General Manpower Questions
12.1 This chapter deals with some important general matters affecting NHS workers. We begin with a discussion of the difficult issue of morale, a matter on which we have received much evidence. This leads on to the related issue of industrial relations. We then consider the way NHS workers see their roles and the way they relate to one another. Next we deal with methods of measuring and controlling the quality of the work done by NHS staff and the problems of manpower planning. We finish with a discussion about occupational health services for NHS staff.
Morale
12.2 We said in Chapter 4 that we did not think that the NHS was about to collapse because of the low morale of people who work in it, though some have tried to persuade us of this and many have told us that it is dangerously low. Professor Kogan’s study unequivocally supports the view that morale is low. But morale is difficult to assess, and our view is that while it is lower than we should like to see it, low morale is curiously patchy in its distribution, geographically and among different groups of workers. We set out below what we see as some of the main general causes of low morale amongst NHS workers.
12.3 The following factors affect all sorts and grades of NHS workers to a greater or lesser extent:
- the short-term effects of reorganisation – whatever the long-term merits of reorganisation, it is certain that in the short-term the changes in the organisation of the NHS, and of key administrators in it, led to extensive dislocation of work. Although relatively few staff were directly affected by reorganisation in the sense of having to change jobs, the effects were widely felt. Traditional loyalties were broken. Another aspect of this is the disappointment of many NHS workers that the long heralded reorganisation has achieved so little of what it set out to do. It could well be that in the short-term Professor Kogan was correct in saying:
“The disappointments expressed about reorganisation may say as much about unrealistic expectations as they do about what is happening”
- the country’s economic difficulties – NHS workers have been affected by inflation like everyone else and they have also seen the effects on staffing levels and buildings of continuing public expenditure restraint;
- changing roles and relationships – quite apart from the stresses and strains of reorganisation, the NHS has been subject to pressures arising from changes in attitudes of those who work in the service. Obvious examples are the increasing use of industrial action at all levels, and the growth in influence of nurses and other groups in decisions about the management of services and the treatment of patients;
- criticism of the NHS — unfortunately bad news about the NHS is more likely to be prominently featured in newspapers and elsewhere than good news. However well intentioned criticism of this kind may be, its cumulative effect is to undermine the confidence staff feel in what they are doing. An example of this, which we mentioned in Chapter 4 and refer to again below, is the constant criticism of administrators and administration which has certainly had a most damaging effect.
12.4 Nearly half the evidence submissions which mentioned low morale in the NHS were from doctors. Doctors are important in any discussion of morale because of their influence on other groups of staff. Some consultants felt that their position had been adversely affected by the increasing influence of other hospital staff and the development of an explicitly multi-disciplinary approach to patient care. As one of the best paid groups of health workers, consultants had been considerably affected by pay restraint (though no more than others in the public service at their pay levels), and this had been made no easier to bear by the introduction of the junior doctors’ new contract which resulted in some junior doctors’ earnings exceeding those of some consultants. Again, many doctors had been deeply disturbed by government decisions about the NHS, which they regarded as often having been taken for political reasons. These include the phasing out of pay beds which we deal with in Chapter 18, and the health departments’ priorities for the NHS. Many doctors were critical of these decisions and felt that they were arrived at without adequate consultation. Some also felt that the development of a stronger consumer influence, for example through CHCs, and the more critical attitude towards doctors and other health service workers it encourages, had undermined their position.
12.5 NHS reorganisation was an administrative measure, and administrators have had more than their fair share of difficulties since it took place. They have carried much of the burden of making the new system work, and have been the main recipients of criticism when it does not. The increase in their numbers, dealt with in Chapter 4, has been the subject of criticism both within and without the service. The more senior among them suffered the stresses of applying for jobs in the reorganised service, which clinical staff did not, and one of the consequences was that many found themselves in new places dealing with unfamiliar problems, with no established administrative machine to help Finally, uncertainty about the future structure of the service remains. As the Institute of Health Service Administrators said to us:
“Despite government assurances that no further major reorganisation is contemplated in the short term, many AHAs are actively discussing radical change at local level and the spectre of change resulting from devolution and the Royal Commission itself has appeared on the scene. In such a climate of uncertainty it is little wonder that morale is low.”
12.6 Other groups of staff have their own particular problems, and we have referred to doctors and administrators as illustrations of the importance of the particular circumstances of individual groups in any general discussion of morale. We attempt to deal in later chapters with some of the problems raised, but it is obvious that there is no panacea: each grievance needs to be considered separately. We hope that the recommendations we make elsewhere in this report will, if they are implemented, make some contribution towards a more contented workforce in the NHS.
Industrial Relations
12.7 There is no doubt about the importance of good industrial relations to patient and health service worker alike. This is a difficult and complicated area, and we are conscious that we shall not contribute much to the discussion simply by striking moral postures. In many respects the NHS is quite unlike industry, but some of its industrial relations problems are reflections of national problems which require national solutions. It is apparent, too, that health workers have felt that the NHS has not dealt fairly with them, and this can be seen in their attitude to the service. We hope that the suggestions we make below will help to dissipate this feeling. The importance of enlisting the support and harnessing the idealism of NHS staff cannot be over-emphasised.
12.8 The success or failure of industrial relations is often measured by the frequency of industrial action. This is not a particularly good criterion and is in any case imprecise. There are many kinds of industrial action other than complete withdrawal of labour which can seriously dislocate the service – working to rule, going slow, and selective refusal to co-operate with management are common enough examples. The failure to stimulate the enthusiasm of health workers, or to make the best use of their talents cannot be measured in these terms.
12.9 Table 12.1 gives some figures about strike action in the NHS and compares the average number of days lost per 1,000 workers in the NHS and in Great Britain as a whole. These are the only figures of industrial action available, a fact which reflects the difficulties of definition in this field. The Table is to be studied with the reservations referred to above prominently in In terms of days lost it suggests that the NHS has a much better record than the country as a whole. It also suggests that numbers of stoppages and days lost have increased markedly in the last decade.
12.10 As the largest employer in the country, the NHS will be affected by the same developments which affect other workers in the UK. The most obvious of these in recent years has been the government’s strict control of wages at a time of high inflation. Second, there has been an expansion of trade union membership amongst professional and white collar workers, including those in the NHS.
TABLE 12.1
Comparison of Days lost through Strike Action in the NHS with the Workforce as a Whole: Great Britain 1966-1977
| Year | Number of NHS staff | Number of stoppages | Number of staff involved | Number of days lost | Average number of days lost per 1,000 NHS staff | Average no. of days lost per 1,000 employees in Great Britain |
| 1966 | 728,838 | 2 | 500 | 500 | 0.69 | 100.0 |
| 1967 | 753,486 | 1 | 78 | 200 | 0.27 | 124.7 |
| 1968 | 761,747 | 1 | 80 | 80 | 0.11 | 211.4 |
| 1969 | 778,998 | 8 | 2,500 | 7,000 | 8.99 | 309.1 |
| 1970 | 792,307 | . 5 | 1,300 | 6,700 | 8.46 | 499.2 |
| 1971 | 799,673 | 6 | 2,900 | 4,700 | 5.88 | 625.9 |
| 1972 | 831,753 | 4 | 97,000 | 98,000 | 117.8 | 1,104.3 |
| 1973 | 843,119 | 18 | 59,000 | 298,000 | 353.5 | 324.4 |
| 1974 | 859,468 | 18 | 4,070 | 23,000 | 26.84 | 661.5 |
| 1975 | 914,068 | 19 | 6,000 | 20,000 | 21.88 | 270.6 |
| 1976 | 945,877 | 15 | 4,440 | 15,000 | 15.86 | 149.3 |
| 1977 | 970,900 | 21 | 2,970 | 8,200 | 8.44 | 448.0 |
Source: compiled from statistics provided by health departments and the Department of Employment
Third, the attitudes of professionals to their work has been changing. In the NHS this may be seen in the departure from an open commitment form of contract for junior hospital doctors and dentists, which may be followed by consultants and GPs; and their willingness to take industrial action. Finally, health workers and others in the public service have seen workers in other industries apparently benefiting from strike action. Some of the factors peculiar to the NHS were referred to in paragraph 12.3 above.
12.11 Unfortunately the NHS has so far lacked a systematic approach to dealing with industrial relations problems which arise at local level. This was borne out by a memorandum prepared for us by the Advisory, Conciliation and Arbitration Service (ACAS), with which the health departments were broadly in agreement, and which is reproduced in full at Appendix H. It identified a number of weaknesses in existing arrangements. Clarification of management relationships and responsibilities – not only for industrial relations – would itself be an important step forward. Personnel officers often lacked experience, some districts were without a district personnel officer, and where one had been appointed he might not get adequate support from the district management team. There were defects on the trade union side also. There were inter-union rivalries over recruitment and areas of influence, and in a few places there were problems with participation in local machinery. Machinery for settling disputes at district level was often lacking, but the Whitley Councils were too remote to deal with local problems. The ACAS memorandum emphasised the need for better industrial relations training for both staff representatives and management, including health authority members who are increasingly involved in industrial relations matters, and we recommend that the health departments and staff organisations and unions give this urgent attention.
12.12 Other evidence and Professor Kogan’s report confirmed many of ACAS’s conclusions. ACAS summed up their evidence as follows:
“In our view the NHS has reached the stage where it should review its IR policies and practices. Unless effective remedies are introduced urgently, we can see little prospect of avoiding continued deterioration in IR with associated frustration of management and staff, increased labour turnover, and noticeably poorer quality patient care.”
A number of detailed recommendations are made in the ACAS memorandum and we commend them to the health departments. A recent and welcome development in Northern Ireland is the employment of the Labour Relations Agency, the Northern Ireland equivalent of ACAS, to carry out a review of industrial relations in the health and personal social services.
12.13 The weaknesses in arrangements in the NHS for dealing with local disputes were the subject of a series of meetings held last year by the then Secretary of State for Social Services with representatives of health authorities, the professions and health service unions. The outcome was a draft procedure for dealing with disputes at local level. It was proposed that so far as possible disputes should be dealt with where they occurred. Those that could not be resolved at that level would be referred to area, and if necessary to regional disputes panels. If all else failed it would be open to either party to refer the dispute to ACAS. The proposals are currently being considered by the General Whitley Council and we hope that an agreed procedure can be reached very soon.
Whitley Councils
12.14 At national level, pay and conditions of service are negotiated for most staff by the Whitley Councils. They were established early in the life of the NHS, and there are at present eight functional councils in operation, each dealing with a particular group of staff, and the General Whitley Council which deals with matters common to all. Each council is composed of representatives of staff and management, including the health departments who also provide the secretariat to the management side. They cover England, Scotland and Wales; in Northern Ireland there is comparable machinery which ensures that agreements reached for Great Britain- are followed closely. Between them the Whitley Councils cover all NHS staff, except doctors and dentists and a comparatively small number of other NHS workers who negotiate directly with the health departments. Doctors’ and dentists’ remuneration is subject to the recommendations of the Doctors’ and Dentists’ Review Body. Regulations require health authorities to apply the terms of agreements reached when they have been approved by the health ministers, who, in effect, have power of veto over arrangements, though this is rarely directly used.
12.15 A number of criticisms of the Whitley Councils were made to us in evidence. The Association of Scientific and Technical and Managerial Staffs told us that:
“The present Whitley Council system should be replaced by proper collective bargaining structures, including agreed procedures for settling problems at the workplace.”
but this was not the generally held view, and most complaints were about the lack of flexibility in the agreements to meet local needs, the complexity of the agreements themselves, and delays in reaching them. The Association of Chief Administrators commented:
“there must be an improvement in the ‘quality’ of the agreements reached by the Whitley Councils. Many of the agreements reached in the past have proved to be complicated to apply, with resultant confusion and discontent, thus aggravating the industrial relations situation. The greatest step towards improving the quality of the agreements would be a more informed and co-ordinated Management Side of the Whitley Councils. Second in importance to the quality of the agreements, is the need for speed and clarity in the communication from the Whitley Council to local management of agreements reached.”
12.16 There are some general comments we should like to make. First, it seems to us that a Whitley Council system of some kind is needed in the NHS for the great majority of staff. Standardised, centrally negotiated terms and conditions promote the unity of a national service and relieve staff and management of the complexities of local bargaining on basic matters such as pay and hours of work. However, some questions need to be settled locally, and it may not be easy to decide where the line between central and local negotiations should be drawn. There is also the perennial difficulty of leaving sufficient flexibility in national agreements to enable local problems to be This is why the involvement of representatives of NHS management in negotiation is particularly important.
12.17 Second, we see no escape from government involvement in negotiations. The Society of Radiographers said to us:
“It has been a constant source of irritation to the Society that the majority of members of the Management Side appear to have little or no control over the total amount of money available. The Society believes that this has often prevented serious negotiation from taking place … We believe that if negotiation is to have any real meaning then all the Management Side members must be able to take a full part in negotiations and not be over-ruled by a few powerful DHSS members.”
However, in a public service the size of the NHS, almost wholly Exchequer financed, and in which 70% of expenditure is on staffing, the government has a duty to the taxpayer to keep a close watch on negotiations. This would be true even if there were not a defined government incomes policy which often requires interpretation in individual cases.
12.18 Third, a weakness of the existing arrangements is that the government apparently acts as both judge and prosecuting counsel in disputes about NHS pay and conditions: the health departments are represented on the Whitley Councils and the final arbiters on matters not settled there are the central departments. This has made the idea of an independent commission or review body to deal with pay seem more attractive. The Doctors’ and Dentists’ Review body is one example, and the Standing Commission on Pay Comparability in the public sector proposed by the last government is another. Other approaches of this kind in the past were represented by the Industrial Court and National Board for Prices and Incomes.
12.19 The Whitley Council system was reviewed in detail by Lord McCarthy in 1976 and his recommendations were subsequently widely discussed. The main points about Whitley Councils made to us in evidence were dealt with in his review. We consider that changes are needed to streamline the system generally, and, in particular, reduce the lengthy periods sometimes taken to reach agreements. Such delays may be resented by the staff concerned and may themselves lead to disputes.
Avoidance of industrial action
12.20 Those who work in the NHS have special responsibilities towards patients, and it is clear that the great majority are conscious of this. It is essential that they should be, but it is equally important that the government should not take advantage, or seem to take advantage, of the obligation health workers feel towards patients. We have already noted that some health workers feel that the NHS has not dealt fairly with them. When disputes occur the fault is unlikely to be wholly on one side or the other. It is too soon to forget the sad events of last winter, but the object should be not to apportion blame but to prevent them occurring again.
12.21 A suggestion made is that NHS workers should forego the right to strike, for example in exchange for compulsory arbitration. While this looks attractive at first sight, we do not think it goes to the root of the problem, or could provide a guarantee of industrial peace. Health workers, like other workers, will not find it necessary to take industrial action if they are satisfied with the arrangements for settling disputes over pay and conditions of service and if disputes which have arisen are seen to be fairly dealt with. If they are not so satisfied, it seems unlikely that the outlawing of industrial action could be made to stick. In the future, workers would not necessarily consider themselves bound by an agreement reached by their predecessors, possibly in different circumstances. There might be difficulties in defining what counted as industrial action. But although it is easy to write down these arguments against agreements of this kind, the benefits which would result both for patients and those who serve them are so great we would not want to dismiss the possibility out of hand, and would encourage those who might have the essential will and tenacity to see such agreements made.
12.22 We have referred to some of the weaknesses in arrangements for settling disputes at local level, and welcomed the procedures proposed for dealing with them. Procedures need also to be worked out for dealing with national disputes. They need to be rapid and generally understood if they are to be effective. Such procedures cannot be worked out when industrial action is taking place: they have to be discussed coolly and agreed when a broad view is possible. Because pay is such an important factor in national industrial disputes, the arrangements for settling disputes need to be linked to those for negotiating or determining pay.
12.23 We consider that a review is needed of the arrangements for negotiating pay and settling disputes at national level. We do not think this can be undertaken by the General Whitley Council, both because the review should cover the role of Whitley Councils themselves, and because it should include all groups of NHS workers some of whom are not represented in the Whitley Council machinery. It would be possible to establish a committee for this purpose, or to remit the responsibility to the Secretary of State for Social Services, but the talking has to start somewhere. We would ourselves suggest that the Secretary of State should reserve his position initially because in the end it is he who has to speak for the patient. On the other hand we were impressed by the progress last winter of the discussions mounted by the TUC with its affiliated unions and other bodies to work towards a national disputes
12.24 We therefore recommend that the TUC should take the necessary steps in initiating discussions which must involve not only those bodies affiliated to the TUC but bodies representing the interests of other NHS workers as well. Once a basis for wider discussion had been established, it might be helpful for a wider range of opinion to be brought to bear, perhaps at a series of conferences involving NHS management as well as staff interests. The object would be to recommend agreed procedures to the Secretaries of The method of reaching that objective would depend on progress made.
12.25 We do not attempt to predict the outcome of the discussions we propose should be launched, but two matters seem to us certain. First, the process we have sketched will take a considerable time, certainly months and quite possibly more than a year. It should be started as soon as possible, but it cannot be rushed. It requires patience and goodwill from those concerned, and above all a determination to succeed. Second, the eventual outcome will not seem startling or even novel in its basic approach. There are no magic wands to be waved in this field. It will be important that those most closely involved in the exercise should not start with preconceptions of its outcome. An approach which has been unsuccessful in the past may turn out to be acceptable today.
Roles and Relationships
Flexibility
12.26 The role of health workers is subject to many kinds of change but particularly those brought about by developments in techniques in health care. As the Regional Medical Officers told us:
“The character of health care is constantly changing, sometimes rapidly and extensively, more often quietly and imperceptibly, and this condition in turn gives rise to a continuous although unstructured process in which tasks and functions are redistributed between professions.”
To meet these changes staffing structures need to be flexible and so must be the attitude NHS workers adopt to their roles. Staff should be prepared to take on new work, if necessary with additional training or retraining, and be given the incentives to do so. Duties need to be defined, but not over zealously provided responsibilities are clear. In a service in which resources are in short supply it is also important that aides and unqualified staff should be used where possible, releasing skilled workers for jobs which require their expertise. The attitude of both staff and management should be one of encouragement towards innovation and experiment in the use of staff.
12.27 It is easier to advocate flexibility than to achieve it. The heavy investment in existing personnel, training syllabuses and institutions, Whitley Council agreements and professional codes of practice ensures that even the most marginal changes in activity are often extremely difficult to achieve. Staff may feel that their jobs are at risk, particularly in times of high unemployment, and that their status may be eroded if their traditional functions are not jealously guarded. In a few cases there may be legal problems.
12.28 One illustration of the difficulties can be seen in the efforts to amalgamate the professions of remedial gymnastics and physiotherapy. There are about the equivalent of 350 remedial gymnasts employed in the NHS in the UK. They have only one training school. The differences between the training, qualifications and activities of a remedial gymnast and physiotherapist are marginal. The Report of the McMillan Committee, on which both physiotherapists and remedial gymnasts were represented, said “Although each has a particular contribution to make, we recognise that there are great similarities between them”, and went on to recommend that the two professions should amalgamate. Despite this recommendation and the encouragement of the health departments, amalgamation has still not occurred.
12.29 The Institute of Health Service Administrators drew our attention to the growth of professionalism in the NHS:
“The high degree of professionalism in the NHS, which is fundamentally good, does, however, generate problems of using staff flexibly as skills become increasingly narrow. The pathology service provides a good example of this. The various branches of pathology are now largely separated and the professional and technical staff are no longer interchangeable.”
They went on to suggest that:
“The professional ethic is dominant in the NHS and leads quite naturally to the desire of non-professional staff to achieve this status. Specialist training has developed in a wide range of fields – theatre attendants, mortuary attendants, porters and many groups in the scientific fields. Whilst there is little doubt that the NHS has benefited from these increased skills, it has meant that the total manpower available is increasingly more difficult to re-deploy without re-training.”
The Institute saw the development of common-core training schemes as a way of encouraging flexibility between staff groups.
12.30 We think that it is certainly “in the interests both of the patients and of those who work in the NHS” that health workers, be they doctors, nurses or ambulancemen, serving the patient should feel pride in their work, should feel their jobs to be worthwhile and well-regarded, and should practise them to the best of their ability. But it will be the exception rather than the rule that patients will be looked after by only one kind of health worker, and if those caring for them are more concerned with their own status than the patients’ health and well being then the patients will be the losers.
12.31 At the same time staff will want to know what their broad responsibilities and duties are. In a team working closely together, for example, the surgeons, anaesthetists, nurses and orderlies working in an operating theatre, this should not be a problem, but in a less defined and constrained environment uncertainty about role can lead to trouble.
12.32 The solution does not lie in attempts to define precisely the roles of those caring for the patient. An interesting illustration of the difficulties of such an approach is provided by the Dentists Act 1957. This Act defines dentistry with the intention of confining the practice of dentistry to those on the Dental Register. It provides the following definition:
“For the purposes of this Act, the practice of dentistry shall be deemed to include the performance of any such operation and the giving of any such treatment, advice or attendance as is usually performed or given by dentists.”
In other words, dentistry is what dentists do. The Medical Acts wisely do not attempt to define medicine or to confine its practice to those on the Medical Register. If they did then the mother who diagnosed measles in her child and the wife who offered her husband aspirin for a headache would soon be in trouble. More seriously, the present-day nurse or physiotherapist now undertakes procedures which the doctor of yesterday would certainly have held to himself.
12.33 We consider it to be extremely important to the interests of the patient that flexibility of roles be exploited and built upon. Of course there will be procedures which can be undertaken safely only by a nurse trained in a particular way or a doctor with particular skills, and it will be the responsibility of all those caring for the patient to see that nothing but the best standards of care and treatment are offered to him.
12.34 Flexibility in training arrangements is particularly important. The Todd Royal Commission’s concept of an initial “general professional training” for doctors, with the emphasis on a common ground of experience and training before specialisation, has not prospered. The opportunities for switching over from one path of specialist education to another, for those uncertain about their career choice or wishing to change it, has not been facilitated. But many doctors still change their decisions about which specialty to pursue, and we think that there should be a further effort to create a wider and more flexible base for their post-graduate education. There is likely also to be an increasing demand for re-training; not only because changes in the need for particular services may require it, but because it may be stimulating for a specialist after a number of years of practice to enlarge or re-direct his interests. Where retraining is not incompatible with the needs of the service, it should be done without financial loss to the individual.
12.35 Another aspect of flexibility is the importance of the NHS making arrangements to employ those with domestic commitments who can only work part-time. Women constitute about 70% of the total NHS workforce, but the proportions vary between different categories of workers. About 90% of nurses, 75% of administrative and clerical staff” and about 67% of hospital ancillary workers are women, but only 18% of doctors. Part-time workers account for about half the workforce of hospital ancillary workers and one third of nurses, and the great majority of part-time workers are women. It is obviously extremely important that, relying as heavily as it does on part-time women workers, the NHS should make every effort to ensure that the best use is made of them, and maximum opportunity given to them to work in the health This will involve flexible working times, the provision of crèches, and opportunities for part-time training and re-training.
Aides and unqualified staff
12.36 Roughly one-quarter of all nursing staff in the UK are nursing auxiliaries and assistants who at best will have received only a brief in-service training. Substantial numbers of helpers are employed also in occupational therapy (where they outnumber registered staff) and physiotherapy. A few are employed in chiropody, radiography and speech therapy departments and in medical laboratories. The Briggs Committee, the McMillan Working Party and the Quirk Committee on Speech Therapy all supported the use of aides. The Briggs Committee saw them as an indispensable part of nursing teams. They also noted that the borderline between the role of the qualified and the unqualified nurse was indistinct and liable to change.
12.37 Aides require proper supervision, and there are limits to what unqualified people can be expected to do. In some cases they have been employed in response to shortages of trained staff in particular categories, and while the demand for qualified nursing and para-medical staff remains strong, they are likely to be welcomed by the professions. If there is over-production of trained staff, however, they may be seen as a threat – a cheap way of manning the service. There is already resistance to employing-aides, particularly from dentists, radiographers and the medical laboratory scientific officers. Nonetheless, where there are simple unskilled tasks which cannot be automated, as there are in laboratories, it is wasteful to use skilled staff to perform them. We understand that the introduction of a grade of aides for laboratories has been opposed by the Staff Side of the Whitley Council, and we regret this. The NHS should make the best use it can of the skilled manpower available and we think that more should be done to assess the scope for employing aides for the simpler tasks.
Inter-professional relationships
12.38 Uncertainties over role, the drive for professionalism, developments in the approach to treating patients, and the difficulty of giving guidance on how health professionals should work together in the treatment of patients may all be observed in the evidence we have received about what is referred to as the “multi-disciplinary clinical team” (MDCT). By this is meant a group of colleagues acknowledging a common involvement in the care and treatment of a particular patient. The staff in question may be doctor, nurse, social worker, and members of other disciplines, depending on what is wrong with the patient. The relations between members of the MDCT are unlikely to be formalised. The same questions arise whether one is talking of care in hospital or the community. Some of the problems put to us about the MDCT were questions of leadership, corporate responsibility, legal responsibility and confidentiality of records.
12.39 Most heat is generated over which member of the MDCT is to be regarded as its leader. The BMA told us:
“No doctor fails to recognise the necessity of co-operation with the nursing profession and with other medical workers and the benefit which he can derive from their experience. But this does not mean that the doctor should in any way hand over his control of the clinical decisions concerning the treatment of his patients to anyone else or to a group or team.”
12.40 The question then arises of what are to be regarded as “clinical decisions”. In practical terms the decision to operate on a severely injured patient is unlikely to be one to which the social worker, for example, will normally be expected to contribute. At the other end of the spectrum, the decision to discharge an elderly person into the community may depend crucially on the social worker’s view of the home circumstances. The Royal College of Nursing told us in oral evidence that:
“In the MDCTs the leadership role should be determined by the situation; in some circumstances, e.g. geriatrics, the nurse may reasonably assume the leadership role in continuing care situations, this currently happens and should be formally recognised.”
These examples will probably not be seriously disputed by any of those involved in patient care: it is those in between which seem to cause the difficulty.
12.41 In the past the doctor’s long and broad training, and his higher pay and status, made him pre-eminent amongst his non-medical colleagues. Many factors have come together to change this, among them changes in social attitudes and the increasingly sophisticated nature of the training undertaken by other professions. Whereas formerly the doctor probably took most decisions affecting patients on his own, he may now look to the nurse, speech therapist or dietitian for advice on particular aspects of treatment or care. Non-medical members of the MDCT will be experts in their own right, and as we have seen, there will be aspects of care where the doctor is not necessarily the best person to judge the patient’s interests. But if he is not, who should be “in charge” of the patient?
12.42 It would be impracticable to answer this question by specifying how an MDCT should work in all circumstances. The possible combinations of staff involvement and patient needs are infinite. In any case, we doubt whether in practice the problem is as difficult as it appears to be in principle. It is sufficiently clear that each health professional is likely to have the last word on matters which are clearly within his professional competence. It is pointless for us to rule on who should be “leader”, or indeed whether there should be a team leader in the ordinary sense. We are in no doubt that it is in the patient’s interests for multi-disciplinary working to be encouraged, provided that it is clear to the patient or his relatives, and to those professionals involved in his care, where responsibilities lie.
12.43 At national level the health departments do not regard it as their business to determine professional matters, or to settle demarcation disputes that may arise. This function is performed by a number of bodies, including for the medical and dental professions the General Medical and General Dental Councils and the Royal Colleges; for nursing and midwifery, the General Nursing Councils, Royal College of Nursing and Royal College of Midwives; and the Council for Professions Supplementary to Medicine. There are other bodies, statutory and otherwise, that govern other health service professions, and some Whitley Council agreements specify the functions of the staff they cover. What appears to be lacking is a mechanism for considering the functions of the different groups of health service workers looked at together and arbitrating between them. It seems clear to us that management of the NHS involves consideration of the roles of those who work in it, and that this is something to be undertaken by the health departments in consultation with the national bodies responsible for staff matters. We recognise that the handling of differences between the professions as to what their roles should be is, to put it mildly, a delicate matter, but it is one that the departments cannot duck. We recommend that they should intervene on those occasions when the health professions cannot reach agreement.
Measuring and Controlling Quality
12.44 The importance of ensuring high quality of treatment and care offered by those working in the NHS is certainly not something that need be argued. We have referred to the difficulties of measuring the performance of the NHS, and some of the same problems arise over deciding whether the right treatment is being used and the right sort of care given. Medicine is still an inexact science, and many of the procedures used by doctors, nurses and the remedial professions have never been tested for effectiveness. They are used because they have always been used and patients seem to get better. But patients get better anyway in most cases and a particular procedure or treatment hallowed by time and use may have little to do with it: certainly, the fact that one procedure helps does not mean that another procedure may not help more.
12.45 In attempting to measure quality of care the first thing is to establish standards. This is by no means easy. The obvious approach is to assess the outcome of treatment or care – is the patient better as a result of whatever treatment he has received? But the difficulties we refer to in Chapter 3 of denning and measuring health arise here also. The end product of health care must be the benefit to the patient. Uncertainties about whether and how far a patient has improved and what his improvement has been due to, or whether he has been well cared for, will be reflected in difficulties of establishing standards or norms for starring or procedures.
12.46 It is usually accepted that data about quality of-health care may be of three types:
- input – the resources used, mainly staff and institutions, but including such factors as the type and qualifications of staff and the accessibility and equipment of institutions;
- process – what is done to the patient under treatment, which includes diagnosis and care, and the after-care given;
- outcome – the effects of treatment and care, or the lack of it, on the patient.
These three approaches to the measurement of quality are linked. A favourable outcome to treatment depends on sufficient input of resources and the right processes being used. The old joke that “the operation was a success but the patient died” illustrates the risk of concentrating on process at the expense of outcome. An increasingly important consideration is the cost effectiveness of treatment. The development of sophisticated procedures, often extremely expensive in terms of staff and equipment, poses special problems. This is an aspect which cannot be ignored.
12.47 It is not easy to set national standards for any of these aspects of quality of care, even for input. It is easy to count hospital beds and numbers of staff, but attempts to set norms have usually met with failure or at best a good deal of resistance. Part of the problem is the difficulty of determining the need for services. The demand for services may not accurately reflect need, and may be internal, deriving from the health professions and reflecting in part perhaps a wish for extended career opportunities. Another aspect of the problem is the way health services have developed locally: hospital beds may be plentiful in some areas and the pattern of treatment and manning may reflect this. Some types of staff may be in short supply in particular areas. Trends in treatment change.
12.48 A number of techniques have been developed to assist evaluation of quality of care. One method of measuring the outcome of treatment is the randomised controlled trial (RCT) which is a method of obtaining a bias free result in comparing two treatments, or a treatment with no treatment. Professor Cochrane told us:
“there are large areas very much neglected, e.g. GP prescribing, length of hospital stay, and place of treatment, or looking at it from another angle Psychotherapy, Physiotherapy, Rehabilitation, Dermatology, Geriatrics and Obstetrics (although the situation in Obstetrics seems likely to be remedied in the near future).”
Large scale studies of this kind raise many practical problems. Large numbers of patients may be involved. Studies may take several years to set up and carry through, and reliable measures of outcome will be required. Studies of this kind may also raise ethical problems: a doctor’s obligation is primarily to his individual patient, but if a doctor taking part in an RCT comes to consider that his “control” patient would benefit from the treatment under examination, he has either to withdraw the patient from the RCT or suppress his own views. Nor can an RCT show how acceptable to patients the treatment may be. Nonetheless, there seems little doubt that the more widespread use of RCTs could eliminate procedures whose benefits are at present accepted simply because they have never been systematically challenged.
12.49 RCTs can also be used to evaluate services; and it would be a major advance if the health departments would as a matter of routine promote the testing of new and expensive services before their general introduction. The difficulties are formidable, the gains would be great.
12.50 Reliable case records are an invaluable vehicle for studying outcomes of treatment and quality of care. Far too often clinical records are illegible, incomplete and badly kept. The problem-oriented medical record is a form of structured record keeping which facilitates the retrieval of information and evaluation of outcomes; and we hope that current experimentation in its use will be continued and expanded. In Chapter 7 we discussed the need for upgrading generally the quality of record keeping in general practice. In hospitals standard extracts from in-patient records are processed by computer for the Hospital Activity Analysis (HAA); and a 10% sample of the HAA cases is analysed by the Office of Population Censuses and Surveys and the results published as the Hospital In-Patient Enquiry (HIPE). The data thus produced are required for examining the use of resources; for example, the throughput per hospital bed. They can be used also to some extent for studies of outcome: but relatively little use of them for this purpose has been made by clinicians and the reports of the HIPE have had less attention than they deserve. There is room here for progress, as there is in the development of record linkage (ie the linking of medical records which relate to the same individual) which allows outcomes of treatment to be evaluated more clearly.
12.51 We have referred to techniques for evaluating the outcome of We now turn to methods of improving the performance of individual health workers. Most NHS professions are hierarchically organised, and the junior will normally look to his superior for praise, blame and correction. However, medical and dental consultants and general practitioners, for example, are their own masters. There is no one to tell a consultant that he may not prescribe a particular drug or undertake a particular procedure, and in practice there are limits to the extent to which such staff as senior nurses and physiotherapists can supervise juniors. This independence is highly prized by the professions. A number of methods have been developed to ensure that staff who are exercising their own judgment should be aware of how their performance compares with that of their colleagues elsewhere. One form of checking is “professional audit” which involves, like financial audit, an examination of the books, in this case to see what treatment a patient has received. The idea is that clinical decisions should be checked, errors pointed out, and future improvements in performance achieved. While there is the difficulty of establishing standards already referred to, there are plenty of occasions when it would be agreed that a treatment was “bad” or “good” in particular circumstances. A successful application of this approach is the Confidential Enquiry into Maternal Deaths, launched in England and Wales in 1952 under which doctors review with a representative of the Royal College of Obstetricians and Gynaecologists the avoidable risks in each case of maternal death.
12.52 An informal variation on professional audit is peer review under which practising clinicians evaluate the quality and efficiency of the services provided by themselves and their colleagues. This may be no more than an informal discussion between two or three colleagues on the best way of dealing with particular problems, but in many hospitals it has become more formalised in regular clinical reviews of the treatment and progress of individual patients, or “death and complications” conferences. Peer review has the advantage that it is not imposed by some external body, and it avoids the difficulty of appearing to apply some ill-defined national standard, but unless it is undertaken systematically it will lack public credibility. We welcome the trend towards the introduction of regular peer review sessions and consider that it should be given every encouragement.
12.53 At an institutional level, the NHS has its own form of quality checking body in the Health Advisory Service in England and Wales and the Hospital Advisory Service in Scotland. These are teams of doctors, nurses and other staff who are seconded to work with the advisory service and who visit and evaluate mental illness, geriatric and, until recently, mental handicap services. On the whole their activities have been welcomed by the great majority of staff working in the field. We consider in Chapter 19 whether the functions and powers of the advisory services should be extended.
12.54 There are other approaches to encouraging higher standards: for example, NHS laboratories which do not take part in the UK National Quality Control Scheme may be refused approval as training institutions. Such an approach could be extended and we recommend that the Joint Higher Training Committees for post-graduate medical education should approve only those units and departments where an accepted method of evaluating care has been instituted. There may also be a place for “demonstration centres” of good practice and innovation in hospitals and elsewhere.
12.55 Systems of monitoring, whether run by a profession itself, or imposed by health departments or some other organisation, have their disadvantages. The feeling that someone may come round and blame you for your mistakes is not necessarily a healthy one. In the USA where a great deal of litigation is undertaken against doctors and where the courts have been willing to award high damages, “defensive medicine” has developed, characterised by doctors insisting on many expensive tests and procedures more designed to ward off blame than to establish a diagnosis. There is also a danger of establishing and perpetuating a rigid orthodoxy of approach and so discouraging innovation and experiment. We understand that there is also a legal difficulty here. Communications between doctors are not “privileged” for legal purposes, and, as the law stands, a doctor who had “audited” another doctor’s treatment of a patient could be obliged to reveal what the audit had shown. If it suggested that a mistake had been made it could form the basis for legal action against the doctor who had made the mistake. This consideration would need to be borne in mind if the introduction of any system of compulsory audit were under discussion.
12.56 While we are well aware of the difficulties of establishing standards it does not seem to us that they need discourage experiment in procedures for raising the quality of care. One issue is whether some form of audit should be imposed on the professions from outside. The Royal Colleges have for long given leadership in maintaining and raising standards of practice, and they have promoted much discussion of and some experimentation with clinical audit. Evaluation of patient care and post-graduate education are also closely linked and this is widely recognised. Audit is a responsibility of the clinical divisions in hospitals, but its progress in this setting has been slow. We are in no doubt that initiatives in this field can best come from the professions themselves, but despite recent developments we are not convinced that the professions generally regard the introduction of audit or peer review of standards of care and treatment with a proper sense of urgency. We recommend that a planned programme for the introduction of such procedures should be set up for the health professions by their professional bodies and progress monitored by the health departments.
Manpower Planning
12.57 Over one million people are employed in the NHS in the UK. The major staff groups are shown in Table 12.2. It is impossible with our present knowledge to say how many workers the NHS needs and of what type: roles are not always clearly defined, the level of training required may not be clear, and the difficulty of establishing standards of quality, referred to in the last section, is reflected in the absence of generally accepted staffing standards.
This lack also makes it difficult to monitor effectively over- and under-manning even locally. Nor do international comparisons of staffing levels offer much guidance. Finally, calculations about numbers of staff needed must take account of their relative cost and the availability of cash to pay them. The aim should be to provide as much good quality care as possible from a given budget.
TABLE 12.2 NHS Staff: UK 1977
| Category of staff | Unit | Numbers/wtes of staff (rounded) | Percentage of the total |
| Total ………………………………………………….. | number/ wte | 1,003,000 | |
| Doctors’ Hospital, community and school health medical staff and locums2 |
wte | 39 500 | 3.9 |
| General medical practitioners | number | 27 700 | 2.8 |
| Dentists1 Hospital, community and school health dental staff and locums3 | wte | 3 200 | 0.3 |
| General dental practitioners | number | 13 900 | 1.4 |
| Other Practitioners’ Hospital pharmacists and opticians |
wte | 3000 | 0.3 |
| Ophthalmic and dispensing opticians in the GOS, ophthalmic medical practitioners and pharmacists in the GPS | number | 24 800 | 2.5 |
| Nursing and Midwifery Staff Hospital, community, school health, blood transfusion service and agency staff |
wte | 430,500 | 43.0 |
| Professional and Technical Staff (excluding works) Scientific, technical, dental ancillary and remedial staff | wte | 64 700 | 6.5 |
| Ancillary Staff and Others Catering, laundry, domestic, portering etc staff | wte | 219 700 | 21 9 |
| Ambulance Service Staff Ambulance officers, control assistants and ambulancemen4 | wte | 20 900 | 2.1 |
| Administrative and Clerical Staff Administrators, clerical staff, support services managers etc |
wte | 123 200 | 12.3 |
| Works and Maintenance Staff Regional, area and district works staff and hospital maintenance staff |
wte | 31 600 | 3.2 |
Source: compiled from health departments’ statistics.
Notes: ‘ The addition of numbers and whole-time equivalents involves an element of duplication as some practitioners are included in both categories.
2 GPs holding hospital appointments are excluded.
3 Dentists holding hospital appointments are excluded.
1 Other ambulance service staff are included under the respective staff category.
12.58 Several of those giving evidence drew attention to a lack of national manpower planning for the NHS. The Institute of Health Service Administrators suggested that consideration should be given to establishing a national manpower committee comprising representatives of employing authorities and professional associations. National planning of medical manpower was regarded as particularly important, and the Regional Administrators suggested to us that:
“The key to the redeployment of manpower resources in the NHS is the redeployment of medical staff, for the necessary support in terms of other professional staff will follow providing the financial resources are likewise redeployed.”
12.59 There are two broad aspects to manpower planning: estimating the total numbers needed, for example how many physiotherapists overall are required; and getting them to the right places, for example ensuring that doctors are correctly distributed both geographically and by specialty. It is important to bear this distinction in mind when it comes to considering what the arrangements for manpower planning might be.
Existing arrangements
12.60 While strenuous efforts have been made to assess the numbers of doctors needed and to arrange for their proper distribution, comparatively little attention has been paid to other health service workers. The reasons for this neglect are partly historical: since 1948 the object has been to recruit more nurses, physiotherapists, technicians, without much regard to how many were needed. Attempts to establish norms have been made in the past, but have not commanded general acceptance. Furthermore, the majority of NHS staff, including ancillary and clerical workers, and many nurses and other professional and technical staff are recruited and trained locally, and there has been advantage in leaving local employers to recruit them in the numbers and mixtures they could afford and attract. This arrangement leaves the management function of manpower planning largely to health authorities and the function of estimating numbers largely in abeyance. It has the advantage of flexibility.
12.61 On the other hand, numbers of doctors required have been the subject of a succession of studies and there is elaborate central machinery to direct them to specialties and areas where they are most needed.1 There is obvious sense in this: doctors’ training takes a long time and is expensive. It also involves the universities. The expansion of medical training facilities is therefore a complicated and long-term business. However, attempts in the past to determine the numbers of doctors required have not been altogether successful for several reasons; role flexibility and the resource implications of alternative forecasts were not considered, and the data base was inadequate. The health departments are aware of the deficiencies of the statistical information, and their discussion paper, Medical Manpower – The Next Twenty Years, is a welcome development in this field.
Central planning machinery
12.62 Some of those who sent us evidence proposed a central planning body which would be independent of and advisory to the government and have the function of assessing the numbers and types of staff required for the NHS and the implications for the educational system. We are doubtful about establishing such an advisory body, and particularly one which would attempt to deal with all types of NHS staff, because we think it would have little to contribute to what we see as the main difficulty for the NHS in this field, that of ensuring the proper distribution of its workers. In our view this must remain the business of health departments and the health authorities. Furthermore, it would be a force for centralisation, whereas we consider that in general it should be left to the health authorities to recruit and train the staff they need within an overall policy. It is essential that those concerned with manpower planning at all levels should consult fully the representatives of the staff concerned and the health departments should ensure that they do so. There are already a number of bodies for the main groups of NHS staff with responsibilities for their recruitment, training and development. For example, in England and Wales there are the National Staff Committees which cover administrative and clerical, nurses and midwives, and some other groups of staff (though not doctors or dentists). These bodies are comparatively recent creations and should be left to get on with their jobs.
12.63 Nor do we see a lot of point in replacing the Central Manpower Committee for doctors and its equivalents in Scotland and Northern Ireland. However, the existing machinery is concerned with the distribution rather than the overall numbers of doctors, and we do not regard the present system of collecting views on numbers of doctors needed ad hoc every decade or so as satisfactory. It seems clear to us that there should be regular and more frequent reviews (approximately every two years) of the medical manpower position, following open and public discussion, and supported by better data than have so far been available. The responsibility for conducting these reviews should rest with the health departments. We recommend accordingly.
12.64 The manpower planning for one staff group needs to take account of changing roles, etc, of other related staff and while we do not advocate new central manpower planning bodies, we do consider that a more positive approach to manpower planning generally is required. The need for adequate data, which should be available locally, is urgent. It is important that local managers should keep records of staff turnover, their reasons for leaving, etc, and pay proper attention to planning career development of those who work for them.
12.65 In addition to improved statistical information more work is needed on numbers and roles. Experiments with different mixes of staff in different contexts, and the development of inter-professional training should be encouraged and we so recommend. Unless matters of this kind are studied deliberately changes in function to meet changing circumstances may occur haphazardly and become established before they can be evaluated. The health departments should ensure that the results are evaluated and make the information available to those involved in manpower There is a role here for the independent Health Services Research Institute which we recommend in Chapter 17.
Occupational Health Services For NHS Workers
12.66 Occupational health was discussed in Chapter 5. Here we comment on the need for an occupational health service for NHS staff. There was considerable support in our evidence for the proposal that the NHS should develop an occupational health service for its own employees. As the TUC said:
“We firmly hold the view that an occupational health service is essential for staff employed within the NHS and that this should be established as a matter of urgency.”
Most of the evidence urged that the proposals of the Tunbridge Committee should be implemented without delay. This Committee, which reported in 1968, recommended that hospital authorities “should aim at setting up an occupational health service for all their employees”, and added that while their recommendations were too wide-ranging to be quickly implemented throughout the hospital service, the NHS had a particular responsibility in occupational health which had in their view been neglected, and that a start needed to be made on a broad front.
12.67 The Tunbridge recommendations were accepted in principle by the government, but progress towards their implementation has been slow and uneven largely because of limitations on financial and manpower resources for which there are many competing demands. The health departments are consulting the NHS professions and trade unions on guidance to be issued on occupational health services for NHS staff. We hope that these discussions can be brought to an early conclusion. The NHS should assume the same responsibility as any other employer for the health and safety of its staff and set up an occupational health service. We recommend accordingly.
Conclusions and Recommendations
12.68 In this chapter we began by considering the morale of workers in the NHS. We were told by many people that morale was low, but we see this as a symptom rather than an underlying or constitutional disorder. We make no recommendations about morale itself, but we hope that the recommendations we make here and elsewhere in the report will lead to improvement.
12.69 We are in no doubt that industrial relations in the NHS are in need of improvement. At local level adequate machinery and staff are often lacking and it is clear that urgent action is needed. We welcome the proposals for procedures to deal speedily with local disputes which have been put to the General Whitley Council and hope they can soon be introduced. We also welcome the survey into industrial relations in the health and personal social services which is being undertaken in Northern Ireland. There is no single solution to the problem of industrial action in the NHS, but better local procedures should help to eliminate local disputes of the kind which have plagued the service in recent years.
12.70 The pay of NHS workers is a major cause of dispute at national The Whitley Council system has a number of faults: in particular, its sometimes cumbersome procedures may lead to excessive delays in reaching new agreements. We hope that Lord McCarthy’s review will lead to improvements. As pay negotiating bodies, the Whitley Councils are weakened by being insufficiently independent of government. This means that pay disputes may have to be resolved in some other forum.
12.71 We think it essential that a procedure should be worked out for resolving national disputes about pay. This will involve a review of existing pay arrangements, including the role of the Whitley Councils. It will take time and we think the initiative can best come from the TUC. In due course proposals should be put to the Secretaries of State and the NHS management interests.
12.72 The changing character of health care requires flexibility in the roles of those working in the NHS. On the other hand responsibilities and duties should be clear. In certain circumstances the two may pull in opposite Multi-disciplinary working brings out some of the difficulties. Another aspect is the need to assess the quality of the treatment and care provided by NHS workers. This can best be undertaken by the professions themselves, but the health departments should ensure that adequate progress is made. We considered whether it would be possible to lay down staff norms, to forecast needs and deficiencies, and eliminate shortages. We concluded that the needs and resources of different parts of the UK varied so greatly that centralised planning for all NHS staff would be wholly impracticable. Recruitment decisions should, for the most part, be made locally in the light of local needs within an overall policy. An exception to this is medical and dental manpower, both because it takes ten years or more to expand facilities for training doctors and dentists, and because of the extent of the involvement of the universities. In all cases staff interests need to be consulted and health departments should ensure that the machinery for this is adequate.
12.73 We consider that the NHS should assume the same responsibility as any other employer for the health and safety of its staff.
12.74 We recommend that:
- the health departments and staff organisations and unions should give urgent attention to industrial relations training for staff representatives and management (paragraph 12.11);
- the TUC should take the necessary steps in initiating discussions on a procedure for dealing with national disputes in the NHS which must involve not only those bodies affiliated to the TUC but bodies representing the interests of other NHS workers as well (paragraph 12.24);
- the health departments should intervene on those occasions when the health professions cannot reach agreement on staff roles (paragraph 43);
- the Joint Higher Training Committees for post-graduate medical education should approve only those units and departments where an accepted method of evaluating care has been instituted (paragraph 12.54);
- a planned programme for the introduction of audit or peer review of standards of care and treatment should be set up for the health professions by their professional bodies and progress monitored by the health departments (paragraph 12.56);
- the health departments should undertake, approximately every two years, a review of the medical manpower position, following open and public discussion, and supported by better data than have so far been available (paragraph 12.63);
- experiments with different mixes of staff in different contexts, and the development of inter-professional training should be encouraged (para graph 12.65);
- the NHS should assume the same responsibility as any other employer for the health and safety of its staff and set up an occupational health service (paragraph 12.67).