Health Authorities and Their Organisation
20.1 In the last chapter we discussed the responsibilities carried by Parliament, health ministers and their departments for the NHS. In this chapter we discuss the organisation and administrative structure of the NHS The recurring theme of our report is that the NHS is a service to patients. It follows that the structure and management of the NHS must be judged by how well they serve patients and the efficiency and humanity with which the resources put at the command of the NHS are used. These resources, paid for in the end by the patient, are on a huge scale. Good, clear administration is therefore essential.
20.2 We deal with three broad topics in this chapter. We discuss first a number of aspects of management; the “consensus” style of management by representatives of different disciplines, the involvement of health professions in the planning and management of health care and administration below district Second, we consider the structure of the administration of the NHS, including the role of each of the tiers in the structure, and we include in this the important matter of the separate existence in England and Wales of family practitioner committees (FPCs). Last, we discuss the arrangements for making health authorities accountable to the communities they serve.
Present Arrangements
20.3 The reorganisation of the NHS took effect on 1 October 1973 in Northern Ireland and in Great Britain on 1 April 1974. It was the result of a lengthy process of discussion and consultation. The generally held view before reorganisation was that unification of the health services which were the responsibility of separate hospital, family practitioner and local health authorities would bring undoubted benefit. Unification of the tripartite structure was the starting point for NHS reorganisation. Speaking in a debate on his Green Paper, Mr R H S Crossman, then Secretary of State for Social Services, said:
“most of the faults and failings of the system derive from its tripartite structure”
and the 1972 White Paper for England said:
“unification offers solid advantages to the individual and the family, because their needs for health and social services are not divided into separate compartments. A single family, or an individual, may in a short space of time, or even at one and the same time, need many types of health and social care, and these needs should be met in a co-ordinated way. Otherwise they will get an unsatisfactory service or even no service at all.”
20.4 We were told in evidence from the DHSS that in addition to unification the main principles underlying reorganisation were:
“the integral involvement of the health care professions in planning and management at all levels of the service;
decentralisation and delegation of decision making but within policies established at a higher level;
a territorial structure and organisational mechanisms which allowed closer collaboration with local authorities and facilitated joint planning and working on matters of common concern;
provision for effective central control over the money spent in the service to enable the Secretary of State to discharge responsibilities laid upon him by Parliament.”
20.5 These principles were followed in the four parts of the UK. Although the arrangements introduced to implement them differed slightly, there were several common features. Below each health department there were a number of tiers. Regional health authorities (RHAs) in England only, area health authorities (AHAs) or boards, and health districts. The health district was seen as the basic unit for planning, management and operation of health care services. Each tier had a team of officers drawn from various disciplines and working, as equals, by consensus. Collaboration between health and local authorities was facilitated in most places by coterminous boundaries. Management of the service was separated from representation of the views of consumers as expressed by district based community health councils (CHCs) and their equivalents. There have been minor modifications of these arrangements since 1974, the most important of which has been the conversion of some multi-district AHAs into single district areas in England. Below district level are sectors covering hospital and community services. Units relate to individual hospitals.
Criticisms of the present arrangements
20.6 In Chapter 4 we noted a number of factors affecting the NHS at the time of reorganisation. They included the grave economic difficulties which the country has faced since 1974; the consequent effect on remuneration and the development of the NHS generally; changes in the organisation of nursing following the 1966 Salmon Committee Report; the increased unionisation of staff and the development of more “industrial” attitudes; the shortage of personnel officers in the NHS, and the emergence of new professional groups, for example in the laboratories. To quote Professor Kogan:
“We emphasise that many of the sources of low morale have nothing to do with reorganisation. It is a bad time to be a public servant. Management faces virtually incessant bombardment from employees wanting changes of status as well as of conditions and salaries, from clients who want a voice in the management of the system, from members who are under far more political pressure than used to be the case within the former hospital service.”
The NHS is, of course, by no means unique among public services in attracting criticism about the way it functions.
20.7 Many of the complaints heard today were being made about the NHS before 1974. For example, Mr Crossman speaking in a Parliamentary debate in 1971 referred to:
“the insensitivity of the health service to local feeling and patient criticism, the remoteness of the service, its bureaucratic nature, its refusal to understand local needs, the setting up of hospitals with no transport to them, the creation of great marble palaces and the closing down of well-loved small hospitals.”
20.8 Much the most common criticism of the reorganised NHS is that the machinery for decision making is expensive, cumbersome and slow. “Matters which should be corrected in minutes or hours now take weeks or months with the obvious effect of slowing down the whole service”, as one doctor told us. The reasons given for this vary. The King’s College Hospital Group Medical Executive Committees said:
“The proliferation of committees and introduction of democracy has meant unlimited opportunities for extremists to manipulate the system for their own ends, and for postponement of decisions to faceless committees at higher levels.”
Another favourite cause of delay offered in evidence was the number of tiers. Another doctor commented:
“The present reorganisation. . . has proved too cumbersome and involves too many tiers at which decision-making is expected to take place. All too frequently it has meant that decision-making has been deferred for fear of what the next tier up may say.”
It would be possible to multiply these quotations many times. The research we commissioned from Professors Kogan and Perrin has helped us to assess these criticisms more thoroughly and Professor Kogan’s report confirmed that there was:
“a great deal of anger and frustration at what many regard as a seriously over-elaborate system of government, administration and decision making. The multiplicity of levels, the over-elaboration of consultative machinery, the inability to get decision making completed nearer the point of delivery of services, and what some describe as unacceptably wasteful use of manpower resources were recurrent themes in most of the areas where we worked.”
Much the same conclusions were reached by Pofessor Perrin in his report.
Our approach
20.9 We have seen our task throughout as helping the NHS to help itself. We do not intend, therefore, to lay down a detailed blue-print for the organisation and management of the service although we indicate later where the main responsibilities for reform should lie and what these reforms should be. Some discipline needs to be imposed on the structure, for example to enable monitoring and review to be carried out at the appropriate levels, but we feel strongly that there is plenty of room for variation in local arrangements and local initiatives and experiments should be encouraged. It seems to us obvious enough that the way health care should be brought to the people of Wester Ross and to the people of Tower Hamlets will be entirely different; and that there is no reason, other than the false god of administrative tidiness, why the service management arrangements should be the same or, indeed, why they should even resemble each other to any great degree. This theme of introducing flexibility into the administration of the NHS is behind much of our thinking in this chapter.
20.10 Our impression is that management arrangements have tended to be inflexible and to follow too closely the guidance issued by the health This may not be surprising given the pressures under which the reorganised service started work. For most of the UK there were only nine months between the passing of the enabling legislation and its implementation, during which several thousand appointments had to be made, authorities established, and so forth. But it is not to be expected that all health authorities can be organised and managed in the same way. With flexibility should go more experiment to test how the NHS can be better run locally.
20.11 In the “Task of the Commission” we said:
“we think that large organisations are most efficient when problems are solved and decisions taken at the lowest effective point.”
Nothing we have learned since has led us to change our minds. The advantages hardly need to be laboured, but the main benefits are likely to be speed in decision taking and responsiveness to local needs. NHS workers have complained without cease that management decisions are removed from the people best suited to make them. Despite the emphasis in the 1971 Consultative Document and the 1972 White Paper on “maximum delegation downwards matched by accountability upwards”, it is all too clear that so far the emphasis has been on the latter. We discuss the reasons for this later in this chapter, but a major cause is that many of those in all the disciplines responsible for administering the reorganised service found themselves in jobs in unfamiliar places performing unfamiliar roles and working with colleagues who were in much the same position. In the circumstances it is not surprising that decision makers looked for help higher up the ladder and felt anxious about the rungs below them.
Consensus Management
20.12 Consensus management predates the reorganisation of the NHS. It is one aspect of the general complaint about excessive consultation. It was explained in guidance from DHSS at reorganisation in terms of the district management team (DMT) as follows:
“the DMT will take decisions jointly on matters which are not exclusively the responsibility of any one of them and which are not provided for in approved plans nor regulated by established policies of the AHA.”
The decision to involve different professions as equals was a reflection of the growth in influence of the non-medical professions, nurses in particular, in the NHS. The alternative was some form of chief executive.
20.13 Professor Kogan and his team found that “support for consensus management was wide-ranging, and only a small minority of respondents thought that it could never be successful”. The main advantages seen were that it “gave a wider dimension to decision making, bringing in different points of view, allowing these different views to confront each other, and portraying the impact of one set of factors upon others”; and that it brought “a stronger commitment to decisions and [resulted] in better implementation”.
20.14 Problems with consensus management were reported to us. Clashes of personality, domination by an individual and the need to reach compromises could make its operation difficult. Consensus management might encourage team members to ignore a difficult problem or to present a united view to their authority where their proper role was to present health authorities with options for decision. Difficulties occurred in extreme form at Solihull where in 1977 unresolvable differences between members of the area team of officers led to their replacement. Consensus management may mean that decisions take longer to reach, but when they are reached they may be better ones and more rapidly implemented. This is debatable, but Professor Kogan’s findings suggest that the chief executive alternative would not be popular in most places.
20.15 It is important not to exaggerate the extent to which consensus management has changed the way workers in the NHS go about their jobs. It must always have been necessary in the NHS, as in other large organisations, for those responsible for particular services to be at least in broad agreement with their colleagues in different disciplines about decisions which directly affected their own responsibilities. Before reorganisation, no sensible hospital or group secretary would have tried to tell the matron how to do her job. There was consultation and discussion then as now. Perhaps the main difference is the extent to which this has been formalised. Consensus management need not itself be a cause of inefficiency, provided that there is a clearly identified responsibility to implement team decisions. The co-ordinating role of the administrator is highly important here. There is a risk that consensus management may sap individual responsibility by allowing it to be shared: it is important that managers should not be prevented from managing the services for which they are responsible. Clearly consensus management works best where individual team members have a firm grasp of the distinction between their personal responsibility and those of the team. We recommend further guidance from the health departments to clarify this question. Greater involvement by health authority members in monitoring services as we recommended in Chapter 19, and the changes in the structure of the NHS, which we recommend later in this chapter, will affect the operation but should not detract from the principle of consensus management. But like all “principles” of management, it is good only so far as it is useful and leads to greater efficiency.
Advisory Committees
20.16 The 1972 White Paper said that:
“Strong professional advisory machinery will be built into the new structure … It will function at each level of management, and will ensure that the RHA and AHA and their staffs make decisions in the full knowledge of expert opinion. It will ensure, too, that at all levels the health professions exercise an effective voice in the planning and operation of the NHS.”
Legislation lays a duty on health ministers to “recognise” representative committees of doctors, dentists, nurses and midwives, pharmacists and ophthalmic and dispensing opticians at health authority level. In multi-district areas there are district medical committees representing both hospital doctors and general practitioners. At hospital level medical advice is given through the divisional system. The divisions consist of clinicians from one or more hospitals, grouped in specialties. Their main functions are advice giving and clinical audit, plus an element of management.
20.17 It is important to distinguish principle from present practice in this field. Professional advice, arising out of the practical needs of daily patient care, is essential to the NHS and professional advisory committees are an integral part of the multi-disciplinary approach to running the NHS. The number of disciplines represented reflects the growth in influence of the non-medical professions. Their introduction was generally supported by the professions concerned at the time of reorganisation and their involvement in decision taking should improve the quality of decisions and increase professional commitment to them. The principle that the professionals should be involved in the running of the NHS through advisory committees is right.
20.18 In practice, however, the process of consultation has proliferated unduly, particularly in the medical profession. Medical committees of one kind and another are particularly numerous. In a multi-district area, for example, there may be local medical committees of GPs, divisional and medical staff or executive committees of hospital doctors, district medical committees, and area medical Although the arrangements differ in Scotland and Northern Ireland, the machinery is similarly elaborate. This is vividly illustrated in Appendix J prepared for us by staff of the Regional Medical Officer’s Department at Trent Regional Health Authority. A survey carried out for the Doctors’ and Dentists’ Review Body found that:
“Some 95% of consultants were members of one or more professional committees and about one in six consultants of five or more.”
20.19 Commenting on the arrangements in general, the Regional Medical Officers in England said:
“Professional advisory machinery is extravagant of professional time in the way it relates to over-complicated management structures. Representatives find themselves debating the same issues with very nearly the same people on different occasions. In practice one ‘tier’ of professional advisory machinery tends to lapse.”
Furthermore, some of the committees may not be particularly good at their jobs. Professor Kogan’s report noted that “nurses themselves commented strongly on their inexperience of committee work”. In our view the amount of discussion of and consultation about forward planning is often disproportionate to the amount of change which is possible in the NHS in the short term. It is this that leads to much of the frustration with the consultative process. The task of monitoring and improving the quality of services which are actually being delivered to patients should not be hindered by time spent on excessive consultation.
20.20 No doubt some of the problems in the professional advisory structure are to do with making unfamiliar machinery run smoothly. The changes to the structure of the NHS which we recommend later in this chapter should lead to some reductions in the number of committees; others may simply fall into disuse as their limited usefulness emerges. However, in our view stronger measures are called for and we recommend that the health departments should urgently consider with the professions concerned the best way of simplifying the present structure.
Hospital Management
20.21 There were many complaints in the evidence about the quality of hospital administration in the form of allegations that the local administration could or would not take decisions, and that as a result of the development of different functional hierarchies getting quite minor problems dealt with was unnecessarily difficult and delayed. Professor Kogan reported a widespread feeling that arrangements were working significantly less well than they had before reorganisation. It is clear to us that the three main professions involved in the efficient management of a hospital, administrators, nurses and doctors, need to devise mechanisms to ensure that decisions can be made quickly and implemented effectively. This will best be achieved by the creation of an executive team representing these three disciplines, advised as appropriate by the other professions involved. It would have responsibility for the day to day management of the hospital.
Administrators
20.22 Although the paragraphs that follow deal with the problems of hospital managers, much of what is said, particularly about status and pay, applies equally to those who administer community services below district level. In Chapter 4 we referred to the often repeated allegation that there are too many administrators in the NHS. We recorded that they were often blamed for what has gone wrong in the NHS since reorganisation. For the most part we think this blame unfair. Administrators have perhaps been seen as the personification of new and unpopular management arrangements. The passing of the hospital secretary, the group secretary and board of governors’ administrator is mourned by many doctors. The Royal College of Surgeons, England, said:
“before reorganisation, there were at the hospital level many experienced and capable administrators who performed this task well and some who performed it with great distinction.”
It is impossible to assess the quality of NHS administration with precision, but we have been impressed by the many able administrators we have met, the products either of in-service training or the national graduate trainee schemes, who are performing highly responsible tasks with distinction.
20.23 While some administrators in their fifties opted to retire at the time of reorganisation, the cadre of administrators must have been much the same on 1 April 1974 as it was on 31 March 1974. Many of the secretaries to hospital management committees or boards of governors were appointed administrators to the new districts and areas. At this level, the administrator is involved in the management and planning of all NHS services and inevitably he does not have the close relationship with hospital administration that the group secretary had before 1974. This is as it should be; the decisions taken at district should reflect not just the interests of the hospital service but those of all parts of the NHS at that level.
20.24 Because important decisions about hospital matters affect patients and will have repercussions for other parts of the NHS, they cannot be taken by administrators alone without consultation with other colleagues in different disciplines, nor can they be taken by administrators whose responsibilities are solely for hospitals. A consequence is that the unit (hospital level) administrators often find themselves fourth or fifth in line in the administrative structure whereas before reorganisation the secretary of a large hospital would have been the second most senior administrator in a substantially autonomous Their grading and pay in the reorganised service reflects the change. Before reorganisation the secretary of one of the large hospital groups could receive the same salary as a secretary to a regional hospital board. While the hospital secretary was paid less he had reasonable prospects of promotion to a group secretary job. Although there are good promotion prospects in the NHS administrative structure, the hospital administrator, may have to move into a wider field of administration rather than, as in the past, being able to make his career exclusively in hospital administration.
20.25 One of the results of NHS reorganisation has therefore been to down-grade the importance of administrators who deal solely with hospital matters. This has been compounded by the fact that membership of health authorities – previously at hospital group level, with house committees taking an interest in individual units – was concentrated at area level. We have more to say about this later in the chapter.
Functional management
20.26 Some supporting services are organised on a district, area or even regional basis. A hospital engineer, for example, is answerable for his professional work to his immediate superior, though his day-to-day responsibilities, and the workload that he carries, arise at the hospital where he works. There are potentially more than 20 such “functional” disciplines, including works, catering, supply, personnel and engineering, which may be represented at various management levels. Professor Kogan’s report points out that functional management is not new in the NHS and was fairly well developed before reorganisation although the new structure considerably increased its importance and scope. Functional management was said to conflict with the collective decision-making of district teams. One effect of strengthened functional management has been to reduce the discretion of officers at sector and unit levels. Professor Kogan noted that:
“The boundaries of roles of different functional managers were said to be unclear, and there were misunderstandings about the extent of authority of functional managers, and about how much ought to be delegated to lower levels. Functional managers were in a service-giving relationship to other staff, yet it was not clear that the meaning of this was understood.”
20.27 It is clear that the quality of management of institutions has suffered substantially since reorganisation for the reasons we have indicated. The administrator in charge of the hospital (graded as a sector or unit administrator depending on the size of the hospital) is a key figure. His grading must reflect the substantial responsibilities he carries. Perhaps new titles are needed for hospital administrative posts. We consider that the chief administrator in a hospital should be clearly responsible for co-ordinating all services in the institution. This means that staff who are part of a functional hierarchy in hospital, while remaining professionally answerable for their services, should be responsible to the administrator in charge for their day-to-day work. The administrator should co-ordinate the budget for all the functional services in hospitals, although decisions on the use and allocation of the budget should be taken jointly with the unit and functional managers concerned. Functional management at levels above the institutional level may well be required in certain of the more specialised disciplines like engineering, but the role in most cases is likely to be advisory rather than supervisory. We would expect that some of the posts above institutional level would be unnecessary. We recommend that the role of the hospital administrator at unit or sector level should be expanded. This may lead to the regrading of many posts and will need to be discussed by the Whitley Council concerned. We recommend also that there should be a review of the number of functional managers above unit level.
Nursing
20.28 The implementation of the Salmon Committee’s recommendations for senior nursing staff preceded reorganisation. The structure has proved adaptable and in some cases has resulted in fewer levels of nursing management. The grade of the chief nurse in a hospital may vary, but in all cases there is a clearly identifiable nurse in charge. The management of community nursing and hospital nursing services has been integrated in a number of different ways under one nurse at district or area level. We deal with the nursing career structure in Chapter 13.
Doctors
20.29 A doctor should be a member of the executive team to which we referred in paragraph 20.21. The health departments expected that a representative of the doctors in a hospital would be found from the membership of the specialist clinical divisions, elected by his colleagues. The concept of clinical divisions is sound but its implementation has been very patchy. In many places the divisional system has not been developed effectively; and problems have been particularly acute in the large multi-specialty district general hospitals. Here it was envisaged that the chairmen of the various clinical divisions would meet together to co-ordinate their policies, that they would elect a chairman and that he would make the medical contribution to administration on behalf of them all. This has rarely taken place and the lay administrator has had in many hospitals to negotiate with each specialty separately. Various types of ad hoc and usually more or less unsatisfactory mechanisms have been set up to bridge the gap; for example, deriving a medical advisory committee from the divisions. In many places community physicians have been brought in from district on a sessional basis, to act in effect as part-time medical superintendents, although this is clearly a misuse of their role. The situation has been further confused by the existence in hospitals of groups of doctors in more or less informal staff and house associations and committees outside the advisory structure.
20.30 There are important problems here which should have the serious attention of the health departments and the medical profession. Decisions made by clinical divisions can have implications for other services and good links with ^ nursing management in particular are important. An effective medical contribution to administration at unit level is essential. We do not ourselves see any practical alternative to making the divisional system work, short of returning to the appointment of medical superintendents to hospitals which we believe would be a retrograde step. We realise the difficulties: many clinicians do not have the time, the desire or the skills to engage in administration and get little or no education about their role in management. However, the chairmanship of a division, and more so the chairmanship of a committee of divisional chairmen, is a position of considerable responsibility and must be recognised. Election to such positions should be for long enough to give stability and continuity and for the individual to make his mark (probably for three to five years). There should be adequate secretarial support and information services. This essential part of the advisory and administrative structure is unlikely to function properly unless these appointments are given status, facilities and reward.
Psychiatric hospitals
20.31 The problems of hospital administration which we have dealt with in the preceding paragraphs apply to all hospitals, but psychiatric hospitals have had special difficulties. We see no reason in principle why they should be administered differently from other kinds of hospitals; but their administration may be particularly difficult because they are often large, isolated and have complex catchment areas. Instead of the strong administration they need there has been sometimes almost an administrative vacuum. Psychiatric hospitals particularly need administrative staff of good quality.
20.32 The quality of psychiatric hospital administration in recent years has been affected by several factors. Medical or physician superintendents, the heads of the old hierarchical and patriarchal structure, have been abolished, and the chairmen of clinical divisions have often not provided the drive and leadership which was given by the best of the medical superintendents, not least because they have not had the time to do so. Here, as elsewhere, hospital or group secretaries have been replaced by junior and less experienced sector or unit administrators. The functions of the old hospital management committee have been assumed at least in part by the district management team, but often there has been no member of the DMT with experience of psychiatric hospital administration. A multi-disciplinary approach to management and to the delivery of clinical services may have gone further in these hospitals than elsewhere and run into more difficulties. Trade union activities have led to unit concerns being referred to higher levels. The clinical functions of the hospitals have often been undertaken by sub-divisions or independent teams, serving different populations. The DHSS has now realised how serious their administrative problems are and has set up a working group which is likely to report shortly.
Structure
20.33 There was general agreement in our evidence that the structure of the NHS needed slimming. Evidence from England was the most emphatic on this point, perhaps because of the existence of the regional tier, but criticism was by no means confined to England. In Scotland, Wales and Northern Ireland the district was sometimes seen as the redundant tier. Abolition of a tier seemed to have assumed symbolic importance and was seen as the universal solution to the problems of managing the NHS. We do not ourselves regard abolition of a management tier as a panacea. There are many reasons for the present difficulties in the NHS and structure is only one of them.
20.34 Indeed, talking simply of abolishing a tier is not necessarily helpful. We have preferred to think in terms of the levels at which functions can best be performed. There are two broad groups of functions discharged by health authorities, the planning of services and their delivery to the patient. Although these activities are related, and it may not always be possible to distinguish them clearly, we have found it helpful to bear the distinction in mind.
Regions versus areas
20.35 In England, the discussion about structure has tended to focus on whether regions or areas should be abolished. Not surprisingly, most of the evidence we received from those working in, or associated with, areas put forward the view that the area was more useful than the region; those working in regions and districts saw the area as the redundant level. In terms of weight of criticism, there was no doubt that the areas were the most often attacked. Some of the issues were referred to in Chapter 4. We consider below the arguments for and against abolishing region or area, but there are two prior points to be considered.
20.36 The first consideration is what might be achieved by abolition of a tier. Regions are responsible for strategic planning, major building and specialised clinical services. If regions were abolished, these services would either have to be performed by the area or the health department; and if the area disappeared its responsibilities would similarly have to be redistributed. We agree with Professor Kogan that:
“Any reduction in [the] number of levels must simplify decision making if only by a reduction in the communication and co-ordination inevitably required where authority is located in many centres.”
However, the results may not be as startling as many of those giving us evidence seem to expect.
20.37 Second, it is clear that the abolition of a tier would have significant implications for the staff involved and their interests must be kept firmly in mind when major upheavals are considered.
20.38 The health departments told us that AHAs were introduced as:
“the main operational health authorities [with] boundaries which match those of the non-metropolitan counties, metropolitan districts and the London boroughs or groups of London boroughs since these were to be the local authorities responsible for providing personal social services.”
The AHA’s broad functions were described in the England 1972 White Paper as:
“operational NHS authority, responsible for assessing needs in its area and for planning, organising and administering area health services to meet them.”
The area is also the level where lay membership is involved which is closest to the consumer. AHAs come in different sizes ranging from Essex, Kent, Lancashire and Surrey with populations of well over one million to others below the 200,000 mark. There are much smaller areas in Scotland, Wales and Northern Ireland. The largest AHA in population terms, Kent, is only slightly smaller than the smallest RHA, East Anglia, both of them with populations of about 1.5 million. The largest AHAs contain five or even six health districts.
20.39 The main arguments advanced to us for abolishing the area tier were that its collaborative functions with local government had not turned out to be very successful and that there was a duplication of planning between area and district. Area was too remote from the delivery of services to be effective in organising and administering them, or to be responsive to local needs; and the separate area team of officers confused the relationship between criticisms of the effectiveness of collaboration between the NHS and local At reorganisation hospital management committee roughly translated into district, and regional hospital board into regional health authority, and for workers from the hospital service AHAs seemed an unnecessary addition.
20.40 The main objections to the RHA were that it duplicated the planning and personnel function of AHAs and was altogether remote from local requirements; and the role of the RHA member was sometimes in practice confined unsatisfactorily to a narrow range of functions, for example regional services and consultant appointments.
20.41 One effect of abolishing AHAs would be that in the larger regions RHAs would have to deal with 15 to 20 districts. Another effect would be to remove the involvement of health authority members even further from the point of delivery of service, a matter to which we return below. The abolition of RHAs would leave the DHSS dealing with AHAs, and the view taken by the government at the time of reorganisation was that:
“a central Department operating from London could not hope to exercise effective and prompt general supervision over area authorities.”
Arrangements would have to be made also for the regional planning and centralised services to be performed if RHAs disappeared.
Districts
20.42 The health district was described in paragraph 45 of the 1972 White Paper for England as forming “the natural community for the planning and delivery of comprehensive health care”. We consider that it is also the natural management Whereas the area and regional levels are primarily concerned with planning, the emphasis at district level is on the delivery of services. District boundaries do not conform, except in the case of single-district areas, to those of local authorities. For the most part they are determined by the catchment area of the district general hospital or equivalent. In England there are about 200 districts each with an average population of about 230,000. In 1977 the typical district in England had about ten hospitals and working within it about 145 hospital doctors, 1,400 hospital nurses, 110 GPs, 60 general dental practitioners and 150 community nurses. It employed directly almost 4,000 workers. It thus forms a very large management unit.
20.43 In England the DMT is responsible to the AHA; outside England there is a line relationship between officers at area and district. In multi-district areas, therefore, the districts compete with each other for area resources. Professor Kogan found that single-district areas function more harmoniously than multi-district areas and this is supported in the evidence we have received. For example, the Confederation of Health Service Employees said:
“If there has been any success stories in the management structures of the reorganised NHS we must say that these have been the single district areas.”
Single-district areas also have the advantages that their management costs appear to be significantly lower than multi-district areas and member involvement is closer to operational level. On the other hand, the general feeling about multi-district areas was that the relationship between district and area was difficult and led to duplication of work, frustration and delay. The solution for these problems was often felt to be the development of more single-district areas. This can be done by merging existing districts or by splitting existing areas.
20.44 As we remarked earlier, the health district is mainly concerned with delivery and the area and region mainly with planning services. The current structure of the NHS, therefore, effectively separates authority members from involvement in detailed arrangements for health care delivery. This results in these members being remote from the patients they serve and the health workers they employ, a very unsatisfactory situation. The substantial majority of members should be laymen and it is essential that the authority they serve should not be so big that its size stifles the influence and participation of members at all levels.
Proposals for change
20.45 In the NHS we consider that there is one tier too many in most We recommend that in England RHAs should continue to be principally responsible for planning and for the major functions they carry out at present, for example in relation to regional specialties. In addition, they will have greater responsibilities devolved from the DHSS as we recommend in Chapter 19. The relationship between regions and lower tier health authorities should remain on the same basis as that which exists between RHAs and AHAs at present, backed by the powers which regions have to direct AHAs to perform certain functions. The DHSS should ensure that this is clearly spelled out.
20.46 Below region in England, and elsewhere in the UK below health department, we recommend that, except in a minority of cases, one management level only should carry operational responsibility for services and for effective collaboration with local government. These authorities would be formed from existing single-district areas, by merging existing districts, or by dividing areas. They need not be self-sufficient in all facilities, nor would their boundaries always conform to existing health authority boundaries. However, in some places it will not be appropriate for reasons of geography, history and population to depart from existing area boundaries. In these circumstances health services may be more easily organised on a wider basis than can be provided by existing districts.
20.47 Very large authorities would be difficult to manage, and here the answer may be to retain a managerial structure below authority level. In these cases there should be a line relationship between teams of officers. It is not essential uniformly to have both sector and unit management below authority
20.48 The NHS is not a tidy construction and it still bears the marks of the haphazard growth of health services before 1948. Arrangements which will suit one part of the UK well will be wholly unsuited to another. We referred earlier in this chapter to the need for flexibility of structure.
20.49 A strong argument for making all health districts into health authorities is that one tier could be abolished in multi-district areas, but there are other considerations. Most important of these is the relationship between health and local authorities. In single-district areas there would normally be no change from the present position, but where new health authorities were based on the existing health districts, coterminosity with the matching local authority would be lost. One place where coterminosity does not apply, but where in the view of those concerned good relationships have been developed between health and local authorities, is Strathclyde where the regional council and the four health boards within its boundaries have established one liaison committee. In London, however, problems arise through the lack of coterminosity which affects 12 out of the 16 London AH As. The London Boroughs Association commented in evidence to us:
“the arrangements subsequently made in some, but not all, Area Health Authorities for the Health Districts to overlap AHA boundaries, with complicated and somewhat theoretical ‘agency’ provisions, damaged and in some cases virtually destroyed the principle coterminosity.”
A good deal of doubt was expressed in our evidence about the usefulness of coterminous health and local authority boundaries. As we noted in Chapter 16, effective collaboration does not depend on coterminous boundaries, although it may be assisted by them. The benefits of coterminous boundaries have, therefore, to be balanced in each locality against other considerations.
20.50 If our approach is adopted, the position of the FPC will need consideration in England and Wales. We discuss later the relationship of the FPC to the NHS and we will simply note here that this is a highly sensitive matter for the contractor professions. Changes in the structure below region would also have implications for community health councils. At present they represent the users of the NHS at district level. We dealt in Chapter 11 with the important part which CHCs have to play. Where districts are amalgamated it may be appropriate to retain more than one local CHC.
20.51 We recommend that each RHA 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 DHSS should monitor this review in England. The review would be carried out with full consultation of all those concerned, including health and local authorities, staff and CHCs. Its aim should be to set up a structure which is the most appropriate to the area
20.52 Since we are recommending no simple, universal panacea for the cure of the administrative ills of the NHS – indeed, we are against uniform solutions – it perhaps behoves us to recapitulate the broad ideas behind the recommendations we have made in the preceding paragraphs. They are:
- it is convenient, and will lead to better administration, to think of the management of the NHS as made up of a planning level and a service level;
- each of these levels will have authorities composed largely of laymen; that is to say, not employed by the NHS and so able to represent patients easily;
- only rarely will it be administratively useful and in the interest of the patient to interpose a layer between the two levels we describe;
- the authorities at the service level should be of a size to encourage natural and easy discourse between authority members, patients and health service workers; and to link effectively with other services;
- we would encourage a flexible and imaginative approach to management arrangements at both the planning and service levels and to interaction between them.
Family practitioner committees
20.53 We consider elsewhere questions arising from the independent contractor status of the four contractor professions (general medical practitioners, general dental practitioners, pharmacists and opticians). We are concerned here only with the family practitioner committees (FPCs) in England and In Scotland FPCs do not exist, the functions of the former executive councils having been taken over at reorganisation by the health boards. Our evidence suggested that this arrangement was satisfactory, and had brought some advantages.
20.54 FPCs in England and Wales were established at reorganisation. They administer the contracts and terms of service of individual practitioners and the statutory disciplinary arrangements. They deal directly with the health departments on these matters and are centrally financed. However, the 1972 White Paper indicated that the AHA would have significant responsibilities for:
“the planning and development of health centres; the approval where necessary of practitioners’ own proposals for providing premises; plans for contractor services in new towns and redevelopment areas; and general arrangements for the nursing and other skilled staff employed by the AHA or by the local authority to work with family doctors in their own practices, whether in health centres or elsewhere.”
20.55 The main criticism of the arrangements in England and Wales made in evidence was that complete integration of the three parts of the NHS was prevented so long as FPCs retained their independent status and membership. It was also argued that they were poor at dealing with service problems such as inadequate waiting room accommodation, waiting times, appointment arrangements and so forth; and they did not always help GPs, for example to improve their premises; and that FPC administrators had divided responsibilities between the AHA and FPC. Some of the difficulties turn on the contractual status of the practitioners with whom they deal, but we propose no considerable change here.
20.56 By and large health authorities supported some form of close integration between FPCs and AHAs, while the evidence from the representatives of the medical profession and bodies representing family practitioner committees supported the status quo. The latter argued that it was convenient to have specialist staff to administer contracts; that integration of the FPC with the AHA would reduce the independence of professional contractors which was provided by the direct relationship between the FPC and the health departments; and that an AHA could not conveniently and satisfactorily run services provided both by contractors and salaried workers. It was also argued that since the family practitioner services represented an open-ended financial commitment, whereas the rest of the NHS was run on cash limits, the AHA would have a difficult problem in managing the FPC’s finance.
20.57 Experience in Scotland and Northern Ireland suggests these objections are not conclusive. In these parts of the UK it appears that the absence of separate machinery for administering family practitioner services assists the integrated planning of health services. We recommend the abolition of FPCs in England and Wales and the assumption of their functions by health authorities as a step towards integration. It must allow them to influence more positively than they can at the present the distribution and quality of surgeries and other practice premises, the balance and relationship between hospital and community care, the movement of staff across institutional boundaries and deputising services. AHAs or their replacement authorities should take over existing FPC responsibilities and we recommend accordingly. The position of existing FPC staff would need to be safeguarded and handled sensitively.
Accountability
20.58 We discussed in Chapter 19 the implications of the relationship between Parliament, the health departments and the NHS for central financing of the service, and in Chapter 11 we considered the role of community health councils. We comment here on the membership of health authorities, some of the considerations which affect them and some of the proposals for change.
20.59 The membership of health authorities is important because members make the broad strategic decisions about what goes on in the NHS. They are answerable for the expenditure of exchequer funds to Parliament through the health departments and secretaries of state, but they have responsibilities also towards the communities they serve and the workers they employ. They have to be responsive to, or at least be aware of, pressure groups in the community and the NHS. They may be pulled in several different directions: local interests versus national pressures, contradictory staff pressures and local authority interests which may be incompatible with those of the NHS.
20.60 The 1972 White Paper said:
“The Government believes that, as in the past, the NHS should be administered by trained staff, under the general direction of authorities composed of part-time members who give their services voluntarily. Members of the area and regional health authorities will serve in an unpaid capacity though they will be entitled to travelling and other allowances. The chairman will however have a specially heavy and time-consuming job and it is desirable that there should be no financial barrier that would prevent those with other commitments from giving adequate time to the health service.”1
We think this general principle and approach are correct. We are reassured by Professor Kogan’s research which confirmed that those working the NHS were satisfied with the calibre of health authority members.
20.61 We concluded in Chapter 16 that the NHS should not be transferred to local government at the present time but that the question should be looked at again if regional government became a possibility in England. One of the main arguments advanced by those who advocate that the NHS should transfer is that the NHS is “undemocratic” because health authority members are for the most part nominees. At present the chairmen and members of RHAs and the chairmen of AHAs are appointed by health ministers after AHA members in England are appointed by RHAs after consultation. Outside England members of health authorities are appointed by the health ministers. They reflect a cross-section of local interests and include professional members and representatives of trade unions, voluntary organisations and local authorities. The detailed composition of authorities varies with the authority’s teaching responsibilities, but outside Scotland roughly one third of members are local authority nominees, one third are drawn from the professions and the universities and the rest from other sources. In Scotland the proportion of local authority members is lower.
20.62 A number of trade unions giving evidence to us, and the TUC itself, suggested that health authorities would be more “democratic” if the membership were equally divided between the nominees of local authorities and the trade unionists working in the NHS. In a consultative document published in 1974, the DHSS canvassed the possibility that each health authority might include among its members two elected representatives of the staff who worked for the authority, in addition to workers already appointed under existing The publication of the Bullock Committee Report gave some stimulation to this question, although the committee itself did not deal directly with the NHS. We hope that all health authorities could be constituted in a way which reflects the fact that their prime task, over-riding all other considerations, is to serve the patient and that those members who are NHS workers would keep this constantly in mind. Since we believe firmly that the NHS must work easily with local authorities, we see no reason for departing from the principle that there should be representation of local authority members, as well as health workers and the public at large. A health authority should not normally exceed 20 members, though multi-district authorities might require a slightly larger membership. Authorities should work through properly constituted sub-committees which could, of course, contain members who were not also members of the authority.
20.63 For the most part, members of authorities are nominees of some kind. It was put to us that they should instead be elected, on the grounds that if health authorities are to run the service for the benefit of local communities they should be responsible to them in the same kind of way as local authority councillors are responsible to their electorate. There are one or two countries, notably New Zealand, where health authorities are elected. There are, however, a variety of difficulties and objections to elections of this kind. Some of the more obvious ones are obtaining the right mix of professional experience and lay membership, the costs and complications of running a new set of elections, the inevitable involvement of party politics in the arrangements and the possible lack of public interest (judging by turn-outs in local authority elections) in the procedure. The present appointment arrangements are similar to those which existed before 1974, and we think it preferable to retain them in something like their existing form. If our proposals for structural change are adopted, the involvement of health authority members will be brought closer to the services they provide. We stressed in Chapter 19 the importance of effective monitoring of services by members, including visiting hospitals and other facilities.
20.64 Although health authority chairman receive an honorarium, health authority members at present may only receive out of pocket expenses and financial loss allowances. We understand that a scheme to introduce payment of elected members of local authorities is being discussed. If local authority appointed members of health authorities receive some form of payment matching provision should be made for other health authority members.
Implementation
20.65 We hope that the proposals we make here and elsewhere in this report will improve the working of the NHS but there are two important questions of timing. The first is whether any significant change should be made in the structure of the NHS for the moment, and second is whether the changes to be introduced should be carried out rapidly or gradually. In Chapter 4 we mention problems not caused by reorganisation which became more apparent after it was introduced. Further structural change would not help those problems, and we do not in any case propose any alterations on the scale of 1973/1974. However, there was, and probably still is, a strong body of opinion that, with all its faults, the present structure should be left untouched until the scars of reorganisation have healed completely, people have got used to working the new system and a better appreciation can be made of what changes are required.
20.66 It is easy to write down proposals for change as we have done in this To put them into effect requires consultation, thought and time, all of which will properly inhibit precipitate and ill-considered action. That seems to us entirely right when the working habits of so many people will have to change. Nevertheless, we would urge that those who will be responsible for acting upon this chapter of our report should do so with the greatest speed consistent with making changes with humanity. “Planning blight” is not something which settles only upon buildings; it can settle upon human organisations too. We acknowledge that our approach calls for different solutions for different communities and that it will take some time for the best solutions to be identified. We recommend that the process of introducing these changes should be completed within two years from the end of the period of consultation.
Conclusions and Recommendations
20.67 Although the reorganisation of the NHS came under attack in the evidence, the pre-1974 system was criticised on many of the same grounds. Other factors over which the NHS has little control adversely affected the morale of those who worked in the service at the time reorganisation was being We have tried, therefore, to see the changes in perspective.
20.68 The introduction of consensus management and the proliferation of advisory committees have been criticised and we suggest ways in which practical difficulties in their operation may be overcome. A more serious problem is the decline in the quality of hospital administration. The status of the institutional manager must be improved and a satisfactory medical contribution to hospital administration achieved.
20.69 Although the importance of structure in the efficient operation of the NHS can be exaggerated, we received an impressive weight of evidence which suggested that in most places there was one tier too many. We have already recommended that in England RHAs should assume additional powers from the DHSS. In our view RHAs should be the main planning authorities and the structure below region should be simplified. We consider that, except in a minority of cases, there should be one tier below RHA or health 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. However, a flexible approach to structural change will be very important. The other main change we should like to see in the structure is the abolition of separate FPCs in England and Wales and the adoption there of the Scottish pattern of administration of
family practitioner services.
20.70 We recommend that:
- the health departments should give further guidance about the role of members of consensus management teams (paragraph 20.15);
- the health departments should urgently consider with the professions concerned the best way of simplifying the present professional advisory committee structure (paragraph 20.20);
- the role of the hospital administrator at unit or sector level should be expanded (paragraph 20.27);
- there should be a review of the number of functional managers above unit level (paragraph 20.27);
- RHAs in England should continue to be principally responsible for planning and for the major functions they carry out at present (paragraph 45)
- below region in England, and elswhere 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); - each RHA 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 DHSS should monitor this review in England (paragraph 20.51);
- FPCs in England and Wales should be abolished and their functions assumed by health authorities as a step towards integration (paragraph 20.57);
- the process of introducing the changes recommended in this chapter should be completed within two years of the end of the period of consultation (paragraph 20.66).