Royal Commission on the NHS Chapter 4

What Others Say

4.1 In this chapter we outline some of the main themes which emerged from our evidence and add some comments of our own. We return to the questions raised here in later chapters, where they are discussed in greater

4.2 Most of our evidence came from people who work in the NHS, and much of it was critical. ‘Of the 2,460 written submissions received, 1,640 were from organisations in or concerned with the NHS and 820 were from individuals. Of the 820 individuals nearly half were workers or ex-workers in the NHS. This did not surprise us since those who work in the NHS have the greatest direct interest in how it works and the strongest views on methods of improving it. We would have been concerned by an apathetic silence, but we were surprised not to hear more from individual users of the We hope their views were adequately represented in the evidence we received from community health councils, other bodies representing patients and in the surveys of patient attitudes referred to elsewhere in our report.


NHS reorganisation has not worked

4.3 Many of those submitting evidence referred to what they saw as the debilitating effects of NHS reorganisation, even though the structural changes that were introduced in 1973 in Northern Ireland and in 1974 in England, Scotland and Wales should have directly affected relatively few NHS workers. But clearly changes in administrative structure have repercussions far beyond the structure itself – a consideration we bear in mind when formulating our views on the merits of further change. It is important to distinguish between the structural changes which were the result of reorganisation, and other processes which became apparent at roughly the same time.

4.4 Some of the changes that affected the NHS in the early 1970s were external to the service, others were developments within it. The main ones were:

  • shortage of funds – almost since its inception there had been a slow but steady growth in the resources available to the NHS. More money in real terms could be spent each year on staff, buildings and equipment. By 1974 it was clear that these rates of growth would not be sustained and schemes for improving the service had to be cut back or postponed. We deal with general questions relating to the funding of the NHS in Chapter 21;
  • worsening industrial relations – NHS workers at all levels are now prepared to risk the well-being of patients by disrupting or withdrawing services. This has contributed to longer hospital waiting lists and probably lowered morale. We say more about this in Chapter 12;
  • the changing status of the medical profession – the status and influence of doctors has been eroded in recent years. Their authority has been challenged by the rise in influence of other NHS professions, and there has been a narrowing of pay differentials between them and the less well paid workers in the health service. We discuss various matters relating to doctors in Chapters 7 and 14;
  • the position of nurses nurses have acquired more influence in the management of the NHS partly due to the restructuring of the profession after the Salmon and Mayston Reports and partly due to their increased participation in management through reorganisation. We discuss various matters relating to nurses in Chapters 7 and 13;
  • the pay beds argument – the then government’s decision to phase out pay beds from NHS’ hospitals was announced at a time when hospital consultants were already under pressure. The pay beds issue was also the occasion for industrial action to be taken by ancillary and other workers for motives which were not directly connected with their conditions of service. We deal with pay beds in Chapter 18;
  • local government reorganisation – health and local government reorgani­sation took effect at the same time in England and in Wales and Northern Ireland. In Scotland local government reorganisation occurred roughly a year after health services were reorganised. In Northern Ireland an important innovation was bringing health and personal social services together under the same authorities. We discuss the relationship between the NHS and local authorities in Chapter 16.

4.5 The unification of the three parts of the NHS under single health authorities was generally supported before reorganisation was introduced. There were arguments about the means of achieving it, but the principle of unification was not seriously disputed. Indeed, the desirability of unification had been part of the conventional wisdom for many years. The difficulties of introducing the new arrangements were undoubtedly underestimated, and one important part of it, the NHS planning system, was not launched until two years after the transfer of staff and responsibilities had taken place. One commentator offered us the following advice:

“It will probably be at least a decade before its [ie the 1974 reorganisation’s] advantages and faults can be properly determined. For the moment perhaps one of the more significant contributions the Royal Commission on the National Health Service may be able to make is to encourage both the public not to make unrealistic demands for, and of, health care and also individuals working in the NHS not to have unrealistic expectations regarding the speed and manner in which the service’s problems can be resolved.”

NHS has too many tiers

4.6 The most common complaint in evidence about the reorganisation of the NHS was that it added an extra and unnecessary tier of management.  Many people suggested to us that this had resulted in delays in decision making, buck-passing, excessive quantities of administrators and paper, dupli­cation of work, too much consultation and too many meetings, and a lack of effective accountability at local level. The most popular solution suggested in England was abolition of the area health authority (AHA) but some people thought that the regional tier was unnecessary. Outside England, the function of the management team at district level was sometimes criticised.

4.7 The AHA in England and Wales (health board in Scotland and health and social services board in N. Ireland) is often seen as the new, tier, probably because before reorganisation there was no level in the hospital service which corresponded to it. The case for these authorities is founded on the interde­pendence of the NHS and local government in providing an integrated service to patients: for example, they provide medical advice to the matching local authority and the local authority provides social work services to the NHS. The overlapping functions are recognised in the common boundaries of most health and local authorities, and by local authority appointments to health authority membership. The pros and cons of these arrangements are dealt with in Chapter 16.

4.8 The case for the Regional Health Authority (RHA) is based largely on management needs. The White Paper on NHS Reorganisation in England said that regional health authorities were needed because:

“a central Department operating from London could not hope to exercise effective and prompt general supervision over area authorities whose numbers will be six times those of their counterparts in Scotland and eleven times those in Wales”.

RHAs also provide a number of services which are organised above area level, major building schemes, ambulances, blood transfusion and strategic planning, for example. However, common services like these do not require a regional tier. Regional health authorities do not exist outside England, but the Common Services Agency in Scotland provides ambulances, blood transfusion and other services for the health boards without exercising the monitoring role of RHAs in England, and similar agencies exist in Wales and Northern Ireland.

4.9 Reorganisation introduced new health authorities with unfamiliar roles and since reorganisation defects in the NHS have become apparent. But it does not follow that the one caused the other. Still less does it follow that abolishing one management level will produce an efficient service. We return to this theme in Chapters 19 and 20.

Too many administrators

4.10 There were allegations in our evidence about the swollen number of administrators, their poor quality and the diversion of clinical staff to administrative duties. Some of these were strongly worded. Mr A J N Phair wrote:

“Bureaucracy used to be a term to define the most efficient office procedures now in the NHS it can only be used in its pejorative sense of red tape, buck passing and considerable inexcusable delays which is partly caused by administrators shying away from their responsibilities and receding into the management structure cocoon”.

Nurse administrators

4.11 The implementation of the Salmon Committee’s recommendations on grading is often alleged to have “resulted in efficient Ward Sisters being promoted into administrative positions where their clinical expertise is unused, even though they may have none of the attributes of a good administrator”, as the British Hospital Doctors Federation told us. The argument was not that ward sisters should not be promoted, but that they should not be promoted away from caring for patients. On the other hand nursing organisations tended to support the Salmon structure and the improvement in status for nurses which it and the introduction of consensus management have brought. We make some suggestions about the nurses’ clinical career structure in Chapter 13.

4.12 While these complaints cannot be ignored, the figures do not support the view that the Salmon structure has markedly increased numbers of nurses in the grades above ward sister. In fact the proportion of nurses in these administrative grades has fallen over the period as Table 4.1 shows. There was a similar trend in Northern Ireland but precisely comparable figures are not available. No doubt these figures do not tell the whole story but, taking the UK as a whole, there seems little basis for the complaint contained in evidence from the BMA that “the Salmon Report [removed] from the clinical sphere, to the administrative one, an army of the best and most capable nurses”.

TABLE 4.1 Hospital Nursing Staff: Great Britain 1966-1977

Whole-time equivalent

Year All Nursing Staff Administrative Grades (grade 7 and above) Administrative Grades as % of all nursing staff
1966 252,211 11,768 4.7
1971 287,751 11,511 4.0
1973 311,497 11,228 3.6
1975 346,208 11,226 3.2
19771 379,699 13,822 3.6

Source: Health departments’ statistics. Note:   ‘ Includes midwives.

Administrators (‘The term is used to refer to staff covered by the Administrative and Clerical Whitley Council. These range from regional administrators to clerical and typing grades, and include such workers as catering, laundry, and domestic service managers)

4.13 The number of administrative and clerical staff employed in the NHS has increased substantially in recent years. In England in 1977 the equivalent of 99,000 administrative and clerical staff were employed, an increase of 21,892 (28%) on the numbers of equivalent staff employed in the health service and by local authorities in 1973. Slightly higher increases occurred in other parts of the UK. One explanation is that most of the increase stems from new jobs created by the reorganisation of the NHS: over 600 staff have been employed to service CHCs, for example. Some of the increase is due to expansion and developments which would have occurred anyway, particularly in clerical and secretarial staff supporting doctors and other NHS professionals and in personnel and other management services of the NHS, but some is undoubtedly due to new posts created by reorganisation. Detailed figures are not available before 1977 but are now being collected.

4.14 Many people assume that administrators are too remote from patients to have any substantial effect on their recovery and are at best a necessary evil, so that any increase in their numbers is to be deplored. But the assumption is not necessarily correct: the introduction of ward clerks and appointments and records clerks has enabled nursing staff to be released from clerical work, and the increase in their numbers may have contributed to the fall in the proportion of nurse administrators referred to above. The employment of more reception­ists/clerks in general practice has improved communication between GPs and hospital services; and better management of services may lead to savings. Finally, it is unfair to criticise the number of administrators unless a standard can be applied. We are aware of no research which could enable the “right” number of administrators to be established.

4.15 Administrators have tended to be blamed for a lot of what has gone wrong in the NHS since reorganisation. As one assistant sector administrator in the South of England put it:

“The worst affected is the Administrator, who has been as usual the scapegoat for all the Service’s ills. Indeed the majority of overspending is blamed on the Administrator, and all proposed cut-backs in the Service refer to administration.”

The Institute of Health Service Administrators pointed to the difficulties that administrators in the NHS have had to cope with since reorganisation, and drew attention to the discussions about further changes which might occur as a result of devolution, local amalgamations of health districts, and our own work. They told us that “The debilitating effect that uncertainty about the future has on morale cannot be too strongly stressed.” We have formed an encouraging view of how well many administrators have coped with the real difficulties caused by reorganisation and change, and we would reject criticism of them as a group. There is, however, much that can be done to make their work more effective, including improving standards of recruitment.

Slow decision taking

4.16 We were told about difficulties in getting decisions taken quickly since reorganisation.  Various reasons were suggested, including unclear areas of responsibility, consensus management and the consultation it apparently requires, the advisory committee structure, and the lack of administrators of sufficient seniority and calibre at hospital level.

4.17 Delays in decision making in the NHS seemed to us to be an important criticism of the reorganised service and we therefore commissioned Professor Maurice Kogan to undertake a study for us. His report, “The Working of the National Health Service”, was published in June 1978. Its findings, though to some degree impressionistic, were consistent with what we had been told in evidence. Complaints came mainly from those at operational level in hospitals. Those people working in the community health services may have been less affected, and paragraph 13.17 of the report comments:

“Especially in community services, nurses and doctors seemed to have little contact with the administrative structure, and did not feel hindered in carrying out their functions through lack of decision making. The units within which they worked were small and independent, and decisions about work were almost wholly taken by staff based within the unit.”

The report also makes the important point:

“It is not possible to say whether in fact decision making does take longer now than before reorganisation, but it is true that staff strongly think it does, and this colours their perceptions and feelings about the structure. Without structural modifications, the decision making process may improve when planning has become a more established and certain activity, and as staff gain in familiarity and skill in working the system. Some of the problems discussed above are related to the structure, but others are inherent in the health service.” (Paragraph 13.25)

These issues are discussed more fully in Chapter 20.

Money being wasted

4.18 Our terms of reference required us to consider “the best use and management of the financial” resources of the NHS. We deal with financial matters mainly in Chapter 21. We commissioned and published a report prepared by Professor John Perrin of Warwick University and his team, on the management of financial resources in the National Health Service.

4.19 In an organisation the size of the NHS it is not difficult to find places where money might be saved. Suggestions put to us ranged from smaller helpings of food for patients in hospital to the cost effectiveness of preventive medicine. ‘One interesting proposal put to us was the partial but systematic extraction of children’s teeth. This would save money on later dental repair. We felt that it might be dangerous to generalise this suggestion too widely. But it is important to distinguish between complaints of waste founded on different judgments about what the NHS should spend its money on, and those alleging inefficient use of funds. Professor Perrin’s study showed that while the system of financial management was probably adequate as a means of checking irregularities or improprieties it did little to ensure that resources were efficiently and effectively used.

Staff morale

4.20   We were also required to consider “the interests… of those who work in the National Health Service”. We would in any case have had to consider seriously the allegations in our evidence that morale amongst health service workers was low and what the causes of this might be. We go into *these questions in more depth in Chapter 12, but we say immediately that although there is reason for concern we do not believe that the NHS is on the point of collapse because of low morale, as many of our witnesses would have us believe.

4.21    “Morale” is a vague term, and it is not easy, therefore, to demonstrate convincingly that it is low or high, falling or rising. Professor Kogan’s report suggested that staff equated  morale “with a general state of content or discontent which might relate more to general feelings about the NHS than the feelings of satisfaction with their jobs or working context”.  There are certainly sound reasons for discontent amongst health service workers, but they are not necessarily the same reasons in all cases.

4.22 One factor which should not be overlooked is what the Rt. Hon. Enoch Powell MP (Minister of Health from 1960 to 1963) has called “a vested interest in denigration”. Writing before reorganisation he put his point this way:

“One of the most striking features of the National Health Service is the continual, deafening chorus of complaint which rises day and night from every part of it, a chorus only interrupted when someone suggests that a different system altogether might be preferable, which would involve the money coming from some less (literally) palpable source. The universal Exchequer financing of the service endows everyone providing as well as using it with a vested interest in denigrating it, so that it presents what must be the unique spectacle of an undertaking that is run down by everyone engaged in it.”

It is not true that criticism of the service is unjustified, but it is certainly true, in our view, that some of the problems of the NHS and those who work in it are exaggerated. This is true of morale also. The Mid Glamorgan AHA pointed out:

“What is apparent is that if the leaders of the service and the media continue to state that such a situation [i.e. low morale] exists staff will generally come to believe it.”

A “sickness service”

4.23 A common criticism is that the NHS is a “sickness” rather than a “health” service. Critics point to what they see as an imbalance between what is spent on preventing ill health, health promotion and long-term care and what is spent on the treatment of disease. Some people assume that if large sums were spent on prevention it would make curing unnecessary in most cases, and, as well as saving money, would keep us all much healthier. We think this too simple a view, and we go into the subject and the question of priorities in the next two chapters.


The NHS should get more money

4.24 Easily the most popular remedy for the failings of the NHS, especially and understandably with those working in it, was that much more money should be made available. The Labour Party in their evidence to us said:

“The national health service and the personal social services are under­financed and have always been under-financed compared with other comparable services.”

There is also the feeling that a higher proportion of the gross national product ought to be spent on health services. The BMA in their evidence said that “An insufficient share of total national resources has hitherto been allocated to the health services”. We have more to say on this subject in Chapter 21, but it is important to remember the almost unlimited capacity of health services to absorb resources.

Alternative methods of financing the NHS

4.25 Various ways of raising money for the NHS have been suggested. At present about 90% of the cost of the NHS is raised from taxation, the balance coming from National Health Insurance contributions and charges of various It was argued to us that if only people knew how much it cost they would be more careful in using the NHS. Popular suggestions for raising or
supplementing funds for the NHS put to us included; a lottery or some other method of voluntary fund raising; extending the present charges for NHS services and an insurance based scheme funding the whole or part of the NHS. The first two are usually seen as means of supplementing central funding rather than replacing it.

4.26 Those who support the idea of a lottery to help fund the NHS argue that large sums are spent on football pools, horse racing, etc, and that the profits might just as well be used in a good cause. They argue that people would like to contribute to the NHS if they knew that they were paying specifically for that purpose. A lottery seems a painless way of raising money, and there is the example of the Irish Hospital Sweep Stake available. We were also told that patients would gladly pay for some NHS goods and services, for example by making a contribution towards hospital “hotel” expenses, on the grounds that it costs something to live at home which is saved when meals and accommodation are free in hospital. Some patients are already “charged” for their stay in hospital; long-stay patients receiving pensions or social security benefits have these reduced after their eighth week in hospital, for example. The main alternative to financing the NHS out of central taxation is to do so through a health insurance scheme on the model of Western Europe or North We say more about these suggestions in Chapter 21.

The NHS should be taken out of politics

4.27 Underlying most proposals for alternative methods of raising money for the NHS is the assumption that government control and parsimony can somehow be avoided by an “independent” source of income – a lottery mechanism which delivers money without government strings attached, charges which add to funds automatically without government interference, or an insurance system outside the government fiscal institutions. The BMA, for example, referred in evidence to “the need to maintain a fund for health care separate from central Government funds”. This is one facet of the popular proposal that the NHS should be “taken out of politics”. Another is the feeling that the NHS should be above party political squabbles which may lead to changes in the priorities given to client groups within the NHS or to “political” decisions being made, such as that to phase out pay beds from NHS hospitals. On the same theme, some people consider that lay appointments to health authorities ought to be apolitical.

4.28    A solution often proposed is an independent health commission or board. It is said that such a body might act as a buffer between the government and the NHS, determine the money needed by the service on objective and non-political criteria, and undertake strategic planning and other functions required at national level. The role of the health departments would be modified accordingly. The analogy most often drawn is with the BBC or the nationalised industries. The pros and cons of a health commission are discussed in Chapter 19.

Integrating health and personal social services

4.29    NHS reorganisation in Great Britain was intended to integrate the hospital, family practitioner and local authority health services under the new health authorities, but laid responsibility for providing social work support on local authorities. The importance of collaboration between health and local authorities was constantly stressed to us, and some of those who sent us evidence proposed that the two services should be integrated in some way. The main suggestions were that the NHS should be run by local government, or that relevant social service provision – home helps, residential homes and social workers – be provided by the NHS. We deal with these matters in Chapter 16.

Further NHS reorganisation

4.30    Despite the dislocation and expense of the recent reorganisation, many of those giving evidence to us suggested further structural changes. They felt that the structure had to be got right now even if this meant further upheaval. We have already referred to proposals to drop a tier and to integrate the NHS and personal social services under one authority.  After the upheavals of reorganisation the willingness of some staff to contemplate further major structural change shows an impressive commitment to the welfare of the service, as well as considerable frustration with existing arrangements. The 1974 reorganisation produced:

  • an immense amount of administrative work in preparation for the new machinery;
  • disruption of ordinary work, both before and after reorganisation caused by the need to prepare for and implement the changes;
  • the breakdown of well established formal and informal networks;
  • the loss of experienced staff through early retirement and resignation;
  • the stresses and strains on some staff of having to compete for new jobs.

We were very conscious of these effects when considering further structural change. This is reflected in proposals we make in the chapters that follow.