Royal Commission on the NHS Chapter 22

Conclusions and Recommendations

22.1 In this Chapter we bring together our conclusions and recommendations, but we thought it would be helpful to put them in the context of a brief account of our main lines of work and thinking.

22.2 We should wish to emphasise first that we have tried always to relate our discussion, no matter what the topic, to the patient, his family and those serving them. Will our recommendations help the patient, and help those who serve him to do so more effectively?

22.3 We have tried to take the widest possible view of the NHS and to see it whole. We have also tried to view it not in isolation but in the context of the many links it has with other services and institutions. At no time have we thought that any other approach to our task would be useful, if indeed any other were possible, but this has the disadvantage that we have dealt only cursorily, and sometimes perhaps even superficially, with important topics. Our work can therefore be regarded only as a beginning. It is not for us to say whether it is good or bad, and it must now be put to the refining fire of public discussion. But we hope that even in those areas where we have necessarily had to work sketchily those who will be discussing this report will at least have no trouble in seeing which way we are pointing.

22.4 We are all too conscious that our report will be disappointing to those who have been looking to us for some blinding revelation which would transform the NHS. Leaving to one side our own capacity for revelation of this kind, we must say as clearly as we can that the NHS is not suffering from a mortal disease susceptible only to heroic surgery. Already the NHS has achieved a great deal and embodies aspirations and ideals of great value. The advances to be made – and which undoubtedly will be made – will be brought about by constant application and vigilance.

22.5 In this connection we should like to quote the wise words of the late Sir Richard Clarke who was Second Secretary at the Treasury when he spoke in 1964 about the management of public expenditure in the following terms:

“In the dispersed services such as education and hospitals. . . units of administration are small, and their performance must be uneven. It is difficult to form a judgement about how efficient those relatively small independent units are, and how much scope there may be for saving, and by what management techniques and services this potential saving can be realised – without of course endangering the quality of local responsibility and flexibility to local circumstances which is fundamental to these services. ”

22.6 Sir Richard continued:

“Altogether, there is clearly no room for complacency. But it would seem difficult to argue that there is widespread inadequacy; or to point to substantial improvements which could be made readily. To improve performance is a long slogging job. ” (Sir Richard, Clarke, “The Management of the Public Sector of the National Economy,” Public Expenditure Management and Control: the Development of the Public Expenditure Survey Committee (PESC). (editor Sir Alec Cairncross), London, Macmillan, 1978.)

The NHS has come a long way since 1964 but if we had to sum up our general view of the present-day NHS we could think of no better words to use than those we have just quoted.

22.7 The NHS reflects the society around it – both society’s aspirations towards good health and its careless attitudes towards bad health. Then again, the NHS mirrors, and always will, not only the imperfect nature of medical science but the diffuse and ill-defined understanding we have of our own health, whether good or bad. It would be comforting to think that one day we shall be able to mend broken minds as effectively as we can broken limbs, but we know that that must be a very distant prospect.

22.8 It follows therefore that, within its large and complex framework, the NHS must be sensitive always to the individual voice and its cry for help. It must never lapse into insularity or complacency. It should always strive for improvement and be open to new ideas and influences, rewarding initiative and leadership wherever they may be found.

22.9 We now summarise our conclusions and recommendations. We should warn the reader that what follows is a very brief summary of often detailed and complex material which is dealt with in the earlier chapters of the report.

Part 1 A Perspective of the Nation’s Health and Health Care

22.10 We started this part of our report with a statement of what we felt should be the objectives of the NHS. We believed the NHS should:

  • encourage and assist individuals to remain healthy;
  • provide equality of entitlement to health services;
  • provide a broad range of services of a high standard;
  • provide equality of access to these services;
  • provide a service free at the time of use;
  • satisfy the reasonable expectations of its users;
  • remain a national service responsive to local needs.

22.11 We then looked at how good the service is now. We concluded that we need not be ashamed of our health service and that there were many aspects of it of which we can be justly proud. However, social and geographical inequalities and variations in the provision of resources persist. Although the NHS by itself cannot overcome these problems, they must remain a cause for concern and areas in which the performance of the service can be improved. In spite of the problems of measuring efficiency in health care we were convinced that, apart from improvements which may be achieved through the use of more resources, the NHS can provide a better service by making better use of the resources now available to it.

22.12 We went on to summarise some of the major failures of the NHS and remedies to correct them which had been put to us in evidence. For the most part we discuss these in detail in the main body of our report, and we shall not summarise them all here. We did, however, discuss in some detail in Chapter 4 allegations about the swollen numbers of administrators in the service, including administrative nurses. We found that the figures for nurses administrators did not support the allegation that the Salmon Committee’s recommendations had increased the proportion of nurses in the grades above ward sister. In England there had been an increase of about 28% in numbers of administrative and clerical staff between 1973 and 1977, but the causes of this were not clear, and there was in any case no way of establishing the “right” number of administrators. Some of the expansion in numbers would have occurred whether or not NHS reorganisation had taken place. We formed an encouraging view of how well many administrators had coped with the real difficulties caused by reorganisation, and we rejected criticism of them as a group. We considered, nonetheless, that there was much that could be done to make their work more effective, including improving standards of recruitment.

Part 11 Services to Patients

  1. 13 We began this part of Our report with an identification of the four categories or gradations of care which an individual may need. They were:
  • the care which a healthy person will exercise for himself so that he remains healthy;
  • the self-care which the slightly ill person will exercise which may involve medication and treatment;
  • the care provided by the person’s family and by the health and personal social services outside hospital;
  • the care which can only be provided in hospital or other residential institution.

These categories merge into each other and the administration of health services must not create barriers between them. The chapters which form this part of our report follow the path of these gradations of care, and end with a discussion of the influence of the consumer on health services.

Good health

22.14 We concluded in Chapter 5 that preventive measures were by no means the exclusive responsibility of the NHS, but that a significant improvement in the health of the people of the UK could come through prevention. We considered that there were major areas where government action could produce rapid and certain results: a much tougher attitude towards smoking, towards preventing road accidents and mitigating their results, a clear commitment to fluoridation and a programme to combat alcoholism, were among the more obvious examples. But such action had to be matched by other measures. We saw a need for more emphasis on health education and the development and monitoring of its techniques, for greater involvement of GPs and other health professionals, and for better in-service training for teachers in health education. The imaginative use of radio and television would be important. We felt that much more could be done to emphasise the positive virtues of health and the risks of an unhealthy life style, and that this should include environmental and occupational hazards as well as personal behaviour. We were concerned that local authorities should not let standards of environmental health slip. We considered that the NHS needed to face its responsibilities in prevention.

22.15 Occupational health and safety is not a responsibility of the NHS at present, though some evidence we received suggested it should become so. This is a complicated field and one which in many respects has little to do with the central functions of the NHS.


22.16 In Chapter 6 we considered how priorities in the NHS were set and implemented. The present national priorities were services for the elderly, the mentally ill and mentally handicapped, and children, and the emphasis was on community care. These priorities were not the result of objective analysis but of subjective judgment. Our own view was that they were broadly correct at the present time, but that they were certainly not the only choices. We thought it important to recognise that national priorities emerge from a variety of conflicting views and pressures expressed in Parliament, by the health professions and various patient or client pressure groups amongst others; and that so far as possible discussion which led to the establishment of priorities should be conducted in public and illuminated by fact.

22.17 We found other problems in implementing priorities. There were considerable practical difficulties to be overcome in shifting resources from one patient or client group to another, or in favouring one part of the NHS against others, particularly when funds were short. We could not yet tell how far the NHS planning system introduced after NHS reorganisation would turn out to be an effective mechanism for this purpose, but we were sure that national priorities could be uniformly applied only to a limited extent. Some of the difficulties were to be seen in the efforts to promote community care, and unless additional resources were made available progress would be slow.

22.18 Services for the elderly would make increasing demands on health and local authorities for the rest of this century. We were concerned that without greater shifts in resources than were yet evident neither health nor local authority services would be able to cope with the immense burden these demands would impose. Inevitably the community as a whole would have to share the responsibility and costs. of caring for the elderly at home with appropriate support from the health and personal social services. We noted that the health departments were already tackling the implications and integrated planning was essential in our view. It was clear to us that in the NHS the burden of caring for infirm old people would fall mainly on nurses, and that efforts must be made to encourage them in undertaking this work.

22.19 We dealt with hospital provision for the mentally ill and mentally handicapped in Chapter 10, but in the context of priorities we noted that most problems with a psychiatric aspect were first identified by GPs. It was clear to us that many GPs would benefit from more training in this part of their work. We doubted whether medical care for the elderly and mentally handicapped was best organised on the basis of separate specialties. Other doctors should be involved in the care of these patients, and we saw the development of special interests by doctors in related specialties as being a promising way of achieving this.

22.20 We noted that the Court Committee had recently looked in depth at services for children, and we did not consider it necessary to go over that ground again in detail, but, like others, we had doubts about the wisdom of introducing new specialist staff into this field. Finally, we welcomed recent developments in services for the deaf, and would like to see improved services for the partially sighted.

Primary care services

22.21 In Chapter 7 we noted that changes in the structure of the population and in health care priorities would mean that the demand on and for general practitioner, nursing and related services in the community would increase during the next decade. We found that those services were generally provided to a good standard at present but improvements were needed in a number of directions. The development of the primary health care team was encouraging, but there was a continuing need to encourage closer working relationships and teamwork between the professions who provided care for the community. District nurses and health visitors would have a particularly important part to play. We heard of a number of promising developments in improving the quality of general practice, but we thought that more needed to be done to improve the training and continuing education of GPs. Improvement of the standard of existing premises was required and so were more health centres. In our view better training was needed for receptionists, deputising services should be brought under closer control, and more research was needed into a number of aspects of community services.

22.22 We understood that to a large extent GPs could control their own prescribing costs but had little incentive to keep them down and they were subject to pressures from pharmaceutical companies and patients to prescribe expensively and often ineffectively. We thought that a more radical approach to this problem was required.

22.23 We concluded that the major challenge to community services was the provision of services in declining urban areas. The health needs of patients who live in these areas were complex, and the health departments alone could not provide all the answers. A much more flexible and innovative approach to improving the services in them seemed to us to be needed.

Pharmaceutical, ophthalmic and chiropody services

22.24 In Chapter 8 we identified the main problems in the pharmaceutical services as a falling number of pharmacies and the erosion of the pharmacist’s traditional role with the development of modern packaging of medicines. While surveys had suggested that access to a pharmacy was not yet a serious problem for many people, we thought it might well become so in the future. Pharmacists would continue to have an important role since the use of potent drugs in medicine had increased substantially. We did not consider that they should develop a quasi-medical role, and we thought that their expertise could most usefully be employed in advising doctors on prescribing matters, and the public on self-medication.

22.25 The complaints about the general ophthalmic service were mainly lack of information about NHS treatment and spectacle frames. We noted that the optician had a financial interest in encouraging patients to buy non NHS frames, but we saw no reason why he should not be required also to display NHS frames and the prices of both NHS and non-NHS items.

22.26 The NHS does not attempt to provide a comprehensive chiropody service. We found that within the NHS, chiropody was mainly provided to the elderly, but there were shortages of qualified chiropodists prepared to undertake the work. One reason for this was a shortage of training facilities for chiropodists: another was the attractions of the private sector in which most chiropodists work at present. We considered that the health departments should promote the introduction of foot hygienists.


22.27 We were in no doubt that dental health in the UK had improved since 1948, but the prevalence of dental disease remains at an unacceptably high level. The NHS should strive for the highest standard of care. We recommended a number of detailed changes which should, if implemented, improve the quality of service offered to patients and the efficiency of the present system.

22.28 The prevention policies which we recommended for the future offer a real and attainable improvement – perhaps unique – in public health. It was clear that a determined swing of policy towards a greater emphasis on prevention was needed. The most immediate requirements were for the full implementation of water fluoridation and for the funding of research on prevention and dental health education and the training and employment of more ancillary workers. Individual preventive work should be carried out by the general dental service and a way found for providing fees for treatment of this kind.

22.29 We thought that while these policies would require time to implement and would not bring changes overnight, their effect on the numbers, composition and training of the dental team would be profound. The appointment of the Nuffield enquiry into dental education, referred to at the start of Chapter 9, was, therefore, timely. Because NHS dentistry was likely to change significantly we recommended that a small committee representing government and other interested parties should be set up to review the development of dental health policy and in particular a preventive strategy and the future functions of the community dental service. Its purpose would be to ensure that the impetus for improvement was not lost. Its starting point could be this report and that of the Nuffield Committee.

Hospital services

22.30 We remarked in Chapter 10 that most patients were well satisfied with the treatment they received in NHS hospitals, as they were with other parts of the service, but that there were two grumbles which were both frequent and long-standing. Patients were not given enough information about their treatment, and despite constant complaints over the years they might still feel that they were ignored when doctors discussed them with colleagues. We were also sorry to learn that hospitals persisted in waking patients at the crack of dawn.

22.31 We did not hear a great deal about waiting lists in our evidence, and our OPCS survey found that most patients were not caused great distress by waiting for admission to hospital. The significance of waiting lists had certainly been exaggerated, partly for political reasons, and it was waiting times which should in any case attract attention. The DHSS had commissioned a large scale study on the subject and this might throw more light on the matter.

22.32 We had no quarrel with the district general hospital (DGH) approach to providing specialist services, though flexibility was plainly-required. We thought that the “nucleus hospital” approach was sensible. There was still dispute over the best use of the many small hospitals which were not part of the DGH. It was clear that the community hospital approach was not acceptable and we were relieved to hear that the DHSS were rethinking the present policy. We thought there was plenty of room for experiment in this as in so many other parts of the NHS, and we would deplore too rigid an approach. The development of nursing homes could make a major contribution to the care of the elderly.

22.33 We found that acute hospital services were generally excellent. Most of them were provided by peripheral non-teaching hospitals, often in old buildings and ungenerously staffed. We hoped that our recommendations would improve the position of both those who used them and those who worked in them.

22.34 We thought the mental illness hospitals needed to be rescued. Despite the statement in the DHSS Consultative Document on Priorities, there was a widely held view that the specialist mental hospitals were to disappear. We could find no sign of the nation being able to dispense with them in the foreseeable future. The development of acute psychiatric units in DGHs, itself admirable, had tended to leave the mental illness hospitals with the chronic and most difficult patients. They needed to be clearly reassured about their future, to be integrated fully into a unified psychiatric service, and to receive .a proper share of capital monies.

22.35 Finally, we concluded that communications between the hospital and the community services were not all that they should be, and that the arrangements for community workers to work in hospitals, and hospital workers in the community needed to be improved. Strong links were particularly important in the rehabilitation services.

The NHS and the public

22.36 We noted in Chapter 11 that since their introduction at reorganisation, community health councils (CHCs) had made an important contribution towards ensuring that local public opinion was represented to health service management. We felt they needed additional resources to fulfil this task more effectively, and further guidance from the health departments on their role.

22.37 We thought it very important that patients should be able to make suggestions for improving health services. Those who have complaints about the way the NHS has treated them or their relatives should also be able to make them through a simple, fair and effective mechanism. The changes in procedures which we discussed were likely to improve matters considerably.

22.38 We found that the contribution made by the public, voluntary bodies and volunteers was of major benefit to the service. It should be encouraged. The development of informal patient committees was a constructive way of bringing patient views to bear on the provision of neighbourhood primary care services.

Recommendations on services to patients

(1) Proven screening programmes should be expanded (paragraph 5.7);

(2) the wearing of seat belts should be made compulsory for drivers and front seat passengers in motor vehicles (paragraph 5.12);

(3) health education should be expanded, but some of the increased resources must be spent on developing more effective methods and on monitoring and validating existing and new techniques (paragraph 5.14);

(4) education authorities should examine seriously existing arrangements for health education in schools (paragraph 5.15).;

(5) health education should be emphasised in the forward planning of health authorities (paragraph 5.17);

(6) funds for the Health Education Council and the corresponding bodies in Scotland should be increased to allow them to make more use of television (paragraph 5.21);

(7) the health departments should make public more of the professional advice on which policies and priorities are based (paragraph 6.7);

(8) all professions concerned with the care of the elderly should receive more training in understanding their needs (paragraph 6.34);

(9) further experiments in different ways of meeting the needs of elderly and other patients requiring long-term care should be undertaken urgently (paragraph 6.37);

(10) the legal position regarding responsibility in the use of deputising services in Scotland should be brought into line with that elsewhere in the UK (paragraph 7.8);

(11) health authorities should keep under review the operation of the deputising services in their areas and, if they are unsatisfactory, improve or replace them (paragraph 7.10);

(12) where this does not happen already, the full costs of attendance of GPs receptionists at training Courses should be met by the family practitioner committee or health authority concerned (paragraph 7.12);

(13) before a maximum or minimum list size is adopted, considerable research on an optimum range of list sizes should be undertaken (paragraph 7.16);

(14) there should be a review of the controls on the appointment of GPs exercised by the Medical Practices Committees (paragraphs 7.17 and 7.30);

(15) the health departments should consider offering an assisted voluntary retirement scheme to GPs with small lists who have reached 65 years of age (paragraph 7.18);

(16) the health departments should discuss with the medical profession the feasibility of introducing a compulsory retirement age for GPs (paragraph 7.18)

(17) the health departments should continue their current plans for the expansion of community nursing (paragraph 7.22);

(18) research is required into a number of aspects of primary care (paragraphs 7.27 and 7.34);

(19) national or regional panels should be set up to provide external assessors for each new appointment of a principal in general practice (paragraph 7.30);

(20) GPs should make local arrangements specifically to facilitate audit of the services they provide and the health departments should check progress with these developments (paragraph 7.32);

(21) the introduction of the A4 records system in general practice should be given high priority (paragraph 7.33);

(22) FPCs and health authorities should use vigorously their powers to ensure that patients are seen by their GPs in surgeries of an acceptable standard (paragraph 7.35);

(23) the British National Formulary should be re-issued soon in portable, loose-leaf form with separate information on drug costs, and be kept up-to-date (paragraph 7.40);

(24) the health departments should introduce a limited list of drugs as soon as possible and take further steps to encourage, generic prescribing (paragraph 7.46);

(25) the health departments should consider whether high running costs are acting as a significant disincentive to GPs to work in health centres (paragraph 7.50);

(26) the health departments should consider urgently measures to assist the development as a priority of health centres or other suitable premises to attract GPs to London and other inner city areas where sites are particularly expensive or difficult to obtain (paragraph 7.51);

(27) health authorities when establishing health centres in inner city and deprived urban areas, should experiment with offering salaried appointments and reduced list sizes to attract groups of doctors to work in them (paragraph 7.59);

(28) additional financial resources should be provided to improve the quality of primary care services in declining urban areas (paragraph 7.63);

(29) the establishment of pharmacies in health centres should be encouraged (paragraph 8.15);

(30) charges for NHS and non-NHS items and details of eligibility should be prominently displayed and publicised by opticians (paragraph 8.20);

(31) serious consideration should be given to widening the range of items which can be prescribed and dispensed under the general ophthalmic services (paragraph 8.21);

(32) more chiropody training places should be provided and services to the elderly in the community increased (paragraph 8.26);

(33) until the implications of a shift in policy towards prevention have been identified dental student entry numbers should not be altered but flexibility in meeting demands should be achieved through the increased use of dental ancillary workers (paragraph 9.18);

(34) the dental profession and government should experiment with alternative methods of paying general dental practitioners in addition to a capitation system for children (paragraph 9.23);

(35) the dental profession and government should make rapid progress to the introduction generally of an out-of-hours treatment scheme (paragraph 9.25);

(36) dental care for long-stay hospital patients should be as readily available as it is for men and women in the community (paragraph 9.33);

(37) dental teaching hospitals should be funded directly by region or health department (paragraph 9.35);

(38) the present technical college/dental hospital training schemes for dental technicians should be expanded (paragraph 9.42);

(39) a standardised national basis for the collection of dental data should be introduced (paragraph 9.46);

(40) manpower in the community dental service should be increased (paragraph 9.51);

(41) the Scottish system for recording all information about the dental treatment of children in the same way should be adopted in the rest of the UK (paragraph 9.52);

(42) the availability of dental services to the handicapped should be further improved by the payment of fees authorised on a discretionary basis by the dental estimates boards (paragraph 9.53);

(43) the government should introduce legislation to compel water authorities to fluoridate water supplies at the request of health authorities (paragraph 9.60);

(44) the health departments should pursue an active policy in restricting advertising which may lead to undesirable dietary habits, particularly in children (paragraph 9.68);

(45) the dental profession should consider ways of overcoming the problems of long term clinical research in dentistry (paragraph 9.71);

(46) a small committee representing government and the other interested parties should be set up to review the development of dental health policy (paragraphs 9.18, 9.31 and 9.74);

(47) the health departments should promote more research both on the acceptability of day admissions to patients, and on the benefits to the NHS (paragraph 10.19);

(48) all hospitals should provide facilities for patients and relatives to be seen in private (paragraph 10.28);

(49) all hospitals should provide explanatory booklets for patients before they come into hospital (paragraph 10.29);

(50) hospitals should ensure that the availability of amenity beds is routinely made known to patients when they are given a date for admission (paragraph 10.34);

(51) health authorities should review forthwith wakening times for patients in the hospitals for which they are responsible (paragraph 10.38);

(52) the health departments should now state categorically that they no longer expect health authorities to close mental illness hospitals unless they are very isolated, in very bad repair or are obviously redundant due to major shifts of population (paragraph 10.60);

(53) the government should find extra funds to permit much more rapid replacement of hospital buildings than has so far been possible and they should stick to their plans (paragraph 10.74);

(54) community health councils should have right of access to family practitioner committee meetings and their equivalent in Scotland and Northern Ireland. If FPCs are abolished as we propose in Chapter 20, CHCs should have access to the committees which take over their functions (paragraph 11.9);

(55) CHCs should be given more resources to enable them to inform the public fully about local services (paragraph 11.10);

(56) more resources should be made available where necessary to allow CHCs to act as the “patient’s friend” in complaints procedures (paragraphs 11.25 and 11.26);

(57) health departments and health authorities should continue to give financial support and to encourage voluntary effort in the NHS (paragraph 11.32);

(58) financial support should be given to encourage the setting up of patient committees in general practice (paragraph 11.34).

Part III The NHS and its workers

22.39 In this part of the report we dealt in the main with matters which concern directly those who work in the NHS. We dealt successively with general manpower matters; nurses, midwives and health visitors; doctors; and ambulance, ancillary, professional, scientific and technical, works and maintenance staff.

General manpower matters

22.40 We began Chapter 12 by considering the morale of workers in the NHS. We were told by many people that morale was low, but we saw this as a symptom rather than an underlying or constitutional disorder. We made no recommendations about morale itself, but we hoped that the recommendations we made in this chapter and elsewhere in the report would lead to improvement.

22.41 We were in no doubt that industrial relations in the NHS were in need of improvement. At local level adequate machinery and staff were often lacking and it was clear that urgent action was needed. We welcomed the proposals for procedures to deal speedily with local disputes which had been put to the General Whitley Council, and we hoped that they could soon be introduced. We also welcomed the survey into industrial relations in the health and personal social services which was being undertaken in Northern Ireland. We found no single solution to the problem of industrial action in the NHS, but we hoped that better local procedures would help to eliminate local disputes of the kind which had plagued the service in recent years.

22.42 We were aware that the pay of NHS workers was a major cause of dispute at national level. The Whitley Council system had a number of faults: in particular, its sometimes cumbersome procedures might lead to excessive delays in reaching new agreements. We hoped that Lord McCarthy’s review would lead to improvements. It seemed to us that as pay negotiating bodies, the Whitley Councils were weakened by being insufficiently independent of government. This meant that pay disputes might have to be resolved in some other forum.

22.43 We thought it essential that a procedure should be worked out for resolving national disputes about pay. This would involve a review of existing pay arrangements, including the role of the Whitley Councils. It would take time and patience. We thought the initiative could best come from the TUC, and that in due course proposals should be put to the Secretaries of State and the NHS management interests.

22.44 We observed that the changing character of health care required flexibility in the roles of those working in the NHS, but that responsibilities and duties should be clear. We noted that in certain circumstances the two might pull in opposite directions, and that multi-disciplinary working brought out some of the difficulties. Another aspect was the need to assess the quality of the treatment and care provided by NHS workers: this could best be undertaken by the professions themselves, but the health departments should ensure that adequate progress was made. We considered whether it would be possible to lay down staff norms to forecast needs and deficiencies, and eliminate shortages. We concluded that the needs and resources of different parts of the UK varied so greatly that centralised planning for all NHS staff would be wholly impracticable. Recruitment decisions should, for the most part, be made locally in the light of local needs within an overall policy, but an exception to this was medical and dental manpower both because it took ten years or more to expand facilities for training doctors and dentists, and because of the extent of the involvement of the universities. We considered that in all cases staff interests needed to be consulted and that the health departments should ensure that the machinery for this was adequate.

22.45 Finally, we considered that the NHS should assume the same responsibility as any other employer for the health and safety of its staff.

Nurses, midwives and health visitors

22.46 We remarked that it would be difficult to over-estimate the importance of nursing services in the NHS. We were conscious that nurses were the most numerous and the most costly group of health workers, but more important was the close relationship they had with patients. We were therefore disturbed by criticisms of standards of care made by the Royal College of Nursing and referred to in our evidence.

22.47 Our whole approach to the questions discussed in Chapter 13 was coloured by the report of the Briggs Committee. The Committee dealt with matters which we would otherwise have had to discuss. We were disappointed that more progress had not been made with implementing their recommendations. We understood that there had been disagreement in the profession over some aspects of the Committee’s Report, and, like many other desirable reforms, that the follow-up work on the report had been held up by NHS reorganisation. In particular, we noted that little progress had been made on the clear recommendation, which we endorsed, for more nurse teachers. However, we greeted the Nurses, Midwives and Health Visitors Act 1979, which set up the new statutory educational bodies as a welcome, if long awaited, development.

22.48 We were aware that the profession was going through a difficult period. It had suffered major structural changes following the Salmon and Mayston Reports and was considerably influenced by the management changes introduced at reorganisation. Nurse administrators fulfil a necessary function but to do their jobs properly needed adequate supporting staff. It was evident that the role of the nurse was varied and was being further extended and expanded by, for example, research into the caring function of the nurse, and development of specialisation. We found a need to improve the clinical career structure, and to encourage flexibility in the way nurses worked.

22.49 Developments in nurse education had been delayed pending the new statutory bodies. We concluded that the Central Council for Nursing, Midwifery and Health Visiting would need to review both basic and post-basic education. Linked to this we saw a need to develop the research capacity of the profession.


22.50 We started Chapter 14 with a brief look at the role of doctors. It was clear that what doctors did underlay many of the other problems referred to, particularly the question of how many doctors the community should be training. We found this was an extremely complex matter, but it seemed to us that it would be a mistake to cut back the planned output of medical graduates from UK universities at a time when there were shortages in some specialties and many places and more doctors were likely to be needed in future.

22.51 We gave special attention to certain groups of doctors with special problems. We were concerned that the interests of overseas doctors who had made a valuable contribution to the NHS should not be overlooked. Many of them were established residents in the UK. We thought it particularly important that doctors coming here from overseas should be made aware of the career prospects and standards required. Proper provision needed also to be made for the post-graduate education of women doctors who were coming out of the medical schools in increasing numbers. We thought that Joint Higher Training Committees should look carefully at their policies. Community physicians were another group with problems. It was evident that the specialty needed to be supported in the next few years if it were to survive. This would mean both imaginative recruitment policies and the willingness of health authorities to provide the supporting staff necessary. Those working in universities could be encouraged to have a service commitment in the NHS.

22.52 We did not like the new contracts negotiated for hospital doctors. They seemed to us to be inappropriate to a leading profession and ultimately contrary to the interests of the patients. We did not regard the proposed new contract for GPs with any more enthusiasm. On the other hand we thought that the importance of the relationship between GPs and NHS, the contractor status was exaggerated. We considered that a salary option should be introduced for those GPs whose circumstances required it, but we did not propose that all GPs should be salaried. It seemed to us that the present career structure for hospital doctors had obvious defects. We feared that the current strategy would yield results too slowly and we set out an alternative approach in Appendix I. One aspect of the hospital career structure was the distinction awards system where we welcomed relaxation of secrecy and a shift of emphasis towards rewarding those consultants who deserved most of the NHS.

Ambulance, ancillary, professional, scientific and technical, works and maintenance staff

22.53 We noted that the Professions Supplementary to Medicine Act 1960 had established elaborate registration machinery for eight professions, the vast majority of whose members were employed in the NHS. It had been criticised as leaving too much power in the hands of professional bodies so that desirable developments, such as integrated training for some of the professions, had been blocked. We thought it time that the machinery set up by the Act was reviewed.

22.54 Scientific and technical staff had been considered by the Zuckerman Committee who published their report in 1968 . We understood that its main recommendations, though accepted in principle by the government, had not been implemented, partly because NHS reorganisation had interfered with the structural proposals, and partly because of the difficulties in negotiating the necessary staffing arrangements. We were told that the health departments were considering the best way forward and we supported their general strategy. However, much of our evidence on these services had been about who should head and manage laboratories, and we did not think that the solution suggested by the DHSS of dividing the managerial responsibilities was realistic. We considered that the best available scientist should be appointed as head; the possession of a medical qualification would be an advantage when there were two candidates of equal ability. We considered that moves towards the establishment of a National Scientific Council, proposed by the Zuckerman Committee, should be encouraged.

22.55 We had received comparatively little evidence about the other groups of staff considered in Chapter 15 and we did not feel justified in proposing major changes. We suggested experimenting with ways of providing an ambulance service and we thought it important that more effort should be put into providing induction training for ancillary staff. Works officers were a new group, formed at reorganisation, and we concluded that it would be important to keep the framework within which they operated under review. They were essential to the success of the accelerated building programme which we proposed in Chapter 10.

Recommendations on the NHS and its workers

(59) the health departments and staff organisations and unions should give urgent attention to industrial relations training for both staff representatives and management (paragraph 12.11);

(60) the TUC should take the necessary steps in initiating discussions on a procedure for dealing with national disputes in the NHS which must involve not only those bodies’ affiliated to the TUC but bodies representing the interests of other NHS workers as well (paragraph 12.24);

(61) the health departments should intervene on those occasions when the health professions cannot reach agreement on staff roles (paragraph 12.43);

(62) the Joint Higher Training Committees for post-graduate medical education should approve only those units and departments where an accepted method of evaluating care has been instituted (paragraph 12.54);

(63) a planned programme for the introduction of audit or peer review of standards of care and treatment should be set up for the health professions by their professional bodies and progress monitored by the health departments (paragraph 12.56);

(64) the health departments should undertake, approximately every two years, a review of the medical manpower position, following open and public discussion and supported by better data than has so far been available (paragraph 12.63);

(65) experiments with different mixes of staff in different contexts, and the development of inter-professional training should be encouraged (paragraph 12.65);

(66) the NHS should assume the same responsibility as any other employer for the health and safety of its staff and set up an occupational health service (paragraph 12.67);

(67) the profession and the health departments should encourage and pursue experiments in the development of the nursing role (paragraph 13.23);

(68) research is required into the effect of the use of unqualified nursing staff on patient care and into the best composition of the ward team in different settings (paragraph 13.29);

(69) the health departments should undertake such central manpower planning as is necessary, that is develop a national recruitment policy, assist the setting of standards and objectives, propagate good practice and ensure an adequate data base which will be of considerable importance to the new statutory educational bodies (paragraph 13.31);

(70) the clinical role of the nursing officer should be developed along the lines envisaged by the Salmon Committee (paragraph 13.40);

(71) the development of specialist knowledge and nursing skills both in the community and hospital should be encouraged (paragraph 13.42);

(72) health authorities should establish budgets and develop programmes of post-basic nursing education for their staff (paragraph 13.52);

(73) developments of joint appointments between schools of nursing and the service should be vigorously pursued (paragraph 13.55);

(74) the health departments should show more determination in enforcing their priorities in the medical staff shortage specialities, if necessary by blocking expansion of other specialities, and should be more critically involved in the development of new specialities (paragraph 14.32);

(75) the development of special interests in shortage specialities amongst doctors working in related fields should be encouraged and appropriate training programmes provided (paragraph 14.33);

(76) the UK government should take the necessary steps to make clear to doctors who want to come to the UK what their prospects here are (paragraph 14.41);

(77) a few post-graduate centres to provide medical education and training specifically geared to the needs of overseas countries should be started on an experimental basis (paragraph 14.42);

(78) community physicians should be given adequate supporting staff (paragraph 14.56);

(79) a salary option should be introduced and open to any GP who prefers it (paragraph 14.82);

(80) there should be an independent review of the machinery set up by the Professions Supplementary to Medicine Act 1960. It should include manpower and training needs of the professions (paragraph 15.7);

(81) the health departments should continue their efforts to generate more research into the work of speech therapists, occupational therapists, physiotherapists and remedial gymnasts (paragraph 15.12);

(82) staff in senior posts in the scientific and technical services should normally be science graduates (paragraph 15.20);

(83) pilot experiments should be carried out in providing a regional scientific service for one or more laboratory specialities (paragraph 15.21);

(84) the head of a laboratory should be the most able scientist available (paragraph 15.31);

(85) in one or two instances the accident and emergency ambulance service should be organised experimentally on a regional basis with “community transport services” being provided by the lower tier NHS authorities; and the results closely monitored (paragraph 15.41);

(86) health authorities should ensure that adequate induction training (including access to language courses where appropriate) is available for ancillary staff (paragraph 15.47);

(87) the works staffing structure should be kept under review by the health departments, as should the numbers and training of craftsmen (paragraph 15.53).

Part IV The NHS and other institutions

22.56 In this part of the report we looked at the important links which the NHS has with services and institutions outside it. We dealt successively with the NHS and local authorities; the relationship between the NHS and universities, particularly so far as education and research are concerned; and finally with the relationship between the NHS and private practice.

The NHS and local authorities

22.57 In our view there was no doubting the importance of effective collaboration between health and local authority services. We found that while eventually the integration of these services might become possible, there was little in the present administrative arrangements to prevent or even hamper such collaboration, though its success depended on the attitude of the parties to it. If there was determination on both sides to work together many of the problems could be solved. If, however, authorities or professions were at loggerheads, coterminous boundaries, overlapping membership and joint committees would be ineffective. Post-reorganisation experience had showed that effective collaboration required that those involved should have appropriate training and sufficient authority within their own organisations to carry out the task which was to be performed jointly. Continuity in post of the personnel involved was particularly important.

22.58 It was clear from our evidence that the relationships between health and local authorities ranged from indifferent to excellent. It was hardly surprising to find this variation, given the different circumstances in which the new authorities found themselves when the new services were introduced. We considered, however, that the changes which we recommended in Chapter 20 to the local management of the NHS would greatly improve working relationships. This improvement would be assisted if there were more emphasis on the education and continuing training of health and social work professionals on the importance of inter-professional collaboration. The joint report of the Personal Social Services Council and the Central Health Services Council on collaboration had identified such training carried out jointly, and better communication, the development of multi-disciplinary working and the development of agreed procedures as ways in which better collaboration could be achieved at field level. Good working relationships were clearly of the essence. We endorsed this approach a we identified a number of requirements for effective collaboration and planning at all levels.

22.59 We did not recommend radical changes in the responsibility for either the health or the personal social services in Chapter 16. The evidence we had received tended to divide according to the interest of the organisation concerned: local authorities often argued for local government control of the NHS, and health authorities advocated the absorption by the NHS of the social work services. We were also doubtful of the benefits which might arise from an allocation of responsibility for patient and client groups. It was obvious that no radical solution would command general support, but in any case we did not think changes of this kind were necessary at present simply to achieve better collaboration between the NHS and local authorities. Joint administration of health and local authority services might become feasible if regional government were introduced in England. We considered that if such a change reached the political agenda in the next 20 years, joint administration of health and local authority services would merit serious consideration.

The NHS, the universities and research

22.60 We noted in Chapter 17 that the arrangements that existed for consultation between the NHS and the universities had been disturbed by NHS reorganisation. The transfer of responsibility from boards of governors with direct access to the health ministers to area health authorities would have given rise to difficulty at any time until the new arrangements had down, but had been made much more difficult by the financial pressures on the NHS. We considered that both parties would have to work at getting the new relationship going properly: on the NHS side this would mean making sure that universities were properly consulted on matters which affected them, and on the university side it might mean that the Vice-Chancellor (or Principal) or Dean of the Medical School had to be personally involved. We were doubtful whether consultation arrangements at national level between educational and health interests were adequate.

22.61 We thought it likely that teaching hospitals would have found themselves under financial pressure even if NHS reorganisation had not occurred because of the general pressure on NHS resources since 1974. We observed a conflict between the short-term needs of the NHS and the importance of providing for the future. The teaching hospitals felt themselves exposed to the pressures of keeping the NHS going, but this would have had to be faced whatever the financing arrangements. We strongly supported centres of excellence, but we thought that the teaching hospitals would in the long run gain through their closer integration into the NHS. We observed that it was a difficult time for the teaching hospitals, but the example of Scotland should offer some encouragement. Another aspect of the financial pressures was the tendency for both university and NHS to start counting the cost of services provided to the other. We considered that this was a profitless occupation since the funds being argued over came from the Exchequer in any case, and the loss of flexibility, not to mention the complexities of computation, would merely make for future difficulties.

22.62 Although there had been criticisms of undergraduate medical education this was not an area into which we went in detail. The curriculum had been criticised on the grounds that it was not as relevant as it should have been to the work of doctors in the NHS, and the selection of medical students had been criticised on the grounds that universities relied too much on academic performance and too little on other evidence of suitability. We thought there was room for development in both these areas.

22.63 Biomedical and clinical research were, we found, adequately catered for by the existing agencies, particularly the Medical Research Council. We considered, however, that health services research needed to be developed.

The NHS and private practice

22.64 We were concerned in Chapter 18 with private practice only in so far as it affected the NHS. We concentrated on the facts so far as they were known. Information to enable us to reach precise conclusions about the relationship between the NHS and private practice was lacking, but it was clear to us that the private sector was too small to make a significant impact on the NHS, except locally and temporarily. On the other hand, we felt that the private sector probably responded much more directly to patients’ demands for services than the NHS, and provided a useful pointer to areas where the NHS was defective. One such was clearly the provision of abortion services: half the abortions performed on residents of the UK were undertaken privately. Another was the provision of nursing homes for the elderly; and patients waiting for cold surgery in the NHS might opt to, pay rather than suffer discomfort and inconvenience for months or even years. Other important reasons for choosing the private sector were the convenience of being able to time your entry into hospital to, suit yourself, being assured of reasonable privacy and choosing your own doctor. We thought that the NHS should make mare effort to meet reasonable requirements of this kind.

22.65 We found that from the NHS paint of view that main importance of pay beds was in the passions aroused and the consequential dislocation of work which then occurred. The establishment of the Health Services Board had led to a welcome respite from discussion of this emotional subject. However, we felt that if the Board were to carry out its functions of safeguarding the interests of the NHS it should be able to control the aggregate of private beds in a locality: this appeared to be a loophole at present.

Recommendations on the NHS and other institutions

(88) before any collaboration begins, its purpose, form and resource implications should be identified with the different agencies and professions involved (paragraph 16.3);

(89) in Northern Ireland the present integration of the health and personal social services should be encouraged and further developed (paragraph 16.28);

(90) there should be more emphasis in the education and continuing training of health and social work professionals and the importance of interprofessional collaboration (paragraph 16.31);

(91) there should be no radical change in the responsibilities for either the health or the personal social services (paragraph 16.32);

(92) a formal structure at national level to co-ordinate the policies of the health departments, the University Grants Committee and the universities should be considered by the parties concerned (paragraph 17.12);

(93) an independent enquiry should be set up to, consider the special health service problems of London, including the administration of the postgraduate teaching hospitals, whether London needs four RHAs, whether same special adjustment to the RAWP formula is required to take account of the high concentration of teaching hospitals in Landon, and what additional measures can be devised to deal with difficulties of providing primary care services and joint planning in London (paragraph 17.18);

(94) NHS staff who are required to teach students should have this requirement written into their contracts (paragraph 17.25);

(95) the health departments should as a matter of national policy fund chairs or senior lectureships, or promote joint NHS/university appointments as in Northern Ireland, in the priority specialties (paragraph 17.31);

(96) universities should encourage and monitor experiments in different approaches to student selection which take account of factors other than traditional academic criteria (paragraph 17.32);

(97) an Institute of Health Services Research should be established for England and Wales to encourage systematic research into health care issues and its activities and output should be carefully evaluated. The health departments in Scotland and Northern Ireland should consider their position as separate institutions may not be appropriate there (paragraph 17.39);

(98) health authorities in Great Britain should have the broad objective of providing far about 75% of all abortions on resident women to be performed in the NHS over the next few years (paragraph 18.13);

(99) the capital element of pay bed charges should cover both the interest and depreciation costs pf the capital investment in pay beds (paragraph 18.37);

(100) the Health Services Board should be given power to control, and a responsibility to consider, the aggregates of beds in private hospitals and nursing homes when any new private development is considered in a locality (paragraph 18.39).

Part V Management and Finance

22.66 In this section of the report we looked in detail at how the present system operated and what could be done to, improve matters. We thought that while this part of our report might be of greatest interest to many who work in the NHS, management and finance questions were essentially secondary to those subjects which bore directly on patient care.

Parliament, health ministers and their departments

22.67 The roles of health ministers, permanent secretaries and the health departments, and their relations with the NHS, seemed to us to stem from the way that the NHS was financed. Arrangements for accounting for NHS finance followed the classic Whitehall model under which the minister was answerable to Parliament and the permanent secretary personally accountable, for every penny spent and every action taken in the NHS. This arrangement seemed to, us to, be quite inappropriate to an organisation the size of the NHS whose staff were not civil servants and some of whom – for example, doctors – might not be answerable to, anyone else far the expenditure they incurred. It appeared to us that the system had been made to work by those immediately concerned, to, their credit, but that there was nevertheless a gap between the theoretical and the actual position. The effect of this could be seen in the uncertainties over the respective roles of the health departments and the NHS.

22.68 After a good deal of reflection, and having considered a number of alternatives, we concluded in Chapter 19 that the best solution to this fundamental difficulty was to, place responsibility for the detailed working of the NHS in England with the regional health authorities themselves. We also, mentioned the position outside England. This would end the anomalous position of the Secretary of State for Social Services and his permanent secretary being held responsible far actions over which in practice they could have little control. The division of responsibility between the regional health authorities and the Department of Health and Social Security would need to be worked out, but in broad terms we saw the former as accountable for the delivery of the service and the latter for national policies and functions. It was clear to us that neither the DHSS and Welsh Office, nor some of the health authorities in England and Wales, were carrying out adequately their monitoring functions and this responsibility should have their urgent attention.

Health authorities and their organisation

22.69 Although the reorganisation of the NHS had come under attack in the evidence we received, the pre-1974 system had been criticised on many of the same grounds. Other factors over which the NHS had little control adversely affected the morale of those who worked in the service while the organisation was being implemented. We tried, therefore, to see the changes in perspective.

22.70 The introduction of consensus management and the proliferation of advisory committees had been criticised and in Chapter 20 we suggested ways in which practical difficulties in their operation might be overcome. A more serious problem was the decline in the quality of hospital administration. We concluded that the status of the institutional manager ‘had to be improved and a satisfactory medical contribution to hospital administration achieved.

22.7.1 Although the importance of structure in the efficient operation of the NHS could be exaggerated, we had received an impressive weight of evidence to suggest that in most places there was one tier too many. We took the view that in England regions should be the main planning authorities and the structure below regions should be simplified. We considered that, except in a minority of cases, there should be one tier below region or health department. In most cases this would mean the creation of more single district areas. In some it would mean merging existing districts or creating new authorities by dividing existing areas. We felt a flexible approach to structural change would be very important. The other main change we wanted to see in the structure was the abolition of separate family practitioner committees in England and Wales and the adoption there of the Scottish pattern of administration of family practitioner services.


22.72 We found no objective or universally acceptable method of establishing what the “right” level of expenditure on the NHS should be. Some of our recommendations would increase NHS expenditure, but others should lead to savings. On balance our recommendations would increase the cost of the NHS, but our judgement was that these additional resources would be justified by the benefits which would flow from them. We also considered it right that the nation should spend more on the NHS as it got wealthier.

22.73 We made our own broad assessment of the financial implications of our recommendations, but in most cases we have not included them in our report. The accurate costing’ of any recommendation that affects the NHS in the four parts of the UK would be difficult enough if undertaken by the health departments themselves. For obvious reasons we could not ask them to do this exercise for us and we had neither the time nor resources to make other than the most rudimentary estimates.

22.74 In our view no method of financing a part of national expenditure as large and as politically sensitive as the health service was likely to remove it from government influence. Discussion of the merits of alternative methods of finance ought therefore to focus on their implications for the way the health service was organised and performed, rather than on the total amount of finance they would generate. We were not convinced that the claimed advantages of insurance finance or substantial increases in revenue from charges would outweigh their undoubted disadvantages in terms of equity and administrative costs. The same disadvantages arose from the existing NHS charges.

22.75 We found that the geographical distribution of the provision of health care had become fairer since the NHS was founded but there was still some way to go. It was essential that the resource allocation procedure adopted should be the subject of informed and public scrutiny and we welcomed the recent change to explicit formulae based on estimates of need.

22.76 The system of financial management in the NHS did not sufficiently encourage efficient resource use. Much of the information required for effective management was not produced, or was inaccurate, or too late to be of value. Those held responsible for expenditure were often not in a position to control it. We commended Professor Perrin’s report to the health departments.

Recommendations on management and finance

(101) a select committee on the NHS should be set up (paragraph 19.11);

(102) formal responsibility, including accountability to Parliament, for the delivery of services should be transferred to regional health authorities (paragraph 19.34);

(103) the health departments should give further guidance about the role of members of consensus management teams (paragraph 20.15);

( 104 ) the health departments should urgently consider with the professions concerned the best way of simplifying the present professional advisory committee structure (paragraph 20.20);

(105) the role of the hospital administrator at unit or sector level should be expanded (paragraph 20.27);

(106) there should be a review of the number of functional managers above unit level (paragraph 20.27);

(107) regional health authorities in England should continue to be responsible principally for planning and for the major functions they carry out at present (paragraph 20.45); ,

(108) below region in England, and elsewhere in the UK below health department, except in a minority of cases, one management level only should carry operational responsibility for services and for effective . collaboration with local government (paragraph 20.46);

( 109) each regional health authority in England and the health departments in Scotland, Wales and Northern Ireland should institute a review of the structure for which it is responsible. The Department of Health and Social Security should monitor this review in England (paragraph 20.51 );

(110) Family Practitioner Committees in England and Wales should be abolished and their functions assumed by health authorities as a step towards integration (paragraph 20.57);

(111) the process of introducing the changes recommended in Chapter 20 should be completed within two years of the end of the period of consultation (paragraph 20.66);

(112) it is for government to decide how the NHS should be funded, but there is a firm case for the gradual but complete extinction of charges (paragraphs 21.28 and 21.29);

(113) the health departments should prosecute the research necessary for improvement of the resource allocation formulae (paragraphs 21.41 and 21.42);

(114) there should be an explicit formula for the distribution of funds to the health service in the four parts of the United Kingdom (paragraph 21.43);

(115) the main proposals of the Collier report on equipment and supplies should be implemented as quickly as possible (paragraph 21.49);

(116) health departments should encourage experiments with budgeting (paragraphs 21.52 and 21.55);

(117) a study of the desirability and feasibility of common budgets for family practitioner services and hospital and community services expenditure should be undertaken (paragraph 21.64).

The Future

22.77 We believe that the recommendations we have made will, if accepted, make the NHS more suited to caring for the health of the nation now and in the future. But there are numerous influences on the need for health services not all of which are predictable. This is a highly speculative area, but we felt that we should sketch out some of the more obvious possibilities.

22.78 The demographic change which will be the greatest single influence on the shape of the NHS for the rest of this century, is the growing number of old people and particularly those over 75. This will increase the need for long term care. In addition, demand for services for the mentally ill and the mentally handicapped are likely to grow.

22.79 Changes in social attitudes and life-styles could be of great significance, but their direction and extent are unpredictable. We do not know for example, what percentage of women with families will wish to go out to work and over what period or periods in their lives. What they do will affect the care of old people, sick people and of children, and may influence significantly the emotional stability of children. Life styles of young people in this country have changed dramatically since the NHS was established and further change is certain. Habits of eating, taking alcohol and sexual behaviour could alter with profound effects on health. Groups of the population, now uncaring for their health, might become more self-conscious and take a pride in it, reducing the burden on health services.

22.80 Advances in the sciences basic to medicine will increase knowledge of the causation of disease and thus assist towards its control. Advances in molecular and cell biology, for example, will lead to a better understanding of genetic susceptibility and of some inherited diseases. Immunology is at present a thriving science within medicine. New drugs have in the past decade greatly assisted the treatment of peptic ulcers, asthma, hypertension, Parkinson’s Disease and some blood cancers; and there is every reason to think that progress in pharmacology will continue. Psychology is contributing significantly to the treatment of disturbed behaviour in the neurotically ill and the mentally handicapped. Sociological insights are illuminating the interaction between the providers of services and the patients who seek their help.

22.81 The impressive contribution which acute medicine has made in relieving illness and suffering seems likely to continue. Diagnosis is continually being improved and refined by technological developments. Techniques such as tomography, ultra-sound and radio-isotope scanning have been major advances. Analytical tools of great importance such as mass spectrometry, radioimmunology and radioenzymatic techniques have been added to the battery of 100 or more tests and investigations which a clinical laboratory in a district general hospital now provides. Advanced technology has contributed to the development of incubators for premature babies, renal transplantation, cardiac pacemakers and hip replacement. It is likely that bioengineering will increasingly assist orthopaedics. At the same time the emphasis on acute and high technology medicine is being challenged and more thought is being given to the care of the chronically sick and elderly. These developments are likely to continue.

22.82 Computers will more and more be used in most areas of medical research and practice, in the laboratories, in patient information services, in hospital wards in monitoring patients as well as in recording data about them and the drugs which they receive. Diagnosis in some fields is already being considerably assisted by computers. The micro-electronics revolution is certain to have a major impact in medicine, to a degree which it is likely very few of those working in the NHS at present envisage. Improved data collection would assist better planning of services.

22.83 Technological and service developments in the NHS have implications for its cost. The NHS has already to spend about one per cent more each year merely to provide its existing standard of service on account of the increasing numbers of elderly. While some scientific advances reduce costs, most tend to increase them, so the future state of the national economy will have an important influence on the NHS and its capacity to provide new or better services.

22.84 One aspect of the NHS which is unlikely to change is the importance of its staff. By its nature the NHS is labour-intensive and this places a special responsibility on it to enable its workers to contribute in an effective way.

22.85 Predictions can be made by extrapolation from the state and the trend of things now. It is possible, however, that the greatest changes will come unexpectedly. Certainly changes in society which could potentially have the widest effects are also the least predictable. The NHS should therefore be geared for the maximum flexibility in response.

22.86 In our review of the NHS as it exists we found much about which we can all be proud. Our examination of foreign health systems for the most part reinforced that view. If in considering some aspects in detail” we have made specific criticisms, we have done this in the hope that in the future the NHS can provide a better service, not because we think it is in danger of collapse. The developments which we have suggested the future might bring will produce considerable change for the service and those who work in it. We are confident that they will meet the challenge.


  • Alec Merrison (Chairman)
  • Ivor Batchelor
  • Paul Bramley
  • Thomas Brown
  • Ann Clwyd
  • Peter Jacques
  • Jean McFarlane
  • Audrey Prime
  • Kathleen Richards
  • Sally Sherman
  • Simpson Stevenson
  • Cyril Taylor
  • Christopher Wells
  • Frank Welsh
  • David de Peyer (Secretary)
  • Roy Cunningham (Assistant Secretary)
  • Alan Gilbert (Assistant Secretary)

21 June 1979