realise that during his period of office, as Minister of Health, public expenditure on national health was £499 million. In the Annual Report for 1976, the Secretary of State at the Department of Health and Social Security indicates on the health and personal social services for the year ended March 1977 expenditure of £6200 million, and £11 500 million in social security benefits. Whilst the figures are not comparable by reason of inflation and other factors, they certainly reveal a substantial shift of the national resources into health care. Recently the shift has slowed down as a result of the difficult economic situation and the ceilings of spending in planned public expenditure. Nevertheless, despite the financial stringency of the times, the health services were given a priority to enable some growth, but at a much less fast rate than before. The record, despite the Jeremiahs, is impressive and one must note this before going on to a critical, but, I hope, constructive analysis. More and more people are receiving hospital treatment; in-patients reaching a record total of 5¼ million, and the numbers of day-patients reaching new heights. The number of general practitioners at just over 22 thousand, is some 250 more than last year and the number of practitioners in the general dental service at just over 11 500 is some 300 more. There are nearly 339 000 nurses in the service, an increase of 21 000 on 1973 and the intake of medical students is up from 3468 to over 3600. The proportion of the gross national product spent on the health service has risen from 4.7 to 5.8%. An objective observer looking at these factors for
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the first time, would wonder why there is so much criticism o f the health service. He would find it all in the nine pages of that very admirable document issued so promptly by the Royal Commission, following their appointment, entitled 'The Task of the Commission'. The Royal Commission certainly does not lack advice; indeed they have heard from over 2000 organisations and individuals since they issued their invitation to submit views and it is clear that aU aspects of the health service will receive a thorough examination - a daunting task, but a very rewarding one. The recommendations of the Royal Commission have to be of such a character that when implemented it will be unnecessary for any further shake-up. So far, the 1974 reorganisation has been a traumatic experience and whilst most people interested in the subject appreciate the need for change, they would want to be sure that the next change would be the last for many years. The Royal Commission under the chairmanship of Sir Alec Merrison needs to be congratulated upon the publication of 'The Task of the Commission' as it shows a complete awareness of the problems and the areas of investigation that lie before the Commissioners. There are some critics who suggest that it is far too soon for another look at the health service and that the appointment of the Royal Commission is like pulling up a tree to examine the roots to see if it has grown. This is not a view with which I could agree. Whilst there remain in the service men and women who have had experience of before and after 1974, then the possibility of getting the best out of both worlds remains; if the fresh look were to be left too long, then the possibilities of change would become more remote. Better to have change now, even after so short a period after the reorganisation, than to go soldiering on despite the many imperfections that are so manifest already. All of us who have been engaged professionally or as active laymen over the years want to see an efficient and expanding health service. The amount of evidence received so far, supplemented by visits by members of the Commission to all parts of the country, including talks with patients and staff at local level, as well as those responsible for running the service, supplemented by discussions with two former Prime Ministers and two former Secretaries of State, has already revealed the importance not only of the Commission, but also the importance of making any changes that are shown to be necessary at the very earliest opportunity.
For the long-term future, one would hope that any changes required as a result of experience and altering circumstances, could be done administratively, without violent change. I would like to take the opportunity presented to me by this Crookshank Lecture, to discuss one aspect of the service, which without doubt has created a great deal of frustration and unnecessary expense. I refer, of course, to the administrative structure. It is patently obvious that the 1974 reorganisation has produced, as many of us warned, a top heavy bureaucracy, swollen in numbers, eating voraciously into financial resources, that should be more properly spent on patient care, slowing down decisions, creating a vast amount of paperwork and taking up the time of professional men and women, whose talents, knowledge and experience should be closer to the sick. It is incredible, but true, that since the reorganisation of 1974, 15 800 administrative and clerical staff have been added to the 82 700 then employed, so that by 1976 over 98 000 people were engaged in those tasks remote from patient care. In order to prevent any misunderstanding one must hasten to add that a substantial number of administrative and clerical staff are working close to the patient as ward receptionists, out-patient receptionists, X-ray receptionists, etc., and a number will consist of staff previously working in the health departments of local authorities. Yet, nevertheless, the majority are engaged in clerical and administrative duties far remote from the patient, on work created by the very nature of the management structure itself. Down the line there is much confusion by the overlapping and duplication of functions between the tiers of management and it is largely this heavy administrative burden that has led to the frustrations that has led to the present impasse and the necessity for the Royal Commission. Financial restrictions have of course added to the problem, but if anything this has only gone to demonstrate the obvious. That is, that no matter how big the financial resource allocated to the health service, not one penny should be spent without adequate cause, away from the care of the patient. The Commission has already pronounced what is undoubtedly true - 'it is clear that the potential demand for health care is almost infinite'. This means that the choice of priorities is a matter of infinite investigation and judgement. Again, the Commission states ' . . . there is no universally acceptable set of simple criteria for deciding the best use of NHS resources. Choices between, for example, buying sophisticated technical apparatus or improving the care of the mentally ill involve a large element of
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subjective judgement'. The judgement would be much easier, however, if the many millions spent on additional administrative and clerical staff were available for both. I doubt very much indeed if between now and the end of the century the financial resources available as a percentage of the gross national product, will at any time be sufficient to do everything that is both necessary and desirable. In recent years, the growth has been about twothirds of the first two decades of the existence of the Health Service and over the next four years it is anticipated that it will be about one half. The allocation of inadequate resources is an extremely difficult task, as the Resources Allocation Working Party which undertook a major examination of the methods of sharing capital and revenue resources between regions, areas and districts, soon discovered. I doubt if anyone would disagree with the principle of RAWP on the grounds that it embraces the basic principle enshrined in the whole idea of the National Health Service, i.e. that our Health Service resources should be equitably distributed throughout the whole country on the basis of need alone. Had this principle been introduced at the beginning of the scheme in the years of substantial and fast growth, the impact would never have been noticed. It is the introduction of the scheme at a time of nil growth that the present acute problems have arisen. In any event, the basis of the formula (weighted population figures and special increments for teaching) are inevitably rough and ready and cannot embrace all the intricacies of the special problems posed by deprived inner-city areas. Equally important is the responsibility of the teaching institutions, not just for teaching and training staff, but to be the hub of development in the research field. As I well know as an ex-Chairman of a Board of Governors myself, it is virtually impossible to separate the costs of clinical services teaching and research. Based upon a 'population weighting basis' the Secretary of State has already indicated that the pace of change would have to be slow. For 1977/78 increases in real terms would vary from 0.25% in the most favoured region, to about 3% in the most deprived. All this points clearly to the urgent need to provide an administrative structure that is lean, efficient and effective. The Report from the all-Party Commons Public Accounts Committee clearly recognises the structural defects of the reorganisation of 1974. It pinpoints what has been glaringly apparent to those working professionally within the service, that planning arrangements were not undertaken with full regard to economy, and poses the question, whether too much of the resources for reorganisation were
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devoted to the new management structure to the possible detriment of patient care or remedial measures to correct specific management weaknesses. Sir Patrick Nairn, Permanent Secretary to the Department of Health and Social Security, said that broadly speaking, 45% of the increased costs of administration was due to the more expensive management structure. Indeed, wherever one looks for the fundamental weakness in the Health Service, one is inevitably drawn to the present administrative structure, where Sir Keith Joseph, in 1974, very successfully produced more harness than horse. Again one must be quite fair and make reference to the fact that serious attempts have been made to control the administrative and clerical staff. As early as 1976, expenditure was frozen in this area and efforts made to reduce the number employed over the following 2 years by some 5%. However, the truth is that no amount of tinkering with the present unwieldy administrative structure can really make the administrative savings required. Certainly the problem is not one of lack of excellence in the medical and nursing professions or the quality of the administrators. These stand selfevident, as amongst the highest in the world. While there are a host of other problems which the Royal Commission will have to consider, the administrative structure is undoubtedly the most important. Unless the structure is absolutely right for the essential task that it has to perform in support of the activities designed to cure the sick, then the Health Service cannot be as efficient as it should be, or its financial resources used to best advantage. Finally, in support of my case for a complete change in the administrative structure, I call to my aid, Mr Paine, House Governor of Bethlem and Maudsley, who in an article in the Lancet in November 1976, wrote ' . . . after 25 years in the service and 2½ years of experience of its new structure, I can honestly say that never before have I known staff morale to be lower, staff relationships poorer, time spent in meetings longer, administration more complex, money scarcer and life generally more frustrating and difficult than it is now'. The $64,000 question is 'what kind of administrative structure will provide the essential back-up service both in the short-term and the long-term, to enable the doctors, nurses and other professionals to perform the function for which the National Health Service was formed some 30 years ago?', which simply put is the care and treatment of people who are sick. This is the prime requirement of the service and those in need are neither interested in the forward planning of new hospitals, or in the career prospects of those who serve.
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The main concern of the elderly lady with varicose veins who has been on the waiting list for months is, just when is her complaint going to be attended to? Not until we have removed the need for the question, and the natural anxiety of the elderly lady, can we say that the Service is full, effective and efficient in the public eye. The only point of contact that the sick have is with the family practitioner and the hospital. The problems of the maintenance of the animal house in the teaching hospital, or the wonders of open heart surgery are not for them. It is, therefore, at this point of contact, that we should begin our examination of the administrative structure;what follows is entirely back-ups for the first contact. It is precisely at this point that the structure is weakest. It has no statutory authority, it has no group of disinterested, but able and experienced laymen, standing apart from the professionals to act as a catalyst for the conflicting views of the professionals; it has what is known as consensus management. An organisation of the size of a large modern hospital needs a focal point in a number of such people who can play a part in helping to maintain the ethics of the organisation and who additionally, by social contact and regular visiting throughout the whole of the organisation, can give the component parts the opportunity to explain their work and how they relate to the whole and to that extent maintaining constant encouragement. No business managed on the present basis could possibly succeed - and administration is a matter of management. The Health Districts should be the spearheads of the Health Service, with authority and power to assess the needs of its district and ensuring within its own competence, or in association with other adjoining districts the planning, organisation and administering of the health service to meet those needs. The Health Districts should have management committees, of some 15 to 20 people, consisting of people appointed by the Regional Health Authority, from names put forward by the local authority, trade unions, main health professions and men and women of judgement and experience; people with a good knowledge of administration and management and financial expertise. The Area Health Authorities and the Community Health Councils would be abolished. The Health District Board of Management would be the watchdog for the public interest and ensure the efficiency of the health care in the district. The Regional Health Authorities would remain in being and take over from the Area Health Authorities such functions as could not adequately be delegated to the Health Districts. They would be required to
delegate to the Health Districts the maximum of authority, which might be modestly different from District to District, by reason of geography or size of population. But the delegated responsibility must be absolutely clear in every case, objectives, duties and responsibilities clearly laid down, so that there can be no possibility of escaping responsibility laid down or interference by the Regional Health Authority on delegated matters. The present formula laid down by the Secretary of State for allocation of resources is somewhat tarnished and while there is everything to be said for allocating more resources to those areas which at present are under-f'manced, population only, even with some of the weightings which the RAWP has evolved, produces some very unsatisfactory results, especially in London. It certainly does not appear to take sufficient account of the wide-ranging role of the undegraduate teaching hospital with its regional specialities and of the special problems of a capital or in the provinces a major city, or whether population alone may be misleading as a basis of allocation. The major city creates its own health problems, which are not easy to quantify and there is a justifiable feeling that in keeping London back to help under-financed areas elsewhere, greater harm may be done to existing high levels of achievement, than good in the deprived areas. There is a threshold of resource allocation which is necessary to maintain various specialities as going concerns and if this threshold is reduced these going concerns may well collapse. This may sound like special pleading for the teaching hospitals, but there must always be a concentration of resources at the major teaching centres if medical progress is to be maintained. Without a substantially increased injection of public funds into the Service, strict equality of opportunity for every person in the country to have the same level of care is probably an illusion, but a splendid political vote catcher. There should be established a National Health Commission whose duties would be to agree with the Department of Health and Social Security, on a rolling 5-year plan basis, the financial resources to be made available and for its allocation on the formula now laid down by the Secretary of State - that is the 'weighted population basis', suitably adjusted. The members of the National Health Commission would be appointed by the Secretary of State of the Department of Health and Social Security and be analogous to the board of a nationalised industry, with a full-time chairman, full-time functional members and part-time members representative of local authorities, the TUC, the CBI and the medical and nursing and other professionals. The Department of
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Health and Social Security would relinquish its day to day work with regard to the Health Service and -confine itself to its functions as a banker to the Health Commission, to ensure that the statutory responsibilities are fulfilled and in fact act as the parent ministry in the same manner as nationalised industries relate to their parent ministries. The Health Commission would be responsible for advising the Minister on such matters as he and they considered appropriate. They would be sole employers of those within the Health Service; they would appoint the members of the Regional Health Authorities with due regard to ensuring that the members were as representative as they were themselves. Public accountability could be ensured by a Select Committee of the House of Commons similar to the Select Committee on Nationalised Industries. This kind of organisation would provide but three tiers of management; provide authority at the community level, responsibilities and authorities clearly defined, streamline decisions, provide flexibility where it matters at the point of impact with the patient and ensure public accountability from the district to the Commission. It would ensure that the maximum of the resources available would be concentrated on the prime purpose of the service - to ensure care and treatment by the professionals at a time when people are in need. Any consideration of future change must have for its end result: 1. Freedom for the doctors, nurses and other professionals to carry out their work of healing without the heavy weight of unnecessary bureaucracy; 2. The ability to plan ahead with the resources available as a proportion of the gross national product, recognizing the changing needs of the Health Service that the years ahead will be certain to bring about. Finally, I would like to turn to the matter of the teaching hospitals. First, I must express a personal interest. For some years up to the reorganisation in 1974 I was the Chairman of the Governors of Guy's and up to date am the Chairman of the Governors of the Medical and Dental School. 1 assure my listeners that what I have to say is undoubtedly objective and I have leaned very heavily upon my pre-1974 and post- 1974 experience. For over 2000 years humanity has always understood that no matter how hungry one may be, not under any circumstances whatsoever must one eat the seed-corn, for to do so would destroy the race. One does not want to sound an alarmist, but there is no doubt, in my mind, that the future of our centres of excellence, their research abilities and postgraduate
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training are very much in danger. Today the tip of the iceberg can be seen. The impact of proposals for the distribution to the university hospitals of financial resources for the period 1978-81, is causing grave disquiet and considerable anxiety. Very few indeed feel anything, but greatly disturbed at the possibilities. The deleterious effect on training is likely to be slow at first in undergraduate medical training, but the deleterious impact on the standards of postgraduate training will be seen more quickly. It is true that the general gloom about the future is generated by a lack of financial resources and those responsible for the detailed allocations are in dire difficulties to decide the priorities over the whole field of health care and teaching. I ask the Commission to consider whether it would not be wiser to look at the special position of the university hospitals quite separately for the purpose of funding. I have advocated the setting up of a Health Commission. It would be possible to have, jointly with that Commission, a University Hospitals Division, which would have the responsibility of planning the future requirements of the qualified medical practitioners. Utilising the present physical resources to the utmost, it would plan for any growth required in any part of the country. It would separately fund the university hospitals taking into account the need for the community health care to be adequately catered for. This would be carried out in association with the University Grants Committee and the universities. I regard it as highly important that the training of postgraduate and undergraduate medical and dental students and the furtherance of research working in close collaboration with its medical school or institute, should be looked at quite separately from the administration of the Health Service p e r se. Unless we get the training and research absolutely right, the standards of the Health Service will inevitably suffer. This, then, should be costed separately and provided, so that one could determine with precision the number of students, direction and standards of training within the financial parameters over the year ahead. The task of the university hospitals is to provide the qualified people and the research necessary for the health-care of the nation. This is obviously a high priority and requires special treatment, because the problems are different to the general hospital. Changing medical needs and the accommodation of specialties like geriatrics and mental illness with no increase in total beds available must inevitably mean that there has had to be a reduction in the beds for acute medicine and surgery which form the cornerstone for undergraduate teaching. There are innumerable instances that could be cited to show the
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great difference in requirements o f the university hospitals. Their needs cannot be dealt with by some rule o f thumb to cover all the hospitals in a region. The Royal Commission, I would hope, would consider favourably a separate administration for the teaching hospitals, within the total health service under a Health Commission. The Commission has a momentous task to perform and if it should be considering some arrangement as that suggested in this lecture, they can be assured of a tremendous opposition from all the vested interests that are involved. Not the least will be the Department of
Health and Social Security; the Civil Service tends to drag more fish into its net rather than let any fish go free. But at least for the purpose of an objective report, all the vested interests must be set aside. The report stage must not be a compromise stage ; there is bound to be plenty o f that later. To get the answer right for the benefit o f the sick and not for the administration, the Commission will require the surgeon's knife and this means not only consummate skill, but courage. I am sure the Commissioners have plenty o f that and I wish them well. We shall all await their final report and recommendations with more than a passing interest.
It gives me great personal pleasure to be invited to deliver the Crookshank Lecture this year, for I shared 16 years of Harry Crookshank's 32 years' membership of the House of Commons. As these were the six years of the Attlee Government, before the return of the Conservative Government in 1951, I saw him as a leading light on the Opposition Front Bench and subsequently as a stout defender of Government policies. One could not help but have a high regard for his intellectual abilities and his reverence for Parliamentary tradition and usage. His personal friendship, which I enjoyed, was marked by a geniality and warm-heartedness which, because of his sensitivity, was largely hidden from the public at large. He was well regarded by the House and much respected by Labour members. He was a master of the complex subject of Parliamentary procedure, which made him a formidable parliamentary opponent of the post-war Attlee Government of which I was a member and this mastery stood him in good stead when he subsequently became Leader of the House. He served with distinction in many high offices of State and when the Attlee Government was defeated in 1951, Crookshank was made Minister of Health, combining this office with Leader of the House. Some 8 months later, he resigned as Minister of Health and concentrated upon his task as Leader of the House and a member of Churchill's Cabinet. As a matter of interest, his place as Minister of Health was filled by Iain Macleod, now regrettably passed from us. I often contemplate that the early demise of Iain Macleod and Hugh Gaitskell made a most significant change in British politics. They were both a grievous loss to the country. Harry Crookshank was Leader of the House for 4 years and performed that exacting task with great skill. He was never flurried, never lost his poise, seldom raised his voice. I shall never forget that delicately chiselled countenance with the high domed forehead, which strangely enough always put me in mind o f the portrait of William Shakespeare. Because I enjoyed his personal friendship it makes this occasion a very special one for me. 36
Harry Crookshank's short tenure of office as Minister of Health, was not marked by any special event. He was a good administrator and well liked in the Department. No problem of reorganisation faced him, but had it been the case, I think he would have made a much better job of it than his long-term successor in 1974. He established this lecture as a tribute to his mother, but it has now become also a tribute to an outstanding man, who combined great ability with charm and grace and whose main object in life was to render public service. It seems hard to realise that during his period of office, as Minister of Health, public expenditure on national health was £499 million. In the Annual Report for 1976, the Secretary of State at the Department of Health and Social Security indicates on the health and personal social services for the year ended March 1977 expenditure of £6200 million, and £11 500 million in social security benefits. Whilst the figures are not comparable by reason of inflation and other factors, they certainly reveal a substantial shift of the national resources into health care. Recently the shift has slowed down as a result of the difficult economic situation and the ceilings of spending in planned public expenditure. Nevertheless, despite the financial stringency of the times, the health services were given a priority to enable some growth, but at a much less fast rate than before. The record, despite the Jeremiahs, is impressive and one must note this before going on to a critical, but, I hope, constructive analysis. More and more people are receiving hospital treatment; in-patients reaching a record total of 5¼ million, and the numbers of day-patients reaching new heights. The number of general practitioners at just over 22 thousand, is some 250 more than last year and the number of practitioners in the general dental service at just over 11 500 is some 300 more. There are nearly 339 000 nurses in the service, an increase of 21 000 on 1973 and the intake of medical students is up from 3468 to over 3600. The proportion of the gross national product spent on the health service has risen from 4.7 to 5.8%. An objective observer looking at these factors for
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the first time, would wonder why there is so much criticism o f the health service. He would find it all in the nine pages of that very admirable document issued so promptly by the Royal Commission, following their appointment, entitled 'The Task of the Commission'. The Royal Commission certainly does not lack advice; indeed they have heard from over 2000 organisations and individuals since they issued their invitation to submit views and it is clear that aU aspects of the health service will receive a thorough examination - a daunting task, but a very rewarding one. The recommendations of the Royal Commission have to be of such a character that when implemented it will be unnecessary for any further shake-up. So far, the 1974 reorganisation has been a traumatic experience and whilst most people interested in the subject appreciate the need for change, they would want to be sure that the next change would be the last for many years. The Royal Commission under the chairmanship of Sir Alec Merrison needs to be congratulated upon the publication of 'The Task of the Commission' as it shows a complete awareness of the problems and the areas of investigation that lie before the Commissioners. There are some critics who suggest that it is far too soon for another look at the health service and that the appointment of the Royal Commission is like pulling up a tree to examine the roots to see if it has grown. This is not a view with which I could agree. Whilst there remain in the service men and women who have had experience of before and after 1974, then the possibility of getting the best out of both worlds remains; if the fresh look were to be left too long, then the possibilities of change would become more remote. Better to have change now, even after so short a period after the reorganisation, than to go soldiering on despite the many imperfections that are so manifest already. All of us who have been engaged professionally or as active laymen over the years want to see an efficient and expanding health service. The amount of evidence received so far, supplemented by visits by members of the Commission to all parts of the country, including talks with patients and staff at local level, as well as those responsible for running the service, supplemented by discussions with two former Prime Ministers and two former Secretaries of State, has already revealed the importance not only of the Commission, but also the importance of making any changes that are shown to be necessary at the very earliest opportunity.
For the long-term future, one would hope that any changes required as a result of experience and altering circumstances, could be done administratively, without violent change. I would like to take the opportunity presented to me by this Crookshank Lecture, to discuss one aspect of the service, which without doubt has created a great deal of frustration and unnecessary expense. I refer, of course, to the administrative structure. It is patently obvious that the 1974 reorganisation has produced, as many of us warned, a top heavy bureaucracy, swollen in numbers, eating voraciously into financial resources, that should be more properly spent on patient care, slowing down decisions, creating a vast amount of paperwork and taking up the time of professional men and women, whose talents, knowledge and experience should be closer to the sick. It is incredible, but true, that since the reorganisation of 1974, 15 800 administrative and clerical staff have been added to the 82 700 then employed, so that by 1976 over 98 000 people were engaged in those tasks remote from patient care. In order to prevent any misunderstanding one must hasten to add that a substantial number of administrative and clerical staff are working close to the patient as ward receptionists, out-patient receptionists, X-ray receptionists, etc., and a number will consist of staff previously working in the health departments of local authorities. Yet, nevertheless, the majority are engaged in clerical and administrative duties far remote from the patient, on work created by the very nature of the management structure itself. Down the line there is much confusion by the overlapping and duplication of functions between the tiers of management and it is largely this heavy administrative burden that has led to the frustrations that has led to the present impasse and the necessity for the Royal Commission. Financial restrictions have of course added to the problem, but if anything this has only gone to demonstrate the obvious. That is, that no matter how big the financial resource allocated to the health service, not one penny should be spent without adequate cause, away from the care of the patient. The Commission has already pronounced what is undoubtedly true - 'it is clear that the potential demand for health care is almost infinite'. This means that the choice of priorities is a matter of infinite investigation and judgement. Again, the Commission states ' . . . there is no universally acceptable set of simple criteria for deciding the best use of NHS resources. Choices between, for example, buying sophisticated technical apparatus or improving the care of the mentally ill involve a large element of
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subjective judgement'. The judgement would be much easier, however, if the many millions spent on additional administrative and clerical staff were available for both. I doubt very much indeed if between now and the end of the century the financial resources available as a percentage of the gross national product, will at any time be sufficient to do everything that is both necessary and desirable. In recent years, the growth has been about twothirds of the first two decades of the existence of the Health Service and over the next four years it is anticipated that it will be about one half. The allocation of inadequate resources is an extremely difficult task, as the Resources Allocation Working Party which undertook a major examination of the methods of sharing capital and revenue resources between regions, areas and districts, soon discovered. I doubt if anyone would disagree with the principle of RAWP on the grounds that it embraces the basic principle enshrined in the whole idea of the National Health Service, i.e. that our Health Service resources should be equitably distributed throughout the whole country on the basis of need alone. Had this principle been introduced at the beginning of the scheme in the years of substantial and fast growth, the impact would never have been noticed. It is the introduction of the scheme at a time of nil growth that the present acute problems have arisen. In any event, the basis of the formula (weighted population figures and special increments for teaching) are inevitably rough and ready and cannot embrace all the intricacies of the special problems posed by deprived inner-city areas. Equally important is the responsibility of the teaching institutions, not just for teaching and training staff, but to be the hub of development in the research field. As I well know as an ex-Chairman of a Board of Governors myself, it is virtually impossible to separate the costs of clinical services teaching and research. Based upon a 'population weighting basis' the Secretary of State has already indicated that the pace of change would have to be slow. For 1977/78 increases in real terms would vary from 0.25% in the most favoured region, to about 3% in the most deprived. All this points clearly to the urgent need to provide an administrative structure that is lean, efficient and effective. The Report from the all-Party Commons Public Accounts Committee clearly recognises the structural defects of the reorganisation of 1974. It pinpoints what has been glaringly apparent to those working professionally within the service, that planning arrangements were not undertaken with full regard to economy, and poses the question, whether too much of the resources for reorganisation were
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devoted to the new management structure to the possible detriment of patient care or remedial measures to correct specific management weaknesses. Sir Patrick Nairn, Permanent Secretary to the Department of Health and Social Security, said that broadly speaking, 45% of the increased costs of administration was due to the more expensive management structure. Indeed, wherever one looks for the fundamental weakness in the Health Service, one is inevitably drawn to the present administrative structure, where Sir Keith Joseph, in 1974, very successfully produced more harness than horse. Again one must be quite fair and make reference to the fact that serious attempts have been made to control the administrative and clerical staff. As early as 1976, expenditure was frozen in this area and efforts made to reduce the number employed over the following 2 years by some 5%. However, the truth is that no amount of tinkering with the present unwieldy administrative structure can really make the administrative savings required. Certainly the problem is not one of lack of excellence in the medical and nursing professions or the quality of the administrators. These stand selfevident, as amongst the highest in the world. While there are a host of other problems which the Royal Commission will have to consider, the administrative structure is undoubtedly the most important. Unless the structure is absolutely right for the essential task that it has to perform in support of the activities designed to cure the sick, then the Health Service cannot be as efficient as it should be, or its financial resources used to best advantage. Finally, in support of my case for a complete change in the administrative structure, I call to my aid, Mr Paine, House Governor of Bethlem and Maudsley, who in an article in the Lancet in November 1976, wrote ' . . . after 25 years in the service and 2½ years of experience of its new structure, I can honestly say that never before have I known staff morale to be lower, staff relationships poorer, time spent in meetings longer, administration more complex, money scarcer and life generally more frustrating and difficult than it is now'. The $64,000 question is 'what kind of administrative structure will provide the essential back-up service both in the short-term and the long-term, to enable the doctors, nurses and other professionals to perform the function for which the National Health Service was formed some 30 years ago?', which simply put is the care and treatment of people who are sick. This is the prime requirement of the service and those in need are neither interested in the forward planning of new hospitals, or in the career prospects of those who serve.
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The main concern of the elderly lady with varicose veins who has been on the waiting list for months is, just when is her complaint going to be attended to? Not until we have removed the need for the question, and the natural anxiety of the elderly lady, can we say that the Service is full, effective and efficient in the public eye. The only point of contact that the sick have is with the family practitioner and the hospital. The problems of the maintenance of the animal house in the teaching hospital, or the wonders of open heart surgery are not for them. It is, therefore, at this point of contact, that we should begin our examination of the administrative structure;what follows is entirely back-ups for the first contact. It is precisely at this point that the structure is weakest. It has no statutory authority, it has no group of disinterested, but able and experienced laymen, standing apart from the professionals to act as a catalyst for the conflicting views of the professionals; it has what is known as consensus management. An organisation of the size of a large modern hospital needs a focal point in a number of such people who can play a part in helping to maintain the ethics of the organisation and who additionally, by social contact and regular visiting throughout the whole of the organisation, can give the component parts the opportunity to explain their work and how they relate to the whole and to that extent maintaining constant encouragement. No business managed on the present basis could possibly succeed - and administration is a matter of management. The Health Districts should be the spearheads of the Health Service, with authority and power to assess the needs of its district and ensuring within its own competence, or in association with other adjoining districts the planning, organisation and administering of the health service to meet those needs. The Health Districts should have management committees, of some 15 to 20 people, consisting of people appointed by the Regional Health Authority, from names put forward by the local authority, trade unions, main health professions and men and women of judgement and experience; people with a good knowledge of administration and management and financial expertise. The Area Health Authorities and the Community Health Councils would be abolished. The Health District Board of Management would be the watchdog for the public interest and ensure the efficiency of the health care in the district. The Regional Health Authorities would remain in being and take over from the Area Health Authorities such functions as could not adequately be delegated to the Health Districts. They would be required to
delegate to the Health Districts the maximum of authority, which might be modestly different from District to District, by reason of geography or size of population. But the delegated responsibility must be absolutely clear in every case, objectives, duties and responsibilities clearly laid down, so that there can be no possibility of escaping responsibility laid down or interference by the Regional Health Authority on delegated matters. The present formula laid down by the Secretary of State for allocation of resources is somewhat tarnished and while there is everything to be said for allocating more resources to those areas which at present are under-f'manced, population only, even with some of the weightings which the RAWP has evolved, produces some very unsatisfactory results, especially in London. It certainly does not appear to take sufficient account of the wide-ranging role of the undegraduate teaching hospital with its regional specialities and of the special problems of a capital or in the provinces a major city, or whether population alone may be misleading as a basis of allocation. The major city creates its own health problems, which are not easy to quantify and there is a justifiable feeling that in keeping London back to help under-financed areas elsewhere, greater harm may be done to existing high levels of achievement, than good in the deprived areas. There is a threshold of resource allocation which is necessary to maintain various specialities as going concerns and if this threshold is reduced these going concerns may well collapse. This may sound like special pleading for the teaching hospitals, but there must always be a concentration of resources at the major teaching centres if medical progress is to be maintained. Without a substantially increased injection of public funds into the Service, strict equality of opportunity for every person in the country to have the same level of care is probably an illusion, but a splendid political vote catcher. There should be established a National Health Commission whose duties would be to agree with the Department of Health and Social Security, on a rolling 5-year plan basis, the financial resources to be made available and for its allocation on the formula now laid down by the Secretary of State - that is the 'weighted population basis', suitably adjusted. The members of the National Health Commission would be appointed by the Secretary of State of the Department of Health and Social Security and be analogous to the board of a nationalised industry, with a full-time chairman, full-time functional members and part-time members representative of local authorities, the TUC, the CBI and the medical and nursing and other professionals. The Department of
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Health and Social Security would relinquish its day to day work with regard to the Health Service and -confine itself to its functions as a banker to the Health Commission, to ensure that the statutory responsibilities are fulfilled and in fact act as the parent ministry in the same manner as nationalised industries relate to their parent ministries. The Health Commission would be responsible for advising the Minister on such matters as he and they considered appropriate. They would be sole employers of those within the Health Service; they would appoint the members of the Regional Health Authorities with due regard to ensuring that the members were as representative as they were themselves. Public accountability could be ensured by a Select Committee of the House of Commons similar to the Select Committee on Nationalised Industries. This kind of organisation would provide but three tiers of management; provide authority at the community level, responsibilities and authorities clearly defined, streamline decisions, provide flexibility where it matters at the point of impact with the patient and ensure public accountability from the district to the Commission. It would ensure that the maximum of the resources available would be concentrated on the prime purpose of the service - to ensure care and treatment by the professionals at a time when people are in need. Any consideration of future change must have for its end result: 1. Freedom for the doctors, nurses and other professionals to carry out their work of healing without the heavy weight of unnecessary bureaucracy; 2. The ability to plan ahead with the resources available as a proportion of the gross national product, recognizing the changing needs of the Health Service that the years ahead will be certain to bring about. Finally, I would like to turn to the matter of the teaching hospitals. First, I must express a personal interest. For some years up to the reorganisation in 1974 I was the Chairman of the Governors of Guy's and up to date am the Chairman of the Governors of the Medical and Dental School. 1 assure my listeners that what I have to say is undoubtedly objective and I have leaned very heavily upon my pre-1974 and post- 1974 experience. For over 2000 years humanity has always understood that no matter how hungry one may be, not under any circumstances whatsoever must one eat the seed-corn, for to do so would destroy the race. One does not want to sound an alarmist, but there is no doubt, in my mind, that the future of our centres of excellence, their research abilities and postgraduate
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training are very much in danger. Today the tip of the iceberg can be seen. The impact of proposals for the distribution to the university hospitals of financial resources for the period 1978-81, is causing grave disquiet and considerable anxiety. Very few indeed feel anything, but greatly disturbed at the possibilities. The deleterious effect on training is likely to be slow at first in undergraduate medical training, but the deleterious impact on the standards of postgraduate training will be seen more quickly. It is true that the general gloom about the future is generated by a lack of financial resources and those responsible for the detailed allocations are in dire difficulties to decide the priorities over the whole field of health care and teaching. I ask the Commission to consider whether it would not be wiser to look at the special position of the university hospitals quite separately for the purpose of funding. I have advocated the setting up of a Health Commission. It would be possible to have, jointly with that Commission, a University Hospitals Division, which would have the responsibility of planning the future requirements of the qualified medical practitioners. Utilising the present physical resources to the utmost, it would plan for any growth required in any part of the country. It would separately fund the university hospitals taking into account the need for the community health care to be adequately catered for. This would be carried out in association with the University Grants Committee and the universities. I regard it as highly important that the training of postgraduate and undergraduate medical and dental students and the furtherance of research working in close collaboration with its medical school or institute, should be looked at quite separately from the administration of the Health Service p e r se. Unless we get the training and research absolutely right, the standards of the Health Service will inevitably suffer. This, then, should be costed separately and provided, so that one could determine with precision the number of students, direction and standards of training within the financial parameters over the year ahead. The task of the university hospitals is to provide the qualified people and the research necessary for the health-care of the nation. This is obviously a high priority and requires special treatment, because the problems are different to the general hospital. Changing medical needs and the accommodation of specialties like geriatrics and mental illness with no increase in total beds available must inevitably mean that there has had to be a reduction in the beds for acute medicine and surgery which form the cornerstone for undergraduate teaching. There are innumerable instances that could be cited to show the
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great difference in requirements o f the university hospitals. Their needs cannot be dealt with by some rule o f thumb to cover all the hospitals in a region. The Royal Commission, I would hope, would consider favourably a separate administration for the teaching hospitals, within the total health service under a Health Commission. The Commission has a momentous task to perform and if it should be considering some arrangement as that suggested in this lecture, they can be assured of a tremendous opposition from all the vested interests that are involved. Not the least will be the Department of
Health and Social Security; the Civil Service tends to drag more fish into its net rather than let any fish go free. But at least for the purpose of an objective report, all the vested interests must be set aside. The report stage must not be a compromise stage ; there is bound to be plenty o f that later. To get the answer right for the benefit o f the sick and not for the administration, the Commission will require the surgeon's knife and this means not only consummate skill, but courage. I am sure the Commissioners have plenty o f that and I wish them well. We shall all await their final report and recommendations with more than a passing interest.
