Journal of- the Royal Society of Medicine Volume'85 November 1992
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Who cares? -Management and the caring services
Sir Roy Griffiths MA BCL
Little Earlylands, Crockham Hill, Nr Edenbridge, Kent TN8 6SN
Keywords: National Health Service; management; caring services; funding
organization were all discussed but questions of Introduction efficiency or effectiveness were very low profile. Many The year immediately before the management inquiry people in. 1983 argued that management with its of 1983 had seen the NHS subject to a more than connotations of setting Health Service.activities into usually severe attack on its performance. Critics were an economic context had.no real place in the Health. not slow to point out that staff numbers had increased Service and certainly the professions ought not to be by 30% over the previous decade and Government involved. This opinion rested on what wasfelt to be a spending on the NHS over the same 10 years had concordat between professions and Government from risen in real terms by over 28% despite a substantial 1948 onwards that the Government would provide reduction in the number of beds and an increase of only 27% in patient cases. But some -of the criticisms -reasonablefunding and the professions woulddbe free within the constraints of that funding to set their own were broader and more fundamental exhibiting a real priorities largely as a matter of clinical decision. doubt as to whether the public sector in the absence Indeed I learned early on that to talk of economics of competition was capable of responding to the needs or money in -the same breath as care was a form of of consumers. Right wing thinkers were pursuing-the sacrilege almost as if at bysta-nder 2000 years ago alternatives of insurance based schemes for the Health Service which would allegedly give-more choice and -had asked about the per capita cost of feeding the ensure more effective management-under the spur of -multitude with the loaves andfishes. The professions were in 1983 prepared to work similar miracles on competition. For my part I have always sought to be a regular basis with what- they felt to be equally as objective as possible about the NHS. Such views as' limited resources, but certainly didn't want the I had in 1983 reflected the attitude of many of my miracles scrutinized. generation, brought up in areas of deprivation in the 1930s and the War years and which saw the NHS as Management enquiry 1983 the greatest piece of social legislation of the century The -BMJ at the start of the Management Inquiry undertaken (some said, a major foolhardiness) at a wrote to the effect that, 'It is quite possible that the time when other countries were concentrating on the team of -businessmen taking a brisk-march through priorities of economic regeneration rather than social 7the NHS -may have much -greater impact than the progress. establishment of a Royal Commission sitting, for a The reality in 1983 was and in 1992 still is, that the period of years'. It is not for me- more than 9 years NHS is a success story. It is a low cost service (paylater to'-assess the accuracy of that forecast but the ment out of taxation involves the lowest expenditure observation--crystallized the style of working - it was in raising the funds) with most indicators of-health hardly leisurely. Since we were all full time -in the at least as good as many other nations spending far more per head than the British Health Service. Above -privat6*ector-and had only beevi Esked to advise, the taking of formal evidence was -no part of our remit all, the NHS is embodied deep in the affections of the people. But uninterrupted success has led to the long or style. After -a few.weeks of intensive desk work reading the volumino literature- of the-NHS and term ruin of more organizations than: occasional talking and visiting extensively and, yes, actually failure. Success breeds an unwillingness to look listeniing, I' came to the early arid indeed major carefully at how inefficiencies can beimproved land conclusion that the machinery of translating policy a refusal to question whether the sacred-cows should into action and generally of effecting change was be permitted quite such extensive grazing rig-hts. extremely limited. Although this inability to translate To the title of my lecture 'Management and the policy into action was the saviour ofbad policies and Caring Services'. I am inmediateLy in difficulty the despair of good policies, I felt on balance it was because there is no easy definition- of management. undesirable. It embraces responsibility for ensuring that the work That was to' become the theme of the 1980s - the of people for whom the manager has responsibility in simple -observation that' to redress fundamental the running of an organization is characterized by direction, system and method. The role ofthe manager weakness in the ability to implement reforms was quite as important as redressing weaknesses in the is to lead and motivate staff to discharge the bagic policy itself. It was the- startling difference between tasks of the business. In-other words-he -so org&izes the private sector and the public sector. Companies the work of others to get things done. I distinguish it from administration, the main objective ofwhich is -in the private ectorimay very often fail in important areas -of strategy and -policy making, but they do to see that matters are handled according to existing generallyhave the drive to implement and ensure the rules and procedures. Management-is a much more dynamic activity geared to improvement. Certainly implementation of such decisions as are taken. Giving leadership to a great organization is not- primarily a little attention was given to the subject in the first matter of personal charisma or of thinking -great years of the NHS. Methods of funding, relationships between doctors and Government' and forms of thoughts; itis giving vitatity aid getting things done.
Abridged version of Jephcott Lecture, 21 April 1992
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Journal of the Royal Society of Medicine Volume 85 November 1992
It is interesting to look back at the Management Inquiry Report - whilst the Government publicly stated that all the recommendations were accepted and would be implemented, I look back at particular sections which were not wholeheartedly implemented, although all these were picked up later with varying degrees of emphasis. I quote, 'Responsibility should be pushed as far down the line as possible to the point where action can be taken effectively. At present devolution of responsibility is far too slow because the necessary direction and dynamic to achieve this is currently lacking. Surprisingly the NHS lacks any real continuous evaluation of its performance. Rarely are precise management objectives set: there is little measurement of health outcomes; clinical evaluation of particular practices is by no means common and economic evaluation of these practices extremely rare. Nor can the NHS display a ready assessment of the effectiveness with which it is meeting the needs and expectations of the people it serves.'
Note the emphasis on devolution, on quality, on measurement of outcomes, on medical audit etc. All political parties whether through the medium of Trust Hospitals or simply greater delegation to the hospitals now accept that giving as much responsibility at local level is liberating for all staff. Measurement of outcomes is turning out to be a major sunrise industry at least in that it is at the heart of the purchaser/ provider relationship. Again major programmes are under way in both quality and medical audit. The implementation of the 1983 report was a catch-22 situation in that we were asking for a management process to be introduced when there was little management to introduce it. Consequently the Health Service has been learning as it goes, and I believe with some success. The problems were accentuated by the fact that the professions were not brought into the discussions on implementation as fully as we would have wished. This compounded the initial hostility which they felt to the Report. The nurses in particular saw the Report as impliedly attacking the careful career ladders which had been established for the professions by the Salmon and other reports and, indeed, more fundamentally saw the management process as eroding the allegiance to the professions. It was only later that they saw correctly the enormous opportunities which the Report gave to nurses to influence and play a commanding part in the running of the Health Service. The doctors were unimpressed, largely because they saw the management process as distracting from the primary consideration, which they felt to be underfunding of the Service. They felt with Napoleon that there are only three things necessary to fight a war; money, money, money. Indeed the problems of much of the implementation was that it was against the background of funding difficulties as perceived by the professions, the early and mid-1980s were marked by a drop in funding to some 1-2% increase in real terms. This caused problems but had its advantages. It forced health authorities really to examine the efficiency of their operation. The disadvantage was that the mid-1980s seemed all about cost containment and it was certainly demotivating. Questions of cost containment and cost improvement were not so much over-emphasized as not set into the appropriate context. It overlooked the basic principle that running any organization and
particularly great organizations, is primarily about quality - a remorseless obsession about quality of goods and quality of service. The way to motivate professions and indeed any group is to emphasize quality. The trick is to graft onto this the economic aspects and the concern about costs. Prime Minister's Review The funding problems reached their height in 1987 resulting in the Presidents of the Royal Colleges warning the Prime Minister that the NHS was in terminal decline. The Prime Minister's response was to set up her own Review. This started essentially about funding. Alternatives were examined but abruptly dropped. One of the great things about the Review was not so much what it contained, but what it eschewed. It sensibly left -the Service 'free at the point of delivery and largely financed out of general taxation'. It picked up GP fund holding based largely on the American health maintenance organizations and it used the language of the education reform by initially talking about hospitals being allowed to opt out - subsquently ameliorated to their becoming Trust hospitals with greatly devolved powers. Importantly, more felicitous in concept than in language, they gave the District Health Authorities a new role under the purchaser/provider concept, ie it was recognized that District Health Authorities were not primarily in business to deliver services, but to ensure that services were delivered and in so doing they should use any hospital in the public or private sector which could best guaranteee value - this to be achieved under contracts which would spell out outcomes. This followed the role of local authorities in community care which had been set out in my earlier report, 'Community Care - Agenda for Action'.
Post Review agenda The Prime Minister's Review set the agenda from 1989 onwards. Whilst we can never divorce-the NHS from politics there is occasionally a lull in the debate which allows us to examine the way ahead - in the modern parlance a window-of opportunity to look at the forward programme less politically and less emotively. With a new Government with 5 years stretching ahead and a new Secretary of State we can think through where the main emphasis should be in greater precision than an Election manifesto allows. Let us look at these matters in some form of logical sequence. We need -to examine where health care stands as against other demands on the Exchequer; where the NHS itself stands in the field of health care; what funding is available for the NHS; where we are on the Government reforms with particular reference to devolution of responsibility to local level; matters of effectiveness and efficiency; the NHS in relationship to its staff; finally where we are on Community Care. On the first question as to where health stands as against other Government priorities, the health care debate is bedevilled by cliches such as infinite demand as- against finite resources and by the much quoted Royal Commission statement to the effect that one could envisage a position where the whole of the national GDP was absorbed by increasing demands on the Health Service. This could of course be said about Defence, Police, Education etc. It is the responsibility of Government to adjudicate between these priorities. It is not particularly meaningful to talk
Journal of the Royal Society of Medicine Volume 85 November 1992
about demand being infinite. It is for the Government to ensure that funding is kept in reasonable relationship to expectations. This was the problem of the mid-1980s when people's perception as to what is important and necessary changed and this coincided with a lower increase in real terms in the funding of the NHS. Within the field of health we need to think through where the NHS itself stands. The biggest advances in the nation's health may well be improvements in housing and the biggest alleviation to human misery might be by giving more attention to Community Care. I accept that all these subjects are better tackled when extra money is available for the public sector, but we cannot ignore them. There are times when we have to sit down and rethink and not simply proceed incrementally. Priorities again within the broad sector of the Health Service are the responsibility of Government. The Government has indeed felt confident enough to set out for the first time its priorities in the whole field of health care in the consultative document 'The Health of the Nation' and the debate will help determine the priorities for the 1990s. The essence of a priority, however is that other things take second place and there are the beginnings of a debate as to whether there are matters within the present scope of the Health Service which ought not to be there. Involvement of the public and the democratization of the discussions may force a much more open debate, but I personally do not believe that we have reached a point in the funding of the NHS that we need or are ready for or indeed able to control such discussion on an explicit basis - certainly not where a discussion of priorities might imply closing out groups of people on economic grounds and denying them treatment. I also believe that the management process has the potential to release much greater efficiencies and should bend every effort to realize that potential before any examination as to whether a more restrictive role for the NHS is necessary. NHS funding The context for any discussion of funding is an appreciation that health care is rationed either by price as in the United States, or specifically by allocation of resources as in the UK. There is no absolute answer to the level of GDP which is appropriate. International comparisons are too simplistic and naive. The simple fact is that the richer a country is the more it is likely to spend per person on health care. All we can do is to examine continually and sensitively where there is an obvious shortfall in care provided and seek to alleviate that; to place the money where there is the greatest need and where it can bring the greatest improvements in quality of care. And to illustrate that if more money were available certain defined improvements could be made which we would have to forego if the money is not available. That is the management process.
Problems of devolution I mentioned that the agenda for the next few years would essentially concentrate on the implementation of the Government's reforms. It should certainly be a period of consolidation and of seeking to make the Government's proposals work. An important aspect of the reforms is to make the devolution of responsibility to local level work effectively. No one even in the politically fraught months preceding the Election
has argued against the desirability of local hospitals being given much greater powers to run their own show. Any such discussion leads to the quite simple question as to what it is that the Government should retain at the centre. I suggest that what it does need to retain is a consistent emphasis on the values of the Health Service in terms of quality and standards. You can't expect the centre to have its finger on everything happening within the NHS. On the other hand you can expect it to arrange for someone at appropriate levels within the organization to have a hands-on approach and to know whether standards are being met and quality determined. If you have a devolution of responsibility without such control then with hundreds of hospitals likely to achieve Trust status over the next few years you will have the biggest abdication of central responsibility since the 1936 abdication. I would just offer one or two cautions. First that it takes a much better and more sophisticated management to run a devolved or decentralized system than to run a highly centralized operation. Indeed the same comment applies to running a system based on purchasers/providers. The reason is in both cases quite simple - that with a highly centralized system one can run it by giving instructions and by continual intervention. On the other hand in a devolved system and a purchaser/provider system it is necessary to spell out in the contracts the desired outcomes, or put more simply, what has to be achieved. To achieve this we need both measurements of outcome and cost. This is absolutely essential if we are to move from block contracts through to payment per unit of service. All this may trip fairly lightly off the tongue but in practice it is an enormous task. We can attempt to simple costs by some categorization such as DRGs, but this may lack credibility with the professions, particularly in those hospitals which take the more complicated cases. We are at the moment in a very rudimentary position barely able to cost sub-specialties, with limited exceptions. Indeed at the time of the Thatcher Review we had hardly enough management information to run a system of barter let alone a system of costing of medical care. This is not a comment of despair, it is simply pointing out that we may have to take a careful decision as to how sophisticated the system should be. I am all in favour of information necessary to give ideas of costing or of outcome in quality terms, but it is another thing to make it the basis of the contracts. The design and streamlining of such systems is enormously important -streamlining I mention because most people would be surprised not at how much information is produced, but at how much is actually ignored. Striing again because there is too much evidence of duplicate information systems with clinical audit for the clinicians and case mix for managers going along parallel lines as distinct from using the same data base. The final plea on information systems - they are the servants of what we seek to achieve and should only be pursued when responsibilities and objectives are clear and we know precisely what information is necessary to support those responsibilities and objectives.
Effectiveness and efficiency
May I turn now to questions of effectiveness and efficiency. We can over complicate things. In running
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I mentioned in my 1983 report the need to involve any organization one has to be concerned simply with three things - quality of products or service, productclinicians in the management process. Whilst general ivity and finally leadership or motivation of staff to management is linked to my name I really want to beremembered for the introduction ofthe management achieve the first two. We still have little data about which treatment works. Indeed it has been said that process into the NHS. I have a genuine horror that one of the great problems of health care is not poor managers and the various professions will go down management but is the lack of knowledge of the parallel routes barely touching each other and very different objectives. It is important that the effectiveness of different treatments. So we need to be much more careful in finding out and evaluating professions are motivated to play an integral part in management. They were righly incened at being left what results we are getting, and indeed we should be out of the Prime Minister's Review until a late stage considering carefully in many cases whether medical intervention is appropriate at all. I am always astonand have the feeling that even then they were being ished at the figure given by the Audit Commission consulted on decisions which had already been taken. that GPs have 6 million visits a year from people with We have to learn that it is folly to take decisions stress or mild depression -it is one of the major quickly and then take years to implement simply changes from my early days that people now tend to because we have to buy commitment. We have to learn that commitment is built into the decision go to their GP rather than to the Church or Chapel for a prescription in such matters. making process by people being consulted at an early As to the efficiencies we are extremely slow to stage. This may arouse controversy but all important implement improvements which we have known decisions are controversial and I am sure that the about for years - for different staffing arrangements process of early consultation saves time in the- long based on changes within skill mix. We build in run. The alternative leads to confrontation. There is no point in confrontation with the professions since tremendous inflexibilities in professional careers, with Consultants and GPs remaining in the same job the success of the NHS has to be achieved through for 25 years or more with little or no opportunities them. to move. We should be questioning the efficiency of We also have to remind ourselves continually that bed closures as a means of cost containment when all the medical profession is conservative and does the other overheads are left in place. We need to not like being assailed with new global theories, examine capital programmes. We should be questionparticularly economic theories, which they generally ing the advantages of scale in the size of-the large regard as less proven than even alternative medicine. general hospitals. We should be giving more consid- They quite rightly feel that the life of medicine and indeed of the Health Service is not one of theory or eration to minor capital programmes where lack of capital very often is the roadblock - we should of logic or of forms of words, but of people, actions and appreciate the difficulties which many hospitals are experience - a wisdom not borne by thinktanks or of finding in raising the necessary capital to provide day undergraduate essays but gained by touch and by sensitivities. In particular the strength of the NHS surgeries. We should understand that even such minor is not of theory but of its basic values and of a concept underfunding can be a major cause of inefficiency. We should be controlling capital projects more of society which believes that the sick should be healed and the suffering alleviated regardless of the effectively - the average over-run for hospital projects is still unacceptably high. ability to pay. That idea of society was in danger of In short we should be concentrating on doi-ng the losing ground in the 1980s in the face of sturdy self simple things well. There is no point in talking health reliance and there was equally in the 1980s an awful care statistics and forget having to find a bed for the danger that the gap between the deadly. sins and modern virtues was becoming imperceptible. emergency case lying on a stretcher in the corridor. In any organization you get what you emphasize, Consistently with these basic values the professions do have to keep an open mind to innovation and to what you lay stress on but there has to be no unacceptable gap between the rhetorie and the improvement. They should not start from the premise that every Government proposal which does not reality. If you exhibit an obsessive commitment to quality you will get quality. If you are continually reflect customary practice is wrong and is a dangerous putting cost containment first that is what you will precedent. Politicians likewise have to -keep an open mind to appreciate that what they believe to be get and the patients will suffer. This is not to deny that we need continually to examine all costs and necessary firmness in policy may be perceived by staff particularly overhead costs. An increase in overheads as stubborn preconception or unreasoning political may be necessary but we have to ensure that it is -prejudice. carefully and obviously controlled. Until we are doing I-have talked about motivation and leadership. One of my first impressions of 1983 was in fact how little these things well we should refrain from reshaping policies. We do this continuously in any case. We still responsibility the NHS itself felt for its staff. Every feel too much excitement in policy maaking, in the organization is the creature of its history and the attraction of redrawing organizational and geographprofessions had generally looked after their own in ical boundaries. All this sets the adrenalin- flowing. taking responsibility for training and for career There is too little adrenalin flowing in the impleprogression. Not even in pay did management retain mentation of quite simple things - in ensuring that the power to motivate since questions of remuneration were left to the Review Bodies or- to negotiation operations are not cancelled etc. through the tWhitley Councils. Conditions fbr junior Staff doctors are being improved and I admire the efforts Everything I am talking about has to be achieved of Virginia Bottomley in this respect and I do not through staff and we need to understand their motiva- under-estimate-the problems of effeting improvement, tions and the responsibilities which management has but certainly one was left in 1983 with the feeling for staff. We need to involve the staff in decisions. that, by private sector standards, the junior doctors
Journal of the Royal Society of Medicine Volume 85 November 1992
needed not so much a Shaftesbury to improve their conditions as a Wilberforce to release them. We have heard much about Patient's Charter over recent months. This is a healthy turn of the kaleidoscope to reconfirm that everything in the Health Service should be viewed through the patient's eyes. There are however other turns ofthe kaleidoscope to be made one of which is to see how well the Health Service is serving its staff. I suggested some months ago that we needed a staff charter which would move from general statements of commitment to staff through to specific guarantees. I was delighted that the Management Executive through Duncan Nichol have now taken this on board. This is!in fact only one example of what any large organization has to do - that is to recognize that it serves various audiences patients, community, staff, taxpayer (or shareholder) and needs to think through its obligations in specific terms to each of them. And please when we have thought through the obligations to each of these audiences we need to make the obligations part of everyday attitudes and responsibilities of management and staff and to instil these by training and by top level emphasis and not leave them to specialist units. Equally, whilst consultation is at the heart of good management, we don't need as an alternative to action to go overboard with massive surveys, market research or questionnaires as to what the patients want, what the community requires or what staff want. In most cases we already know what is required. In many cases we are alive now to providing it and in other cases we are simply not providing it. I am also anxious that staff should not be overwhelmed by what they see as a new force of managers and a new and alien form of management speak. The essence of any leadership is not a heady brew of complicated statement but a simple clarity of what we are seeking to achieve, what timescales we have in which to achieve it and how many staff and how much money are available. Staff, patients and the general public are certainly not motivated by words such as the internal market or the purchaser/provider relationship. Patients are happy to leave to management as to how a quality service is to be provided and they certainly don't want any feeling that the last thoughts as they go under the anaesthetic and possibly their last thoughts in this life, might be that the surgeon was chosen simply because he had quoted the lowest possible price for the operation. Whilst there has been much adverse comment about bringing commercial principles into the NHS the reality is that the language we are talking as to internal market etc. is the language of economic theorists and not the language of commerce. The second reservation about such words is that they do overstate the position, which leads to many problems with the professions. Had for instance the processes by which the Trust hospitals were set up been described as the hospitals being given extensive powers to run their own show within such limits as are necessary to ensure a -
-
clear and
unified NHS, leaving the District Health
Authority to enter into arrangements with them which would reward quality of service and efficiency, I believe there would have been a ready welcome from everybody. Forward programme What is the programme now? It is too early to claim major benefits from the reforms and it is equally
far too early to recriminate. All the reforms are worthwhile and in the right direction. There is a long way to go and they need a period of consolidation to allow the benefits to come through. The temptation to refine, to restructure, to reorganize and for instance, to merge the FHSAs and the DHAs should for the time being be resisted. There is room for experiments with collaboration but the FHSAs have only recently come into credibility in management. They have to show their abilities to manage the GP contracts and equally the DHAs have-yet to establish themselves in their new responsibilities - a process not helped for many DHAs in that the per capita basis of funding is taking a long time to implement, with the present consequences that some Districts are 10-20% short of the desired funding, exacerbated for those with an above average elderly population.
Comunity care A few words about community care.- I said that the strength of the NHS was essentially in its basic values. The same is true of community care, where the obligation has throughout civilization been accepted to look after people in need,the disabled and the elderly, where the support offered by family life fails. The problem now is that the old sense of community has diminished, the ties of family life have through mobility offered by the motor car and through divorce and one-parent families been weakened. The basic industries round which communities were built have disappeared and we have been for many years struggling to find the best means of providing care. To do this effectively is complicated and difficult. There is one great difference between health care and providing social care. We do aim with the NHS to provide everyone with reasonable health care on a comprehensive basis. People may have to wait but generally we do it well. In social or non-medical care we do not even pretend to provide a comprehensive service through the State. The State provides financial assistance. Most of the care for the elderly and the disabled comes from relatives, often themselves elderly. And almost inevitably most discussions on community care come back very quickly to the question of what money and help is available and how can it best be used. The process of ensuring this is the same as in the Health Service. Give some authority the clear responsibility to establish the need - in this case the local authority. Get them to understand that the first job is not to provide the service themselves but to ensure that services are effectively provided, either through their own directly managed services or the voluntary sector or the private sector. Within that system delegate as much responsibility as possible to local level. Give the person needing assistance, information, opportunity for consultation and choice and tailor the help as far as possible to the resulting requirement. It needs as always clear ideas not only at national level, but at local level of what it is we are seeking to do, the timescales for achievement and a clear idea of the resources available. There are also the problems of interface between medical and non-medical or social care. Government has to be clear whether it is in the business of providing long-term accommodation where the medical services of a hospital are not necessary. My second report, 'Community Care -Agenda for Action' was written on the basis that where medical
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services were not required then patients were better discharged to nursing homes, residential homes or more generally to the community and the local authorities should be responsible for such social care and should be appropriately funded. This is of course an enormously delicate area and the transition has to be handled in a timely, sensitive and well-planned manner. Whilst the NHS has dominated the headlines the major problem in caring is the ageing of the population. Community care is coming up the political agenda for this and other reasons. I would expect that 40% of the votes cast in the Election were by people over the age of 55 years. (A higher proportion of that age group vote than any other.) One can dwell on the problems, the hurdles to be cleared, but the pre-requisite is, as General de Gaulle would have said, 'First the will', by which I mean the determination to see the implementation through. Eagerness for action should match the original eagerness for postponement. The legislation is popular with all Parties, the available money will be well spent, the implementation with good leadership and improving management is a very possible task and the potential to make tolerable many intolerable situations is enormous.
Conclusion Some words by way of conclusion. I am not sure at this point whether you are expecting me to look into a crystal ball or to read the cards. I always try to be objective. Health care is one of the world's largest industries. The NHS is the largest organization within that industry. Even against the background of the recession we are in a growth industry offering reasonable security and terms and conditions for all staff. There is never any doubt as to the worthwhileness of the work being done. It rests on the highest possible moral basis and is founded on the age old precept of care for one's neighbour. Against that background we are continually challenged by the continuous medical advances, by the ageing of the
population and by the rising tide of expectation. We are seeking to meet those challenges and we are as the 1948 legislation made clear accountable to the nation in so doing. I underline that last phrase - not accountable to the professions, not accountable to the Government of the day, not accountable to some economic theory, but accountable to the nation. The endeavour of most of the last 10 years has been precisely to ensure that. Overstatement is in the bloodstream of the Health Service and of politics. Politicians have to overstate the simplest management proposals to give the impression of dynamic action. One politician's dynamic action is another politician's end of the Health Service as we know it. The truth is simpler than politics. We have over recent years changed the thinking so that most people are now positively looking to achieve change in the best interests of the Service. I am confident that there is enough understanding of the basic management approach to achieve what we are seeking and enough catalysts throughout the Service to take us confidently through the next 10 years. I recognize that I have left one significant omission. No comment on the caring services is complete without a reference to Aneurin Bevan. The run up to the Election was marked by his relatives stating what they felt his opinion on the NHS reforms would have been. I will not join in that particular seance. I do know, however, that his favourite quotation was from WB Yeats: 'The years like great black oxen tread the world And God the herdsman goads them on behind And I am broken by their passing feet'
It is remotely possible that that weariness may have derived from his difficult negotiations with the medical profession. I am different - I have enjoyed it all.
(A copy of the full text of this lecture is available from the Publications Department of the Royal Society of Medicine)
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Who cares? -Management and the caring services
Sir Roy Griffiths MA BCL
Little Earlylands, Crockham Hill, Nr Edenbridge, Kent TN8 6SN
Keywords: National Health Service; management; caring services; funding
organization were all discussed but questions of Introduction efficiency or effectiveness were very low profile. Many The year immediately before the management inquiry people in. 1983 argued that management with its of 1983 had seen the NHS subject to a more than connotations of setting Health Service.activities into usually severe attack on its performance. Critics were an economic context had.no real place in the Health. not slow to point out that staff numbers had increased Service and certainly the professions ought not to be by 30% over the previous decade and Government involved. This opinion rested on what wasfelt to be a spending on the NHS over the same 10 years had concordat between professions and Government from risen in real terms by over 28% despite a substantial 1948 onwards that the Government would provide reduction in the number of beds and an increase of only 27% in patient cases. But some -of the criticisms -reasonablefunding and the professions woulddbe free within the constraints of that funding to set their own were broader and more fundamental exhibiting a real priorities largely as a matter of clinical decision. doubt as to whether the public sector in the absence Indeed I learned early on that to talk of economics of competition was capable of responding to the needs or money in -the same breath as care was a form of of consumers. Right wing thinkers were pursuing-the sacrilege almost as if at bysta-nder 2000 years ago alternatives of insurance based schemes for the Health Service which would allegedly give-more choice and -had asked about the per capita cost of feeding the ensure more effective management-under the spur of -multitude with the loaves andfishes. The professions were in 1983 prepared to work similar miracles on competition. For my part I have always sought to be a regular basis with what- they felt to be equally as objective as possible about the NHS. Such views as' limited resources, but certainly didn't want the I had in 1983 reflected the attitude of many of my miracles scrutinized. generation, brought up in areas of deprivation in the 1930s and the War years and which saw the NHS as Management enquiry 1983 the greatest piece of social legislation of the century The -BMJ at the start of the Management Inquiry undertaken (some said, a major foolhardiness) at a wrote to the effect that, 'It is quite possible that the time when other countries were concentrating on the team of -businessmen taking a brisk-march through priorities of economic regeneration rather than social 7the NHS -may have much -greater impact than the progress. establishment of a Royal Commission sitting, for a The reality in 1983 was and in 1992 still is, that the period of years'. It is not for me- more than 9 years NHS is a success story. It is a low cost service (paylater to'-assess the accuracy of that forecast but the ment out of taxation involves the lowest expenditure observation--crystallized the style of working - it was in raising the funds) with most indicators of-health hardly leisurely. Since we were all full time -in the at least as good as many other nations spending far more per head than the British Health Service. Above -privat6*ector-and had only beevi Esked to advise, the taking of formal evidence was -no part of our remit all, the NHS is embodied deep in the affections of the people. But uninterrupted success has led to the long or style. After -a few.weeks of intensive desk work reading the volumino literature- of the-NHS and term ruin of more organizations than: occasional talking and visiting extensively and, yes, actually failure. Success breeds an unwillingness to look listeniing, I' came to the early arid indeed major carefully at how inefficiencies can beimproved land conclusion that the machinery of translating policy a refusal to question whether the sacred-cows should into action and generally of effecting change was be permitted quite such extensive grazing rig-hts. extremely limited. Although this inability to translate To the title of my lecture 'Management and the policy into action was the saviour ofbad policies and Caring Services'. I am inmediateLy in difficulty the despair of good policies, I felt on balance it was because there is no easy definition- of management. undesirable. It embraces responsibility for ensuring that the work That was to' become the theme of the 1980s - the of people for whom the manager has responsibility in simple -observation that' to redress fundamental the running of an organization is characterized by direction, system and method. The role ofthe manager weakness in the ability to implement reforms was quite as important as redressing weaknesses in the is to lead and motivate staff to discharge the bagic policy itself. It was the- startling difference between tasks of the business. In-other words-he -so org&izes the private sector and the public sector. Companies the work of others to get things done. I distinguish it from administration, the main objective ofwhich is -in the private ectorimay very often fail in important areas -of strategy and -policy making, but they do to see that matters are handled according to existing generallyhave the drive to implement and ensure the rules and procedures. Management-is a much more dynamic activity geared to improvement. Certainly implementation of such decisions as are taken. Giving leadership to a great organization is not- primarily a little attention was given to the subject in the first matter of personal charisma or of thinking -great years of the NHS. Methods of funding, relationships between doctors and Government' and forms of thoughts; itis giving vitatity aid getting things done.
Abridged version of Jephcott Lecture, 21 April 1992
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It is interesting to look back at the Management Inquiry Report - whilst the Government publicly stated that all the recommendations were accepted and would be implemented, I look back at particular sections which were not wholeheartedly implemented, although all these were picked up later with varying degrees of emphasis. I quote, 'Responsibility should be pushed as far down the line as possible to the point where action can be taken effectively. At present devolution of responsibility is far too slow because the necessary direction and dynamic to achieve this is currently lacking. Surprisingly the NHS lacks any real continuous evaluation of its performance. Rarely are precise management objectives set: there is little measurement of health outcomes; clinical evaluation of particular practices is by no means common and economic evaluation of these practices extremely rare. Nor can the NHS display a ready assessment of the effectiveness with which it is meeting the needs and expectations of the people it serves.'
Note the emphasis on devolution, on quality, on measurement of outcomes, on medical audit etc. All political parties whether through the medium of Trust Hospitals or simply greater delegation to the hospitals now accept that giving as much responsibility at local level is liberating for all staff. Measurement of outcomes is turning out to be a major sunrise industry at least in that it is at the heart of the purchaser/ provider relationship. Again major programmes are under way in both quality and medical audit. The implementation of the 1983 report was a catch-22 situation in that we were asking for a management process to be introduced when there was little management to introduce it. Consequently the Health Service has been learning as it goes, and I believe with some success. The problems were accentuated by the fact that the professions were not brought into the discussions on implementation as fully as we would have wished. This compounded the initial hostility which they felt to the Report. The nurses in particular saw the Report as impliedly attacking the careful career ladders which had been established for the professions by the Salmon and other reports and, indeed, more fundamentally saw the management process as eroding the allegiance to the professions. It was only later that they saw correctly the enormous opportunities which the Report gave to nurses to influence and play a commanding part in the running of the Health Service. The doctors were unimpressed, largely because they saw the management process as distracting from the primary consideration, which they felt to be underfunding of the Service. They felt with Napoleon that there are only three things necessary to fight a war; money, money, money. Indeed the problems of much of the implementation was that it was against the background of funding difficulties as perceived by the professions, the early and mid-1980s were marked by a drop in funding to some 1-2% increase in real terms. This caused problems but had its advantages. It forced health authorities really to examine the efficiency of their operation. The disadvantage was that the mid-1980s seemed all about cost containment and it was certainly demotivating. Questions of cost containment and cost improvement were not so much over-emphasized as not set into the appropriate context. It overlooked the basic principle that running any organization and
particularly great organizations, is primarily about quality - a remorseless obsession about quality of goods and quality of service. The way to motivate professions and indeed any group is to emphasize quality. The trick is to graft onto this the economic aspects and the concern about costs. Prime Minister's Review The funding problems reached their height in 1987 resulting in the Presidents of the Royal Colleges warning the Prime Minister that the NHS was in terminal decline. The Prime Minister's response was to set up her own Review. This started essentially about funding. Alternatives were examined but abruptly dropped. One of the great things about the Review was not so much what it contained, but what it eschewed. It sensibly left -the Service 'free at the point of delivery and largely financed out of general taxation'. It picked up GP fund holding based largely on the American health maintenance organizations and it used the language of the education reform by initially talking about hospitals being allowed to opt out - subsquently ameliorated to their becoming Trust hospitals with greatly devolved powers. Importantly, more felicitous in concept than in language, they gave the District Health Authorities a new role under the purchaser/provider concept, ie it was recognized that District Health Authorities were not primarily in business to deliver services, but to ensure that services were delivered and in so doing they should use any hospital in the public or private sector which could best guaranteee value - this to be achieved under contracts which would spell out outcomes. This followed the role of local authorities in community care which had been set out in my earlier report, 'Community Care - Agenda for Action'.
Post Review agenda The Prime Minister's Review set the agenda from 1989 onwards. Whilst we can never divorce-the NHS from politics there is occasionally a lull in the debate which allows us to examine the way ahead - in the modern parlance a window-of opportunity to look at the forward programme less politically and less emotively. With a new Government with 5 years stretching ahead and a new Secretary of State we can think through where the main emphasis should be in greater precision than an Election manifesto allows. Let us look at these matters in some form of logical sequence. We need -to examine where health care stands as against other demands on the Exchequer; where the NHS itself stands in the field of health care; what funding is available for the NHS; where we are on the Government reforms with particular reference to devolution of responsibility to local level; matters of effectiveness and efficiency; the NHS in relationship to its staff; finally where we are on Community Care. On the first question as to where health stands as against other Government priorities, the health care debate is bedevilled by cliches such as infinite demand as- against finite resources and by the much quoted Royal Commission statement to the effect that one could envisage a position where the whole of the national GDP was absorbed by increasing demands on the Health Service. This could of course be said about Defence, Police, Education etc. It is the responsibility of Government to adjudicate between these priorities. It is not particularly meaningful to talk
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about demand being infinite. It is for the Government to ensure that funding is kept in reasonable relationship to expectations. This was the problem of the mid-1980s when people's perception as to what is important and necessary changed and this coincided with a lower increase in real terms in the funding of the NHS. Within the field of health we need to think through where the NHS itself stands. The biggest advances in the nation's health may well be improvements in housing and the biggest alleviation to human misery might be by giving more attention to Community Care. I accept that all these subjects are better tackled when extra money is available for the public sector, but we cannot ignore them. There are times when we have to sit down and rethink and not simply proceed incrementally. Priorities again within the broad sector of the Health Service are the responsibility of Government. The Government has indeed felt confident enough to set out for the first time its priorities in the whole field of health care in the consultative document 'The Health of the Nation' and the debate will help determine the priorities for the 1990s. The essence of a priority, however is that other things take second place and there are the beginnings of a debate as to whether there are matters within the present scope of the Health Service which ought not to be there. Involvement of the public and the democratization of the discussions may force a much more open debate, but I personally do not believe that we have reached a point in the funding of the NHS that we need or are ready for or indeed able to control such discussion on an explicit basis - certainly not where a discussion of priorities might imply closing out groups of people on economic grounds and denying them treatment. I also believe that the management process has the potential to release much greater efficiencies and should bend every effort to realize that potential before any examination as to whether a more restrictive role for the NHS is necessary. NHS funding The context for any discussion of funding is an appreciation that health care is rationed either by price as in the United States, or specifically by allocation of resources as in the UK. There is no absolute answer to the level of GDP which is appropriate. International comparisons are too simplistic and naive. The simple fact is that the richer a country is the more it is likely to spend per person on health care. All we can do is to examine continually and sensitively where there is an obvious shortfall in care provided and seek to alleviate that; to place the money where there is the greatest need and where it can bring the greatest improvements in quality of care. And to illustrate that if more money were available certain defined improvements could be made which we would have to forego if the money is not available. That is the management process.
Problems of devolution I mentioned that the agenda for the next few years would essentially concentrate on the implementation of the Government's reforms. It should certainly be a period of consolidation and of seeking to make the Government's proposals work. An important aspect of the reforms is to make the devolution of responsibility to local level work effectively. No one even in the politically fraught months preceding the Election
has argued against the desirability of local hospitals being given much greater powers to run their own show. Any such discussion leads to the quite simple question as to what it is that the Government should retain at the centre. I suggest that what it does need to retain is a consistent emphasis on the values of the Health Service in terms of quality and standards. You can't expect the centre to have its finger on everything happening within the NHS. On the other hand you can expect it to arrange for someone at appropriate levels within the organization to have a hands-on approach and to know whether standards are being met and quality determined. If you have a devolution of responsibility without such control then with hundreds of hospitals likely to achieve Trust status over the next few years you will have the biggest abdication of central responsibility since the 1936 abdication. I would just offer one or two cautions. First that it takes a much better and more sophisticated management to run a devolved or decentralized system than to run a highly centralized operation. Indeed the same comment applies to running a system based on purchasers/providers. The reason is in both cases quite simple - that with a highly centralized system one can run it by giving instructions and by continual intervention. On the other hand in a devolved system and a purchaser/provider system it is necessary to spell out in the contracts the desired outcomes, or put more simply, what has to be achieved. To achieve this we need both measurements of outcome and cost. This is absolutely essential if we are to move from block contracts through to payment per unit of service. All this may trip fairly lightly off the tongue but in practice it is an enormous task. We can attempt to simple costs by some categorization such as DRGs, but this may lack credibility with the professions, particularly in those hospitals which take the more complicated cases. We are at the moment in a very rudimentary position barely able to cost sub-specialties, with limited exceptions. Indeed at the time of the Thatcher Review we had hardly enough management information to run a system of barter let alone a system of costing of medical care. This is not a comment of despair, it is simply pointing out that we may have to take a careful decision as to how sophisticated the system should be. I am all in favour of information necessary to give ideas of costing or of outcome in quality terms, but it is another thing to make it the basis of the contracts. The design and streamlining of such systems is enormously important -streamlining I mention because most people would be surprised not at how much information is produced, but at how much is actually ignored. Striing again because there is too much evidence of duplicate information systems with clinical audit for the clinicians and case mix for managers going along parallel lines as distinct from using the same data base. The final plea on information systems - they are the servants of what we seek to achieve and should only be pursued when responsibilities and objectives are clear and we know precisely what information is necessary to support those responsibilities and objectives.
Effectiveness and efficiency
May I turn now to questions of effectiveness and efficiency. We can over complicate things. In running
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I mentioned in my 1983 report the need to involve any organization one has to be concerned simply with three things - quality of products or service, productclinicians in the management process. Whilst general ivity and finally leadership or motivation of staff to management is linked to my name I really want to beremembered for the introduction ofthe management achieve the first two. We still have little data about which treatment works. Indeed it has been said that process into the NHS. I have a genuine horror that one of the great problems of health care is not poor managers and the various professions will go down management but is the lack of knowledge of the parallel routes barely touching each other and very different objectives. It is important that the effectiveness of different treatments. So we need to be much more careful in finding out and evaluating professions are motivated to play an integral part in management. They were righly incened at being left what results we are getting, and indeed we should be out of the Prime Minister's Review until a late stage considering carefully in many cases whether medical intervention is appropriate at all. I am always astonand have the feeling that even then they were being ished at the figure given by the Audit Commission consulted on decisions which had already been taken. that GPs have 6 million visits a year from people with We have to learn that it is folly to take decisions stress or mild depression -it is one of the major quickly and then take years to implement simply changes from my early days that people now tend to because we have to buy commitment. We have to learn that commitment is built into the decision go to their GP rather than to the Church or Chapel for a prescription in such matters. making process by people being consulted at an early As to the efficiencies we are extremely slow to stage. This may arouse controversy but all important implement improvements which we have known decisions are controversial and I am sure that the about for years - for different staffing arrangements process of early consultation saves time in the- long based on changes within skill mix. We build in run. The alternative leads to confrontation. There is no point in confrontation with the professions since tremendous inflexibilities in professional careers, with Consultants and GPs remaining in the same job the success of the NHS has to be achieved through for 25 years or more with little or no opportunities them. to move. We should be questioning the efficiency of We also have to remind ourselves continually that bed closures as a means of cost containment when all the medical profession is conservative and does the other overheads are left in place. We need to not like being assailed with new global theories, examine capital programmes. We should be questionparticularly economic theories, which they generally ing the advantages of scale in the size of-the large regard as less proven than even alternative medicine. general hospitals. We should be giving more consid- They quite rightly feel that the life of medicine and indeed of the Health Service is not one of theory or eration to minor capital programmes where lack of capital very often is the roadblock - we should of logic or of forms of words, but of people, actions and appreciate the difficulties which many hospitals are experience - a wisdom not borne by thinktanks or of finding in raising the necessary capital to provide day undergraduate essays but gained by touch and by sensitivities. In particular the strength of the NHS surgeries. We should understand that even such minor is not of theory but of its basic values and of a concept underfunding can be a major cause of inefficiency. We should be controlling capital projects more of society which believes that the sick should be healed and the suffering alleviated regardless of the effectively - the average over-run for hospital projects is still unacceptably high. ability to pay. That idea of society was in danger of In short we should be concentrating on doi-ng the losing ground in the 1980s in the face of sturdy self simple things well. There is no point in talking health reliance and there was equally in the 1980s an awful care statistics and forget having to find a bed for the danger that the gap between the deadly. sins and modern virtues was becoming imperceptible. emergency case lying on a stretcher in the corridor. In any organization you get what you emphasize, Consistently with these basic values the professions do have to keep an open mind to innovation and to what you lay stress on but there has to be no unacceptable gap between the rhetorie and the improvement. They should not start from the premise that every Government proposal which does not reality. If you exhibit an obsessive commitment to quality you will get quality. If you are continually reflect customary practice is wrong and is a dangerous putting cost containment first that is what you will precedent. Politicians likewise have to -keep an open mind to appreciate that what they believe to be get and the patients will suffer. This is not to deny that we need continually to examine all costs and necessary firmness in policy may be perceived by staff particularly overhead costs. An increase in overheads as stubborn preconception or unreasoning political may be necessary but we have to ensure that it is -prejudice. carefully and obviously controlled. Until we are doing I-have talked about motivation and leadership. One of my first impressions of 1983 was in fact how little these things well we should refrain from reshaping policies. We do this continuously in any case. We still responsibility the NHS itself felt for its staff. Every feel too much excitement in policy maaking, in the organization is the creature of its history and the attraction of redrawing organizational and geographprofessions had generally looked after their own in ical boundaries. All this sets the adrenalin- flowing. taking responsibility for training and for career There is too little adrenalin flowing in the impleprogression. Not even in pay did management retain mentation of quite simple things - in ensuring that the power to motivate since questions of remuneration were left to the Review Bodies or- to negotiation operations are not cancelled etc. through the tWhitley Councils. Conditions fbr junior Staff doctors are being improved and I admire the efforts Everything I am talking about has to be achieved of Virginia Bottomley in this respect and I do not through staff and we need to understand their motiva- under-estimate-the problems of effeting improvement, tions and the responsibilities which management has but certainly one was left in 1983 with the feeling for staff. We need to involve the staff in decisions. that, by private sector standards, the junior doctors
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needed not so much a Shaftesbury to improve their conditions as a Wilberforce to release them. We have heard much about Patient's Charter over recent months. This is a healthy turn of the kaleidoscope to reconfirm that everything in the Health Service should be viewed through the patient's eyes. There are however other turns ofthe kaleidoscope to be made one of which is to see how well the Health Service is serving its staff. I suggested some months ago that we needed a staff charter which would move from general statements of commitment to staff through to specific guarantees. I was delighted that the Management Executive through Duncan Nichol have now taken this on board. This is!in fact only one example of what any large organization has to do - that is to recognize that it serves various audiences patients, community, staff, taxpayer (or shareholder) and needs to think through its obligations in specific terms to each of them. And please when we have thought through the obligations to each of these audiences we need to make the obligations part of everyday attitudes and responsibilities of management and staff and to instil these by training and by top level emphasis and not leave them to specialist units. Equally, whilst consultation is at the heart of good management, we don't need as an alternative to action to go overboard with massive surveys, market research or questionnaires as to what the patients want, what the community requires or what staff want. In most cases we already know what is required. In many cases we are alive now to providing it and in other cases we are simply not providing it. I am also anxious that staff should not be overwhelmed by what they see as a new force of managers and a new and alien form of management speak. The essence of any leadership is not a heady brew of complicated statement but a simple clarity of what we are seeking to achieve, what timescales we have in which to achieve it and how many staff and how much money are available. Staff, patients and the general public are certainly not motivated by words such as the internal market or the purchaser/provider relationship. Patients are happy to leave to management as to how a quality service is to be provided and they certainly don't want any feeling that the last thoughts as they go under the anaesthetic and possibly their last thoughts in this life, might be that the surgeon was chosen simply because he had quoted the lowest possible price for the operation. Whilst there has been much adverse comment about bringing commercial principles into the NHS the reality is that the language we are talking as to internal market etc. is the language of economic theorists and not the language of commerce. The second reservation about such words is that they do overstate the position, which leads to many problems with the professions. Had for instance the processes by which the Trust hospitals were set up been described as the hospitals being given extensive powers to run their own show within such limits as are necessary to ensure a -
-
clear and
unified NHS, leaving the District Health
Authority to enter into arrangements with them which would reward quality of service and efficiency, I believe there would have been a ready welcome from everybody. Forward programme What is the programme now? It is too early to claim major benefits from the reforms and it is equally
far too early to recriminate. All the reforms are worthwhile and in the right direction. There is a long way to go and they need a period of consolidation to allow the benefits to come through. The temptation to refine, to restructure, to reorganize and for instance, to merge the FHSAs and the DHAs should for the time being be resisted. There is room for experiments with collaboration but the FHSAs have only recently come into credibility in management. They have to show their abilities to manage the GP contracts and equally the DHAs have-yet to establish themselves in their new responsibilities - a process not helped for many DHAs in that the per capita basis of funding is taking a long time to implement, with the present consequences that some Districts are 10-20% short of the desired funding, exacerbated for those with an above average elderly population.
Comunity care A few words about community care.- I said that the strength of the NHS was essentially in its basic values. The same is true of community care, where the obligation has throughout civilization been accepted to look after people in need,the disabled and the elderly, where the support offered by family life fails. The problem now is that the old sense of community has diminished, the ties of family life have through mobility offered by the motor car and through divorce and one-parent families been weakened. The basic industries round which communities were built have disappeared and we have been for many years struggling to find the best means of providing care. To do this effectively is complicated and difficult. There is one great difference between health care and providing social care. We do aim with the NHS to provide everyone with reasonable health care on a comprehensive basis. People may have to wait but generally we do it well. In social or non-medical care we do not even pretend to provide a comprehensive service through the State. The State provides financial assistance. Most of the care for the elderly and the disabled comes from relatives, often themselves elderly. And almost inevitably most discussions on community care come back very quickly to the question of what money and help is available and how can it best be used. The process of ensuring this is the same as in the Health Service. Give some authority the clear responsibility to establish the need - in this case the local authority. Get them to understand that the first job is not to provide the service themselves but to ensure that services are effectively provided, either through their own directly managed services or the voluntary sector or the private sector. Within that system delegate as much responsibility as possible to local level. Give the person needing assistance, information, opportunity for consultation and choice and tailor the help as far as possible to the resulting requirement. It needs as always clear ideas not only at national level, but at local level of what it is we are seeking to do, the timescales for achievement and a clear idea of the resources available. There are also the problems of interface between medical and non-medical or social care. Government has to be clear whether it is in the business of providing long-term accommodation where the medical services of a hospital are not necessary. My second report, 'Community Care -Agenda for Action' was written on the basis that where medical
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services were not required then patients were better discharged to nursing homes, residential homes or more generally to the community and the local authorities should be responsible for such social care and should be appropriately funded. This is of course an enormously delicate area and the transition has to be handled in a timely, sensitive and well-planned manner. Whilst the NHS has dominated the headlines the major problem in caring is the ageing of the population. Community care is coming up the political agenda for this and other reasons. I would expect that 40% of the votes cast in the Election were by people over the age of 55 years. (A higher proportion of that age group vote than any other.) One can dwell on the problems, the hurdles to be cleared, but the pre-requisite is, as General de Gaulle would have said, 'First the will', by which I mean the determination to see the implementation through. Eagerness for action should match the original eagerness for postponement. The legislation is popular with all Parties, the available money will be well spent, the implementation with good leadership and improving management is a very possible task and the potential to make tolerable many intolerable situations is enormous.
Conclusion Some words by way of conclusion. I am not sure at this point whether you are expecting me to look into a crystal ball or to read the cards. I always try to be objective. Health care is one of the world's largest industries. The NHS is the largest organization within that industry. Even against the background of the recession we are in a growth industry offering reasonable security and terms and conditions for all staff. There is never any doubt as to the worthwhileness of the work being done. It rests on the highest possible moral basis and is founded on the age old precept of care for one's neighbour. Against that background we are continually challenged by the continuous medical advances, by the ageing of the
population and by the rising tide of expectation. We are seeking to meet those challenges and we are as the 1948 legislation made clear accountable to the nation in so doing. I underline that last phrase - not accountable to the professions, not accountable to the Government of the day, not accountable to some economic theory, but accountable to the nation. The endeavour of most of the last 10 years has been precisely to ensure that. Overstatement is in the bloodstream of the Health Service and of politics. Politicians have to overstate the simplest management proposals to give the impression of dynamic action. One politician's dynamic action is another politician's end of the Health Service as we know it. The truth is simpler than politics. We have over recent years changed the thinking so that most people are now positively looking to achieve change in the best interests of the Service. I am confident that there is enough understanding of the basic management approach to achieve what we are seeking and enough catalysts throughout the Service to take us confidently through the next 10 years. I recognize that I have left one significant omission. No comment on the caring services is complete without a reference to Aneurin Bevan. The run up to the Election was marked by his relatives stating what they felt his opinion on the NHS reforms would have been. I will not join in that particular seance. I do know, however, that his favourite quotation was from WB Yeats: 'The years like great black oxen tread the world And God the herdsman goads them on behind And I am broken by their passing feet'
It is remotely possible that that weariness may have derived from his difficult negotiations with the medical profession. I am different - I have enjoyed it all.
(A copy of the full text of this lecture is available from the Publications Department of the Royal Society of Medicine)
