Members of the Commission:
- Sir Alexander Walter Merrison
- Sir Thomas Brown
- Sir Simpson Stevenson
- Lady Sherman;
- Ivor Ralph Campbell Batchelor CBE
- Audrey Mary Prime OBE
- Christopher John Wells OBE
- Paul Anthony Bramley
- Cecil Montacute Clothier QC (resigned January 1979)
- Ann Clwyd;
- Peter Roy Albert Jacques
- Jean Kennedy McFarlane;
- Kathleen Brenda Richards;
- Dr Cyril Taylor
- Frank Reeson Welsh
- Professor Alan Harold Williams (resigned 31.8.1978)
Published July 1979 Cmnd 7615
Chapter 1 Introduction
1.1 We were appointed with these terms of reference:-
“To consider in the interests both of the patients and of those who work in the National Health Service the best use and management of the financial and manpower resources of the National Health Service.”
Our remit covered England, Scotland, Wales and the parallel services in Northern Ireland.
- The Royal Warrant was issued on 19 May 1976 and there have been 35 meetings of the Commission, including five conferences lasting two or more days. Much of our work was done in sub-committees which between them held 83 meetings. In addition we visited each of the four constituent parts of the United Kingdom at least once, and took oral evidence in Edinburgh, Cardiff and Belfast as well as in London. Groups of us visited and held discussions with officials and individuals in Canada and the USA; West Germany; France and Holland; Sweden and Denmark; Yugoslavia and the USSR.
- We received 2,460 written evidence submissions and held 58 oral evidence sessions. In addition we met and spoke informally to about 2,800 individuals during the course of our work and visits in the UK and abroad.
The background to our appointment
- We were appointed at a time when there was widespread concern about the NHS. There had been a complete reorganisation of the service throughout the UK in 1973 and 1974 which few had greeted as an unqualified success.
The NHS had suffered a number of industrial disputes accompanied in some cases by at least a partial withdrawal of labour by ambulancemen, some ancillary staff, and hospital doctors and dentists. The then government’s decision to phase out private beds from NHS hospitals was being heatedly debated in the NHS, and was itself the occasion for some of the industrial action mentioned. In addition to all this, the NHS could not shelter from the country’s chill economic climate in the mid-1970s, so that although it suffered no real financial cut-back it was denied the growth which it had come to expect to help it meet the rising demands made upon it. In Northern Ireland there were continuing strains arising from civil and political disorder.
- There were less pressing, but nonetheless important, reasons why a general inquiry into the use of resources in the NHS was timely. Despite the close attention which had been given to the administration of the service; the three Royal Commissions and the large number of committees which had reported on aspects of it since 1948, the NHS had been considered as a whole only by the Guillebaud Committee and that Committee had not covered, as our terms of reference require us to, the health services in Northern Ireland. Largely because of this we have used the broad scope of our terms of reference to the full.
- It would have been possible to have interpreted our terms of reference in a narrow financial and administrative context and written a straightforward technical report along these lines, but it would have been wrong to do so. The NHS is an institution which enables human beings to offer care, and sometimes cure, to others in need of it. It is a vast institution, with all the administrative consequences which follow from this, and the people who staff it must never be overlooked or the quality of their humane commitment undervalued; they are the foundation on which all else is built.
- Our work has been informed throughout by the idea that the NHS is a service to patients. Necessarily, a good part of our report deals with such topics as the details of NHS administration and the careers of nurses, to give two examples of matters which affect some of those who work in the service but are likely to be of little immediate interest or concern to patients. While the efficient use of resources or the morale of NHS workers cannot be neglected – indeed, we regard them as of central importance – it must not be forgotten that the purpose of the NHS is the care and comfort of patients, and we should want our report to be judged against those criteria. We urge those whose business it is to decide which of our recommendations should be implemented to be mindful of this.
- Our first act was to invite views about which of the problems of the NHS we should examine. Having considered over 1,000 replies we published “The Task of the Commission” in October 1976, which listed topics to be considered and was intended as a guide to those submitting evidence. We remarked in that publication that what was in the interests of those who worked in the NHS would also generally be in the interests of the patients but, where those interests conflicted, the interests of the patient must be paramount. That is not a view from which we would wish to retreat.
- With these points’ in mind we have spent a great deal of our time, at the beginning of our inquiry and subsequently, considering how the patient actually gets service. It seemed to us most important to understand matters of this kind before we began to inquire into questions of administration and We remarked in The Task of the Commission that “large organisations are most efficient when problems are solved and decisions taken at the lowest effective point.” Nothing we have learned in our inquiry would lead us to modify this view.
- We have said already that we have thought it right to see our inquiry as something more than an accounting exercise. We should say too that we certainly would not be the right people to conduct such an exercise and we have felt it right to play to our strength, which we see as the wide experience we possess collectively in NHS matters and matters which affect the NHS. Naturally, we have not been able to consider all aspects of the service in detail nor give some the attention that might have been expected. The one common experience we share is that we have all been patients and have personal reasons for being thankful for the NHS, and all of us have experienced some of its frustrations.
- There is one more important point to be made about the nature of our work, and that is that the measurement of “health” and of the effectiveness of health care are at best uncertain sciences. A good deal of the evidence presented to us, and a good deal of our own work, might be termed anecdotal or subjective. We have not regarded it as less instructive or valuable on that account and, indeed, given the difficulties of quantitative work in this field and the infinite variety of human behaviour, it is hard to see that we could have done otherwise.
- We felt that it was vital for us to talk to as many people in the UK and abroad as we possibly could, given the limitations on our time. We have been met everywhere with friendliness and candour and we should like now to place on record our deep gratitude to those who have given so generously of their time and thought. Perhaps the pleasantest of our duties is to thank our Secretary, David de Peyer, his two Assistant Secretaries, Roy Cunningham and Alan Gilbert, and all those in the Royal Commission Secretariat who have worked so devotedly for us. We are all too conscious of the burden we have put upon them and of the skill, energy and friendliness they have shown in carrying
As Commissioners we shall take with us the happiest memories of the way we have been served in the last three years.
- There were many areas of our inquiry where we considered we could benefit from commissioned research. We decided to concentrate on a few main areas which we considered crucial and to call for work which could be completed within our time scale. We accordingly commissioned:
- a study of the working of the reorganised NHS, primarily aimed at establishing the truth of the frequent allegations of delays resulting from NHS reorganisation, undertaken for us by Professor Maurice Kogan and a team of researchers at Brunel University, published as The Working of the NHS Research Paper Number 1, London, HMSO in June 1978
- a study of the local administration of NHS finance, intended to help us tackle that part of our terms of reference which refers to the “best use and management of the financial . . . resources” of the NHS, undertaken under the supervision of Professor John Perrin of Warwick University (published as The Management of Finance in the NHS Research Paper Number 2, London, HMSO July 1978);
- a commentary on the health departments’ resource allocation arrangements prepared by Professor Rudolf Klein of Bath University and Mr Martin Buxton of the Policy Studies Institute (published as Allocating Health Resources, A commentary on the Report of the Resource Allocation Working Party Research Paper Number 3, London, HMSO August 1978);
- a report on medical manpower forecasting prepared by Mr Alan Maynard and Mr Arthur Walker of York University (published as Doctor Manpower 1975-2000: alternative forecasts and their resource implications Research Paper Number 4, London, HMSO September 1978);
- a study by the Social Survey Division of the Office of Population Censuses and Surveys of patient attitudes towards hospital services which complemented one already commissioned by the Department of Health and Social Security on access to primary health care services (published as Patients’ attitudes to the Hospital Service Research Paper Number 5, London, HMSO January 1979);
- jointly with the National Consumer Council a survey of problems of certain groups in gaining access to primary care services (published as Access to Primary Care Research Paper Number 6, London, HMSO February 1979).
We published these papers to get the reactions of others to them, and because we were sure they would be of value to many of our readers. We have profited too from other work carried out for us by a number of people outside our own secretariat. Some of them are referred to in the text of this report.
- 1.14 The 21 chapters of our report that follow are arranged in five parts:
- a general view of the nation’s health and health care;
- the NHS and the patient;
- the NHS and its workers;
- the NHS and other institutions;
- management and finance of the NHS;
followed by conclusions and recommendations.
- Since “How well are we doing?” is a question which exercises the minds of everyone, the first part of our report, formed of the three chapters which follow this introduction, gives our assessment of the NHS and its strengths and weaknesses at present.
- Throughout the report the four parts of the UK are dealt with together. Wherever possible we have made what we say apply to each part of the UK, but the wide range of circumstances which exist in them may mean that on occasions what we say is not of universal application. Where important differences between the countries exist they are commented on in the relevant chapters, and Appendix D gives details.