867 must
be that it is still considered
as
little
more
than
a
custodial service, and the administrative labels, which
distinguish between "acute services" and "geriatrics and chronic sick", do not help. Geriatric physicians have of course to be skilled in dealing with disability, but to identify the disabled with the old is a disservice to both, and hospital care is only part of a complex of services which the disabled should ideally receive. Geriatric departments often suffer from particularly low standards of accommodation and services, and the of
re-
comprehensive medical service for a quirements community rarely seem to get across in undergraduate clinical teaching. Yet even if these matters were put right, young graduates might well remain reluctant to commit themselves exclusively to working with old people. If that is true, the recommendation that future consultants in the specialty should be general physicians with an interest in geriatrics becomes hard to refute.1 The problem is the work-load. Despite delegation to juniors and other professions, consultants must not only give a competent clinical lead, but must also actively influence the services that are provided and feel committed to relieving the social consequences of illness in old age. If this is to accompany a general medical commitment, a reasonable balance must be kept and the division of responsibility among colleagues must be well organised. But in general medicine there is already a huge body of knowledge to assimilate if the highest cona
temporary clinical standards are to be maintained. Since geriatrics is also a broad specialty, are we not expecting too much? Should we not consider appointing geriatric physicians with special interests to fit in with those of their general medical colleagues? The balance might be better. The essential objective is to provide high standards of medicine for all the illnesses of old age. For that we need the best doctors, and it will not matter if many of them choose to make their commitment part-time.
When all is said (and too much is said) and done (which is much too little), the fundamental fault with the Service is that it is not run. Nobody runs it. It is nobody’s business to run it. Or nearly everybody’s, which comes to the same thing. I am one of the few who remain that were in at the beginning. It is probably hard for those who live in these disillusioned days to credit that the Service began in 1948 not only with high ideals and high expectations but also with a fair degree of mutual trust between the contracting parties. Nye Bevan was a rare political genius. He launched the ship in an atmosphere of goodwill. Even the medical profession was largely prepared to see it have a good sail for its money. So what went wrong? Two things, in my opinion, though when you analyse them they perhaps reduce to two aspects of one thing. But rather than say what they are straight off, I prefer to indulge in a measure of recollection. Those that are retired are prone to reminisce. This time, it is cogent to the main theme. *
*
*
was the medical superintendent of a certain county general hospital; its situation does not matter; except that the county had an administrative system that was reasonably enlightened. I know that "medical In
1948,I
superintendent" has become unspeakable. Before we adopt high moral tones, however, let us examine what-in a favourable set-up-the term meant. It meant, in essence, that there was somebody whose job it was to run the hospital and to foresee its needs: the whole of the hospital, including the Medicine. Yes, but not necessarily by bureaucracy, let alone autocracy. In our case we
larly, the
had
same
had
a
medical committee which
met
regu-
good deal to say, and seldom needed to say thing twice: a channelled democracy. We had a
lay committee which took the ultimate decisions on broad policy and expenditure but which did not attempt to run the hospital. Such an idea had not entered its head. It took the sensible view that it was paying someone to do the running: it would keep tabs on how he was doing, and if he did not do his job, out he went. And, let me repeat, it expected him to run the whole hospital as a medical machine for the benefit of patients. It was no good the superintendent saying that such-andsuch was surgical business or the business of the pharmacist, and so not within his control. Everything was his business. Not the treatment of patients, of course. But the provision of an adequate milieu in which patients could be reasonably treated, that was what he was there for. He had people in other disciplines to help him, and if he treated them properly they did help him-but he was responsible. All right, you may say, but that is an outworn concept. Yes, it is-and more’s the pity. Because what has happened is that responsibility has become so fragmented that no-one is responsible for the whole. It is as though you had a man in charge of the carburettor and a man to keep an eye on the wheels, but no-one to drive a
Points of View THE NATIONAL HEALTH SERVICE: A PARTIAL DIAGNOSIS R. H. M. STEWART* Former Senior Administrative Medical Officer Hospital Board
of a Regional
My point of view is so unpopular that it is not nowadays taken seriously. But old ideas often contain the germs of modern truth. There is little need to belabour the ills of the National Health Service. One point on which all agree is that it is in a parlous state. Yet hardly any two people are of like mind as to what is the matter with it. Vast structures are in any case liable to multiple
pathology. Let
of the way, to begin with. The money, of course. More capital, in particular; if that were to be made available, we might get by with less running costs, and still survive. But money is not the root of this evil. us
get money
Service needs
out
more
*Dr Stewart’s address is Donkleywood House, Donkleywood,
Hexham, Northumberland NE48 1AQ.
the car, let alone anyone to decide where to go. That, in fact, is what took place-gradually-in the years after 1948. Superintendents, medical or otherwise, were rendered powerless, then abolished (some admittedly deserved it). But who took their place? An ill-
868 assorted triumvirate. A medical committee that argued endlessly in circles, a syndrome that is not uncommon in the absence of real power; a lay committee that was so intent on seeing the wheels moving that it kept putting its fingers inside the spokes; and a hierarchy of nonmedical administrators who were allegedly responsible for everything but not in practice for the real essence: the delivery of medical care to the patient. That-raising their hands in horror-was not within their expedient remit. It was the business "of the doctors". Which doctors? All of the doctors. And therefore none of the doctors. The chairman of the medical committee did his best. Yet how could he, who was meanwhile in charge of the clutch department or the brakes department, intervene in a colleague’s daily maintenance of the oil pressure? How, more extraordinarily, was he to climb into the driving seat? It would have been presumptuous to try, and anyway his training had not been along these lines; he was by disposition a brakes man or a clutch enthusiast. He knew about cars, naturally, but was at sea when it came to navigation. Besides, it was likely that, before the journey was well under way, someone else would be sitting in his chair. It did not take long for all and sundry to detect that something was amiss, not only in each hospital but in the Service as a whole. It was just not running properly. So Aladdin must rub his lamp and conjure up a series of correctives. Some new device must always be invented, to paper over the cracks. Another committee? More advisers? A panel of old men to go round as inspectors ? An 0 & M team? An increase in staff at the Department of Health? Better liaison? The application of cost-effectiveness? Another computer? Reorganisation ? A national Ombudsman for medicine? Invention has been fertile, but poor Aladdin is still rubbing. And the car shudders and makes the most horrible noises. Little wonder, really; no-one has looked inside the engine. No-one, in Health Service terms, has examined the medicine. In the last analysis, we can exercise our ingenuity to proliferate the ancillary departments, the record systems, the statistics, we can even make some attempt to tie up medicine with sociology, but if none of our measures has any result in measuring the capacity of doctors to treat patients better, we have not done very much. *
*
*
thought we had gone wrong in two might be two sides of one picture. The first wrong-and here I am opening myself to a howl of abuse-is that there has been too much lay committee interference in day-to-day affairs. The generality of committee members are well-intentioned, honourable, intelligent: splendid people to have a say in what should be done but too often ill-equipped to know how to do it. The second thing that has been at fault is that there has been no single permanent authoritative voice to repreI said earlier that I
ways, but that these
sent, and to care about, the core of the whole matter, the actual doctoring itself, the contact between doctors and patients. All other contacts are subsidiary. So without
such
a
voice, nobody
can
possibly know
where he is
going. Could these be
two
aspects of
one
dilemma? I believe
they might. The public, and politicians in particular, are afraid of allowing too much power to doctors. Doctors, on the other hand, are afraid of giving overmuch power of their number. Both attitudes are understandable. Nevertheless it is their combination that has led us into the present morass.
to one
My diagnosis, then-"partial" probably in more than one-is that there has been, despite the view usual of the profession, not enough administration; senses
and that what there has been is too much of the wrong kind. Administration needs to understand what it is supposed to be administering. To sail a ship to its destination, you appoint a master mariner; the purser, the ship surgeon are answerable to the captain. To run an army (as distinct from deciding whom to fight), you choose a soldier. To run a Church, you look to one of the clergy: To run health, you should be looking to someone who understands the human body, but who on top of that has been trained to take a long view about the health needs of the body of humanity. *
I hear
*
*
sundry objectors getting to their feet. Do I not asks think, one, that what I am suggesting could be achieved by some form of medical audit? Frankly, no. Real auditing requires an auditor, medical auditing a medical auditor. No-one in this country has been trained to such a task. Another voice lays the charge that I have assumed that what might apply to hospitals must apply equally to the whole field of health. And why not? The hospital is the logical local headquarters of health dispensation. Yet another questions the validity of my analogies. Doctors, he says, know about disease. This does not necessarily make them the best judges of what steps are required to run a service attuned to health. This gentleman can be rebutted in his own terms. Does the captain of the ship give up his command when the storm dies down? Is a clergyman a mere specialist in Satanism? No, Sir, you are confusing the issue. Pathology is integral to medical education, but it is based on anatomy and physiology. Indeed it is knowledge of the mechanisms of pathology that distinguishes the doctor from the nurse, the psychologist, or any other health worker. A fourth-less polite-objector simply says I am outdated. Have I not heard of Community Medicine? Surely the answer lies in the hands of its practitioners? Yes, I would reply, if the rest of the profession will put it there. A profession that had united on this would have prospects of convincing the public-who are eager for a workable solution-that there is no other way to get value for money, or (more important) to secure a sound medical basis for the organisation of its health service. The last of the objectors is suavely polite. There may be some merit in this unusual viewpoint, says he, but it deals with no more than one isolated issue in a vast complex of conundrums. Money has been mentioned, but the problem of resource allocation has not. Staffing; the contribution of the community; decentralisation; private practice-one could go on for a long time before one had mentioned half of the many headaches that beset us. No single therapy is likely to cure all these. Precisely. This diagnosis is partial. But it is no good setting about the seborrhoea and the ingrowing toe-nails until we have established a regular rhythm of the heart.
be that it is still considered
as
little
more
than
a
custodial service, and the administrative labels, which
distinguish between "acute services" and "geriatrics and chronic sick", do not help. Geriatric physicians have of course to be skilled in dealing with disability, but to identify the disabled with the old is a disservice to both, and hospital care is only part of a complex of services which the disabled should ideally receive. Geriatric departments often suffer from particularly low standards of accommodation and services, and the of
re-
comprehensive medical service for a quirements community rarely seem to get across in undergraduate clinical teaching. Yet even if these matters were put right, young graduates might well remain reluctant to commit themselves exclusively to working with old people. If that is true, the recommendation that future consultants in the specialty should be general physicians with an interest in geriatrics becomes hard to refute.1 The problem is the work-load. Despite delegation to juniors and other professions, consultants must not only give a competent clinical lead, but must also actively influence the services that are provided and feel committed to relieving the social consequences of illness in old age. If this is to accompany a general medical commitment, a reasonable balance must be kept and the division of responsibility among colleagues must be well organised. But in general medicine there is already a huge body of knowledge to assimilate if the highest cona
temporary clinical standards are to be maintained. Since geriatrics is also a broad specialty, are we not expecting too much? Should we not consider appointing geriatric physicians with special interests to fit in with those of their general medical colleagues? The balance might be better. The essential objective is to provide high standards of medicine for all the illnesses of old age. For that we need the best doctors, and it will not matter if many of them choose to make their commitment part-time.
When all is said (and too much is said) and done (which is much too little), the fundamental fault with the Service is that it is not run. Nobody runs it. It is nobody’s business to run it. Or nearly everybody’s, which comes to the same thing. I am one of the few who remain that were in at the beginning. It is probably hard for those who live in these disillusioned days to credit that the Service began in 1948 not only with high ideals and high expectations but also with a fair degree of mutual trust between the contracting parties. Nye Bevan was a rare political genius. He launched the ship in an atmosphere of goodwill. Even the medical profession was largely prepared to see it have a good sail for its money. So what went wrong? Two things, in my opinion, though when you analyse them they perhaps reduce to two aspects of one thing. But rather than say what they are straight off, I prefer to indulge in a measure of recollection. Those that are retired are prone to reminisce. This time, it is cogent to the main theme. *
*
*
was the medical superintendent of a certain county general hospital; its situation does not matter; except that the county had an administrative system that was reasonably enlightened. I know that "medical In
1948,I
superintendent" has become unspeakable. Before we adopt high moral tones, however, let us examine what-in a favourable set-up-the term meant. It meant, in essence, that there was somebody whose job it was to run the hospital and to foresee its needs: the whole of the hospital, including the Medicine. Yes, but not necessarily by bureaucracy, let alone autocracy. In our case we
larly, the
had
same
had
a
medical committee which
met
regu-
good deal to say, and seldom needed to say thing twice: a channelled democracy. We had a
lay committee which took the ultimate decisions on broad policy and expenditure but which did not attempt to run the hospital. Such an idea had not entered its head. It took the sensible view that it was paying someone to do the running: it would keep tabs on how he was doing, and if he did not do his job, out he went. And, let me repeat, it expected him to run the whole hospital as a medical machine for the benefit of patients. It was no good the superintendent saying that such-andsuch was surgical business or the business of the pharmacist, and so not within his control. Everything was his business. Not the treatment of patients, of course. But the provision of an adequate milieu in which patients could be reasonably treated, that was what he was there for. He had people in other disciplines to help him, and if he treated them properly they did help him-but he was responsible. All right, you may say, but that is an outworn concept. Yes, it is-and more’s the pity. Because what has happened is that responsibility has become so fragmented that no-one is responsible for the whole. It is as though you had a man in charge of the carburettor and a man to keep an eye on the wheels, but no-one to drive a
Points of View THE NATIONAL HEALTH SERVICE: A PARTIAL DIAGNOSIS R. H. M. STEWART* Former Senior Administrative Medical Officer Hospital Board
of a Regional
My point of view is so unpopular that it is not nowadays taken seriously. But old ideas often contain the germs of modern truth. There is little need to belabour the ills of the National Health Service. One point on which all agree is that it is in a parlous state. Yet hardly any two people are of like mind as to what is the matter with it. Vast structures are in any case liable to multiple
pathology. Let
of the way, to begin with. The money, of course. More capital, in particular; if that were to be made available, we might get by with less running costs, and still survive. But money is not the root of this evil. us
get money
Service needs
out
more
*Dr Stewart’s address is Donkleywood House, Donkleywood,
Hexham, Northumberland NE48 1AQ.
the car, let alone anyone to decide where to go. That, in fact, is what took place-gradually-in the years after 1948. Superintendents, medical or otherwise, were rendered powerless, then abolished (some admittedly deserved it). But who took their place? An ill-
868 assorted triumvirate. A medical committee that argued endlessly in circles, a syndrome that is not uncommon in the absence of real power; a lay committee that was so intent on seeing the wheels moving that it kept putting its fingers inside the spokes; and a hierarchy of nonmedical administrators who were allegedly responsible for everything but not in practice for the real essence: the delivery of medical care to the patient. That-raising their hands in horror-was not within their expedient remit. It was the business "of the doctors". Which doctors? All of the doctors. And therefore none of the doctors. The chairman of the medical committee did his best. Yet how could he, who was meanwhile in charge of the clutch department or the brakes department, intervene in a colleague’s daily maintenance of the oil pressure? How, more extraordinarily, was he to climb into the driving seat? It would have been presumptuous to try, and anyway his training had not been along these lines; he was by disposition a brakes man or a clutch enthusiast. He knew about cars, naturally, but was at sea when it came to navigation. Besides, it was likely that, before the journey was well under way, someone else would be sitting in his chair. It did not take long for all and sundry to detect that something was amiss, not only in each hospital but in the Service as a whole. It was just not running properly. So Aladdin must rub his lamp and conjure up a series of correctives. Some new device must always be invented, to paper over the cracks. Another committee? More advisers? A panel of old men to go round as inspectors ? An 0 & M team? An increase in staff at the Department of Health? Better liaison? The application of cost-effectiveness? Another computer? Reorganisation ? A national Ombudsman for medicine? Invention has been fertile, but poor Aladdin is still rubbing. And the car shudders and makes the most horrible noises. Little wonder, really; no-one has looked inside the engine. No-one, in Health Service terms, has examined the medicine. In the last analysis, we can exercise our ingenuity to proliferate the ancillary departments, the record systems, the statistics, we can even make some attempt to tie up medicine with sociology, but if none of our measures has any result in measuring the capacity of doctors to treat patients better, we have not done very much. *
*
*
thought we had gone wrong in two might be two sides of one picture. The first wrong-and here I am opening myself to a howl of abuse-is that there has been too much lay committee interference in day-to-day affairs. The generality of committee members are well-intentioned, honourable, intelligent: splendid people to have a say in what should be done but too often ill-equipped to know how to do it. The second thing that has been at fault is that there has been no single permanent authoritative voice to repreI said earlier that I
ways, but that these
sent, and to care about, the core of the whole matter, the actual doctoring itself, the contact between doctors and patients. All other contacts are subsidiary. So without
such
a
voice, nobody
can
possibly know
where he is
going. Could these be
two
aspects of
one
dilemma? I believe
they might. The public, and politicians in particular, are afraid of allowing too much power to doctors. Doctors, on the other hand, are afraid of giving overmuch power of their number. Both attitudes are understandable. Nevertheless it is their combination that has led us into the present morass.
to one
My diagnosis, then-"partial" probably in more than one-is that there has been, despite the view usual of the profession, not enough administration; senses
and that what there has been is too much of the wrong kind. Administration needs to understand what it is supposed to be administering. To sail a ship to its destination, you appoint a master mariner; the purser, the ship surgeon are answerable to the captain. To run an army (as distinct from deciding whom to fight), you choose a soldier. To run a Church, you look to one of the clergy: To run health, you should be looking to someone who understands the human body, but who on top of that has been trained to take a long view about the health needs of the body of humanity. *
I hear
*
*
sundry objectors getting to their feet. Do I not asks think, one, that what I am suggesting could be achieved by some form of medical audit? Frankly, no. Real auditing requires an auditor, medical auditing a medical auditor. No-one in this country has been trained to such a task. Another voice lays the charge that I have assumed that what might apply to hospitals must apply equally to the whole field of health. And why not? The hospital is the logical local headquarters of health dispensation. Yet another questions the validity of my analogies. Doctors, he says, know about disease. This does not necessarily make them the best judges of what steps are required to run a service attuned to health. This gentleman can be rebutted in his own terms. Does the captain of the ship give up his command when the storm dies down? Is a clergyman a mere specialist in Satanism? No, Sir, you are confusing the issue. Pathology is integral to medical education, but it is based on anatomy and physiology. Indeed it is knowledge of the mechanisms of pathology that distinguishes the doctor from the nurse, the psychologist, or any other health worker. A fourth-less polite-objector simply says I am outdated. Have I not heard of Community Medicine? Surely the answer lies in the hands of its practitioners? Yes, I would reply, if the rest of the profession will put it there. A profession that had united on this would have prospects of convincing the public-who are eager for a workable solution-that there is no other way to get value for money, or (more important) to secure a sound medical basis for the organisation of its health service. The last of the objectors is suavely polite. There may be some merit in this unusual viewpoint, says he, but it deals with no more than one isolated issue in a vast complex of conundrums. Money has been mentioned, but the problem of resource allocation has not. Staffing; the contribution of the community; decentralisation; private practice-one could go on for a long time before one had mentioned half of the many headaches that beset us. No single therapy is likely to cure all these. Precisely. This diagnosis is partial. But it is no good setting about the seborrhoea and the ingrowing toe-nails until we have established a regular rhythm of the heart.
