Enoch Powell 1966
5. Centralisation
Lord Curzon used to say that, ‘if a sparrow twitches its tail in Peshawar, it is assumed that he does it by the direct order of the Governor-General in Calcutta’. This is precisely the situation of the Minister of Health in relation to the hospital service: everything that happens or does not happen in any hospital in England and Wales is deemed to be by the decision of the Minister of Health, and can be treated as such by Parliament and the public.
The result is to impart a unique rigidity and centralisation to the conduct of the activities of something approaching half a million persons in a vast variety of institutions throughout the country. The effects are felt both in the relationship between the state and the professions and in the form the development of the service takes.
In the professions it promotes the sense of being subordinate, in a professional capacity, to lay control and decision. In the last resort, all final decision is lay, whether the decision be that of an individual to undergo an operation or of Parliament to institute a national health service. The principle is not limited to medicine but is universal: the professional is the servant, albeit specially endowed and equipped, while the layman (albeit often called the ‘client’) is the consumer who commands the service and decides whether he will take the advice or no. In all government the last word is of necessity lay, that is, non-expert: the chiefs of staff advise, the cabinet and prime minister decide, the chiefs of staff execute; and so it is with all the expertise— scientific, legal, educational, economic— that lies at the disposal of government. Even if we could imagine (dreadful thought!) the professional becoming dictator, like Plato’s ‘philosophers become kings’, as does indeed happen when the professional soldier seizes power, still the division of function is carried into the individual himself, who decides as layman on the advice he tenders as professional. This is akin to the reason why the doctor, in his capacity as consumer, will call on a colleague to advise ?nd treat himself and his family— not so much to have a second opinion as to secure a separation of the functions of lay and professional.
LAY SUPREMACY
The idea therefore that the professional could ever be ‘on top’, like that of a state health service controlled by the doctors, is a chimera. Even if it were run by men all of whom had high medical qualifications, they would have ceased to be doctors, and their practising colleagues, their serving colleagues, would be quick to tell them so, as they are fain to tell the Senior Administrative Medical Officer of a regional hospital board or the medical staff of the Ministry of Health. It is the form that lay supremacy takes in the National Health Service, and not the fact of lay supremacy itself, that is unique.
There is, it is true, in theory no ministerial responsibility for the action of an individual doctor in his professional capacity in the treatment of an individual patient. Yet even there the responsibility of the Minister is impossible to keep at bay. The hospital authority, which is the Minister’s agent, can be sued for the negligence of its employee. What is more, if that negligence is something that might reasonably have been apprehended and prevented, the Minister is responsible in more than a figurative sense. A purely professional error by a hospital doctor is always potentially a matter of concern to the Minister: if the error is gross and in the nature of the circumstances likely to recur, it is the Minister’s business at least to be able to show that he has done his best to render it impossible for the future. He will almost certainly proceed by instigating professional enquiry; but as his business is to take all reasonable pains to employ competent and rational staff, the decision on what is competent is ultimately his. The room of every Minister of Health is haunted by the ghost of Sauerbruch, the brilliant East German doctor who continued to treat patients after he had ceased to be sane; for he, the Minister of Health, would be responsible if a Sauerbruch were at work somewhere in the National Health Service. He can therefore never disinterest himself from the professional actions of his agents’ employees.
Often it is supposed that the so-called, and miscalled, disciplinary powers exercised over general practitioners by the local health executive councils with whom they are in contract, and ultimately by the Minister himself, are instituted for this purpose. Technically, this is not so. Technically they exist to police the fulfilment of the contracts—I even went so far (‘The Whale and the Elephant‘, British Medical Journal, 27 May 1961) as to compare the proceedings with ‘knocking £10 off a decorator’s contract price for painting a house because he admits having made a mess of the ceilings’— but since ‘all proper and necessary treatment’ is an important stipulation of the contract, those who exercise the powers are often forming a judgement on precisely the issue of competence. The finding of the facts, admittedly, is initially entrusted to a body composed of medical men, and I myself instituted the rule that all contractual cases in which prima facie the General Medical Council might be interested from the profession’s point of view should automatically be brought to its notice; but the jurisdiction itself is that of the Minister, indirectly through his agents, the executive councils, and directly in an appellate capacity.
There is in this instance an interesting paradox. The decisions to ‘fine’ practitioners by withholding remuneration, or rather to confirm or vary the ‘fines’ imposed by the executive councils, are in form the Minister’s. When they attract the attention of the public, they are frequently published in a highly personalised manner: ‘Minister swoops on Clacton dentist’; ‘Powell doubles doctor’s fine.’ In fact, and for good reason, there are no decisions of the Minister that are less personal. It is a requirement of natural justice that the decisions, being essentially judicial, should be as far as possible mutually consistent and uniform, applying the same standards from one case to the next and from one year to the next. The occasional exertion of the judgement of changing Ministers would be bound to have the opposite result, however impartially and conscientiously they sought to go to work. Therefore rightly Ministers have— so far as I know, invariably— accepted these particular decisions as being theirs in only a formal sense.
It is not, however, this sort of contingent lay responsibility for individual professional actions that matters to any important extent. On the contrary, the significant lay responsibility is that for general decisions, where the underlying data are of a professional character. This was illustrated on a large scale when the annual sums provided by the state for hospital building began to be sharply increased at the end of the 1950s and a continuance of that increase for many years to come was projected. If these sums were to be spent on any rational and defensible principle, it was then necessary to take a view on what should be built, and where, over a period of at least fifteen to twenty years ahead.
Such a view, to be effective, could not be confined to general propositions, but must be as specific and concrete as possible. More important still, it had to make, and make for the country as a whole, certain basic assumptions about the ‘right’ nature and scale of hospital provision during the coming generation at least. Once these assumptions were made, and action based on them had started, they were bound to commit irrevocably the application of a great and growing volume of resources, and to impose on the hospital system of the country a pattern which, although it would only progressively be realised, could only progressively be modified again thereafter.
ACTS OF LAY JUDGEMENT
One such assumption was the principle of the district general hospital. The size and content of the district general hospital might be permitted to vary within limits between one place or region and another, and between those started earlier and those coming on later, which could take account of the results of experiment and experience and of changing clinical knowledge and techniques. But the basic decision itself, that the district general hospital, as defined in the Hospital Plan,‘offers the most practicable method of placing the full range of hospital facilities at the disposal of patients’, had to be taken once for all, and once taken, would determine the future of hundreds of existing and projected establishments. The factors involved in the decision were almost wholly professional; but it had to be a lay decision, taken on a lay judgement of where the weight and rightness of professional advice lay.
An equally basic, but infinitely more complex decision, or rather group of decisions, was about the scale of provision at which to aim in the various major branches of hospital care, provision which would for practical purposes not be interchangeable. This decision led to the heart of the most elusive of all the concepts in hospital medicine— that of the bed, universally used, and perhaps indispensable, for statistical, financial, administrative, architectural and other purposes, and yet ultimately defying all attempts at definition as a unit of hospital capacity or a means of measuring quantity and quality of hospital care. Here again the data and judgements to which general reasoning had to be applied were essentially of a clinical character, and the choice of the data and judgements on which the decision was founded had to be ultimately lay. There was no escape, however, from taking the decisions pretty firmly and at once, because upon them had to be based the allocation of the growing sums available for capital projects and the outline briefs without which no detailed planning or preparations could begin.
All lay decisions are in a sense personal, as involving the responsibility of an individual; but some will bear a more personal stamp than others. Where an act of judgement refers to the future (what ought to be done) and not to the past (what in fact was done), personality is an unavoidable ingredient. Any one of, say, three different politicians who might have been at the Ministry of Health in 1960-62 would have set his name to an appreciably different plan for the rebuilding of the hospitals of England and Wales: each would have given a different combination and respective weight to the professional data and advice. Speaking for myself, I can recognise my own signature most clearly— no doubt it is elsewhere as well, if I could only see— in the parts concerned with mental hospitals. Expenditure on provision for the mentally subnormal would have been substantially less— and therefore, of course, provision for patients of other kinds would have been that much more— and the assumption of the progressive break-up of the large, isolated mental hospitals would not have been as marked, without the exertion of the personal viewpoint and inclinations of the Minister. Here again, the data and the various currents of advice were of necessity clinical and professional in character; but they were, and had to be, interpreted and given their relative weight by the lay mind.
This, be it well understood, is not asserted as a virtue. Still less do I suggest that my own lay judgement had any advantage over that of another who might have been in my situation. I stress merely that the exertion of a lay judgement is not optional, or incidental, but is of the essence of the public organisation and provision of medical care, and that what is peculiar about that lay judgement in the National Health Service is only the fact that the provision to which it is applied is ‘national’.
It is, of course, not only in the context of planning, or re-planning, an entire branch of the service that lay judgement must decide on professional data. Almost any issue of policy, meaning a decision that will have general application or that will, or may, create precedent, is likely to involve largely or wholly professional matters, matters that in an individual context would be judged and decided professionally.
Take one or two at random. How much difference does it make to the efficiency of operating theatre staff and, therefore, to the well-being and survival chances of patients, that an operating theatre should be fully air-conditioned? On the reply depends the decision whether to build more new operating theatres sooner without full air conditioning, or to make that requirement obligatory throughout and take the consequences. Only clinical staff and medical advisers can provide the material for an answer; but if they differ (as they did) or if the advice does not put the question of relative priority beyond a peradventure (as it rarely does), the layman still has to follow his nose and plump, bearing in mind that what he agrees or authorises in one case, unless he can sharply distinguish it from the rest, he is in effect deciding once for all.
The instructive story of the cervical smear is much to the point here. A procedure pioneered and demonstrated in one or two centres is all at once recognised generally as a valuable means of preserving life. There is in fact no reason why, if the same clinical judgement had been exercised, it should not also have been in operation elsewhere at the same time. But to the demand that it should immediately be generalised, on the indisputable ground that if useful and needed in one place it must be equally useful and needed in any other, it is vain for the Minister to rejoin, with the priests and elders: ‘See thou to that.’ The answer comes: ‘But this is something extra that we have now to provide: either give us more resources, or take upon yourself the responsibility of saying what existing provision we are to reduce or discontinue.’ Now that they have heard about it, the public too are by this time clamouring to know why what other people’s wives can get in Newcastle, theirs cannot in Harlow— a tricky question to answer, especially in the House of Commons. The Minister is between the devil and the deep sea. So he takes the question into his own hands and makes a national policy out of it, deciding when and where and what.
Exactly the same has happened, and for the same reasons, with major surgical advances, such as the heart-lung machine and the successive developments of the artificial kidney. It will happen, if it has not already happened, with transplants.
LAY ADVICE
The necessity of lay judgement carries with it the corollary of lay advice. Much misunderstanding and, in the past, many bitter wrangles have attached to the primacy of the lay civil servant over the professional at the Ministry of Health, and thus in the administration of the National Health Service. It is not, in fact, so many years since the advice of the Chief Medical Officer, even on a professional point, could be tendered to the Minister only through the lay permanent secretary. This punctilio happily is a thing of the past; but a Minister would be most unwise and in breach of an important convention if he took a decision on professional advice without recourse to the opinion of his lay advisers upon it.
There is a clear and logical reason for this. In the exercise of his judgement, and ultimately of his authority, the Minister is bound, both by prudence and by well-founded convention, to seek and consider, though not necessarily to follow, the advice of his permanent officials. Where a professional issue is involved, the judgement of the Minister is essentially a lay judgement applied to professional data. In applying that judgement the relevant advice must necessarily also be lay; otherwise the decision will in effect be a decision taken (in the literal sense of the term) unadvisedly. It is a serious defect of the subordinate decision-taking authorities in the hospital service— the regional hospital boards— that their senior advisers are by training and background professionals, the Senior Administrative Medical Officers, and that they have no lay officer of comparable, let alone superior, standing.
There is nothing new or peculiar to the National Health Service about the dilemma of lay judgement on medical data wherever and whenever state action has been involved. From the beginning of public health measures, such as the decisions of the Privy Council in the face of the cholera epidemics, the politicians have taken the best line they could between public attitudes and professional advice; and if their decisions sometimes seem strange to us, the same can be said of a good deal of the professional advice they were receiving. Successive Ministers of Health since the war have been martyred by poliomyelitis. (I happened personally to be lucky, in that the worst was over by my time— my own particular bete noire was destined to be smallpox.) They had to take decisions about vaccination and immunisation on the basis of complex and difficult data, hotly disputed in the medical profession at home and abroad in its interpretation, yet knowing that an innocent and perhaps quite unavoidable error in drawing conclusions from the data could cost them their political lives. Because any measure applied anywhere had to be applied or available elsewhere, they were at the mercy of the most violent fluctuations of demand. A method they had been authoritatively advised was safe or effective, could and did become dangerous or obsolete overnight, and they would be hounded on the morrow for failing to have its safe or effective successor instantly available everywhere for everybody— not to mention the endless disagreements of the medical profession about methods of administration and degrees of immunity.
This illustrates another of the consequences of the generality inherent in a state provision or service— that it is not possible for one opinion or method gradually to prevail over another. The state, in the person of the Minister, being a single entity, cannot entertain conflicting views or do inconsistent things at one and the same time. Consequently the changes of policy must be sudden and they must be absolute. Change and modification tend to be delayed until they can no longer be avoided or resisted; but when they do occur, they tend in their turn to be unqualified and equally stiffly held. This is a phenomenon also observable, and for the same causes, in nationalised industries and in nationally planned economies.
The comparison is more than superficial; for the effects of eliminating competition and centralising decision are not peculiar to activities where success and progress are expressed in economic or commercial terms. Indeed, they may be more serious and restrictive where economic and commercial tests and comparisons are in the nature of the case excluded. In all but the most rigidly totalitarian economies it remains possible to form some comparison between the success with which different economic activities are pursued; and in a ‘mixed economy’, in the sense of an economy where some of these activities are conducted by the state and others are not, some comparison of efficiency and results between the one and the other is not only possible, but forces itself even unsought upon public attention. No state or other monopoly can be formed so tight as to defy international comparison, if not competition.
For a hospital service there is no similar efficiency audit— continuous, unofficial and impersonal. The attempts to find satisfactory measurements or yardsticks of performance have been persistently baffled. Enormous effort has been lavished during the twenty years of the National Health Service on the collection of statistics of hospital activity, and on the search among them for the means of making valid comparisons, within the service itself and between the service and other systems. It is a search I myself engaged in with the freshness and hopefulness of inexperience, only to be driven into recognising reluctantly that the search itself was inherently futile. The most carefully constructed parallels between one hospital or hospital group and another dissolved on closer examination into a baffling complex of dissimilarities. Every attempt to apply a common standard had the effect of disclosing a deeper level of individual differences and incommensurables.
CENTRALISATION AND INDEPENDENCE
All this does not mean that where the effects of concentrating decision and initiative cannot be measured or estimated they are less serious. On the contrary, the impossibility of such measurement and estimation makes it the more perilous to eliminate or reduce independent sources of initiative and decision. I believe it is a sense of this danger which underlies professional resentment of the kind of lay supremacy implicit in a state-provided hospital system.
One of the basic attitudes of the medical profession is respect for the independence of individual professional judgement. The doctor is nurtured in this by the unique responsibility he accepts for his patient. I have drawn attention elsewhere to the fact that the frame of mind which this characteristic situation of the doctor presupposes and fosters is diametrically opposed to that of the politician:
‘The politician is all the time concerned with the general consequences of individual decisions. He instinctively asks himself what will be the total cost to the nation if Mrs. Jones is paid another shilling, or whether the net effect of altering the law in Mr. Smith’s favour may not. on balance be to the public disadvantage. The consideration of such consequences or implications as these, which is an essential part of the politician’s duty, has no counterpart in the professional activity of the doctor. With no more than pardonable sharpening of the antithesis, one might say that for the doctor the general law is only relevant so far as it helps the individual, while for the politician the individual case is only relevant so far as it illuminates the general law.
‘The doctor takes his characteristic professional decisions not only for individuals but as an individual, on his own single and ultimately unsharable responsibility: he is used to practising reliance on his separate judgement; indeed, this independence of judgement is one of the attractions of a doctor’s life. The politician is in the opposite case. His duty, and his whole hopeof success, lie in carrying as many others as possible with him: his individual judgement only becomes significant when allied to persuasion. He cannot, so to speak, prescribe medicine for a patient unless his Cabinet colleagues and the party agree, nor can he institute a course of treatment unless the majority votes for it. To sharpen the antithesis again, the politician practises the subordination of individual judgement, the doctor glories in the development and exercise of it.’
The doctor’s claim to the exercise of independent professional judgement cannot end at the frontier of the individual patient. It passes beyond to the setting in which the individual patient is treated and the organisation of the means and methods of treating him. The independence, and consequently the potential conflict, of judgement are expressed in relation to individual patients in the possibility of two patients being treated differently by two different doctors, even of assumedly equal knowledge and skill. In relation to the setting of medical treatment, it implies the possibility of different institutions and organisations for meeting an identical purpose in different ways.
Once this is perceived, the drama of Medicine and Politics on the stage of the hospital service begins to unfold. The further the passage of time enables me to stand back from the scene, the more I am convinced that it is not the rightness or wrongness of the policy decisions that have to be taken by the Minister of Health that exercises the anxiety of the profession, but the fact of the uniform application of those decisions, right or wrong. It is an instinct that hospital care and treatment, and therefore hospital organisation and building, ought somehow to be capable of evolving, like medical treatment as a whole, by diverse processes of trial and error, which will allow of different, inconsistent and even opposing modes being followed at the same time. This, as it seems to me in retrospect, was the demand of the profession, not consciously formulated and not, within a state service, fulfillable, which underlay so much of the debates on the Hospital Plan.
The demand is all the more strongly felt because there is no inherent reason in the nature and purpose of hospital treatment why it has to be organised on a single policy for a whole nation. The subordination of professional to lay judgement and the centralisation of that lay judgement is readily understood and accepted where the nature of the case manifestly requires it. It would occur to no one, for instance, that the armed forces might be a suitable field for the development and practice of alternative policies in different areas. The necessity of subordination and of unitary decision and policy-making goes without saying. Not so, where, as in the hospital service, there is no single aim that can be formulated, but where the whole activity is, and ought to be, the sum of individual and personal judgements, not orientated inwards to the centre but outwards to the individual patient.
SUBORDINATE AGENCIES
The administration of the hospital service through subordinate lay agencies of the Minister, the regional boards, boards of governors and hospital management committees, affords the appearance but not the reality of dispersed initiative and judgement.
These subordinate agents are a unique phenomenon, which is easily misjudged. I confess that before I had practical experience of them as Minister, I was preoccupied with the theoretical problem of their independence. In appearance, that independence is impressive. Though their members are appointed by the Minister, the boards are virtually irremovable except as the expiry of terms of office makes it possible gradually to change their composition. The management committees are appointed not by the Minister but by their respective regional boards, whose choice the Minister has no power, and so far as I know in practice makes no attempt, to influence. The members of the boards and committees are serving voluntarily and gratis and, so far at any rate as chairmen are concerned, make an exceptionally great sacrifice of time in doing so. The chairman of a regional board, for instance, who is normally a person with a big commercial or professional position in his own right, is likely to spend between a third and a half of his working time— and on occasions more— upon the business of the hospital service. Nor for those who seek partial compensation for their public work in terms of publicity or of honours would service on a hospital board or committee be the first choice.
Having thus great independence in the sense of being bound to the service and the Minister by no sort of formal or informal compulsion, the Minister’s agencies are not, on the other hand, publicly accountable. On any and every occasion they can argue that they are cramped and confined by the fiat of the Minister, whose agents they are. In theory therefore they appear to present a superb example of power without responsibility; and certainly if they ever set themselves to thwart a Minister and pursue an independent course, under the open or implied threat of resigning in a body, they could go far without their hand being called. In practice this danger does not materialise. The boards, often in the face of loud public clamour, have always loyally identified themselves with the policy of the Ministry, whatever representations they might privately have made against it. They themselves have not always been quite so unvaryingly supported by their subordinate hospital management committees. Even so, considering the numbers involved— there are on average about three times as many management committees per hospital board as there are hospital boards under the Minister— the exceptions have been remarkably rare. In effect, the boards and committees represent an administrative chain for the transmission of central policy and decision, all the more formidable for being in appearance bodies with an existence of their own and not merely a bureaucracy.
The interposition of the regional hospital boards between the hospital management committees and the Minister has even paradoxically had the effect of rendering centralisation more rigid. Although the hospital medical staff are in form the employees of the regional boards, it is with the hospitals and groups of hospitals where they work that they naturally identify themselves; and from that point of view the regional hospital board, interpreting and applying ministerial policy, often seems to them more remote, impervious and inaccessible than the Ministry itself. Hence the suggestion that rises irrepressibly ever and anon that the regional boards should be dispensed with and the hospital management committees brought into direct subordination to the Ministry, working through liaison officers or regional offices.
It does in fact from time to time happen that decisions taken by regional boards in implementation of Ministry policy fall to be reviewed or varied by the Ministry itself. Where this happens, the status of the regional board as a public body in its own right can cause difficulty in two ways. The decision to be reviewed has normally been taken by the board openly, so that any variation of it is automatically evidence of a difference between board and Ministry and lends itself to dramatisation as a victory over the board by the board’s opponents. Moreover, the Ministry will often have needed to make a separate and independent investigation of the factors underlying the decision, which, in turn, creates a sense of uncertainty, mistrust and duplication. Secondly, whether the board’s decision stands or not, its interpretation to those who will execute or be affected by it, is bound to be less flexible and convincing when between these and the fountain of policy there is an intermediate stage, and that stage a statutory authority.
AUTONOMOUS DEVELOPMENT IMPOSSIBLE
These are all features which make the impossibility of autonomous development within a state service more keenly felt.
It is a delusion, though an understandably favourite one, to suppose that these features could be eliminated by some modification of the financial control by which the administrative unity of the service is held together. For example, the hardy annual suggestion that management committees and boards could have the power of ‘carry-over’, so that underspending in one year, from whatever cause arising, would furnish the means of increased expenditure at discretion in the next or a subsequent year, will not stand up to examination. If, on the one hand, the underspending shows that the intended service could be rendered more economically than had been expected, that is no reason for concluding that an increased or additional service ought to be provided at that point rather than elsewhere. If, on the other hand, the underspending is involuntary, then to add the amount to the allocation for a subsequent period would mean one of two things: either a corresponding amount must be withdrawn from elsewhere or the total must be increased, neither of which consequences would be in any way justified by the fact of a previous estimate being underspent.
It is hopeless to attempt to escape from this impasse by assuming a block grant. Quite apart from the difficulties, already alluded to, of a block grant of public money which provides all, or virtually all, the resources for a service, no one arguing for a block grant would be prepared to agree to its remaining unmodified through a series of years, or even for its being reviewed and modified at longer than annual intervals. In practice, even the annual allocations have to be adjusted within the same year by the allocating authority. But a ‘block grant’ that is redetermined every year is an annual allocation; and so the argument has returned to its starting-point.
Budgetary control is of the essence of all management. It is pursuing a will-o’-the-wisp to look for ways of giving financial independence to the agencies of a nationwide state service.