- Email: [email protected]
VOICE FROM THE NORTH
1082 The DHSS engages in much non-executive activity. It issues circulars and reports. These are advisory only. On clinical subjects these are the consensus views of the health professions compiled by panels of experts from the NHS. They have no executive authority. Pamphlets dealing with policy and plansuch
Priorities
for
Health
and The Way the allocation of resources between the various sectors-acute, geriatric, community, mental illness, mental subnormality, maternity and children-but they have no force. Nor can they have: the tiers of health authorities make their own decisions. Was Owen correct, then, in referring to "a centralised bureaucracy that was stifling effectiveness" and in asserting that "administration must be streamlined and decision making made quicker and more decisive"? Decision making about what? Financial allocations? Planning permissions? Terms and conditions of service? The truth is that the NHS is not centrally controlled except with respect to the functions defined above. This explains why there is little animus against the DHSS and the RHAs. The opposition is to the AHAs, which _ were the child of the 1974 reorganisation. Duplication is open to the same objections in the operational sphere as it is in the upper tiers, but much of the criticism of structure is levelled as much at single district as at multidistrict AHAs. What was genuinely new in 1974 was the introduction of management into the NHS-the management, that is, of the health care of defined populations and of the whole range of health services. The previous concept of a Hospital Service, dominated by the acute sector and the consultants who work in it and divorced from the community health and social services, with small hospital management committees and administrators who were the servants of the health professions, carrying out their will, was abolished. Are the professions and the politicians now at cross-purposes, the former believing that a net of unitary district health authorities will put the clock back, the latter, that such a net will advance the clock still further? Behind the impulse for further reorganisation are three assumptions. The first is that the bureaucratic suprastructure is hugely expensive. Where is the evidence? I understand that the administrative corps is the smallest of any developed country and, with 6% of the NHS labour force, it is smaller than those of the nationalised and larger private industries in the U.K. The second assumption is that by its non-executive activity the DHSS is running the show (and stifling it). The responsibility for so-called monitoring by the RHAs comes into this category. This assumption causes great confusion among those, not employed in the NHS, who engage in its reorganisation. The third assumption, made explicitly by the Royal Commission, is that planning and operational functions are distinct. Planning can only mean capital planning (function 8). This requires capital resource decisions, but otherwise it is a technical problem for architects and engineers. The real planning, the planning that matters in the Health Service, takes place at the operational level and refers to clinical policies and the distribution and strength of the various specialties and sectors providing for the local population. This is the crucial issue. None of this is to deny Owen’s prescription, only his diagnosis. The elimination of bureaucratic suprastructure and of unnecessary administrative jobs (and there are some) is welcome. But the result will be greater centralisation of functions 1, 2, and 3 and, possibly, of 8 and 9 as well, and a redeployment of administrators to the operational level will bring them directly under the influence of professional forces which may not share his views about objectives.
ning issues,
as
Care
Forward, give the Secretary of State’s views
Avon Area Health
on
Authority (T),
Greyfriars, Lewin’s Mead, Bristol BS1 2EE
A. H. SNAITH
VOICE FROM THE NORTH member of a community health council I am reyour Nov. 3 editorial on N.H.S. funding in which you say "Rather less is heard from those parts of the country which gain from redistribution. Is the additional money being put to good use? Or are acutely ill patients dying in London in order that mentally ill patients in the North of England should have lockers by their beds?" Posed in this dramatic way the question is heavily biased towards the needs of the acutely ill but as you have not apparently heard much from the far North I would like to tell you of some of our concerns. In this area we have two big mental handicap hospitals. One of them is one of the largest in the U.K. and serves a population of 1.2 million. Both of these hospitals are very near the bottom of the national "league table" of costs of nursing care per inpatient day and total cost per patient per inpatient day. We accept that someone has to be at the bottom of the pile; the point which most concerns us, however is, the differential in resources available between hospitals around the country. The relatively wealthy mental handicap hospitals are in some cases receiving twice as much money per patient per inpatient day as do those in our area. This means that, despite great
SIR,-As
sponding
a
to
efforts to reduce overcrowding and to discharge able patients, the remaining patients, many of whom are severely handicapped, are nursed in a situation where it is difficult to offer more than custodial care. It is not possible to develop community psychiatric nursing services when hospital staff are so stretched and many initiatives in treatment and training must be frustrated. Last year our area health- authority devoted most of its betterment monies to funding 14 additional nurses in these hospitals-that was wonderful, but we need over a 100 more to attain minimum standards. RAWP’s recommendations do not apply to psychiatric hospitals but, taking the national average budget for psychiatric hospitals as a baseline, one of those on our patch is over 1 million underfunded per annum. The debt we owe to devoted staff is enormous, managers and others alike. Choosing priorities is a painful task in these hard times, but in the underfunded regions and areas you may be sure that every penny of the betterment monies is turned over and over before it is finally allocated. Acutely ill patients may die here too as a result of lack of resources; why is London so special? In my local paper today there is an article stating that the Northern Region is the only region without a comprehensive neonatal intensive-care unit and that more than 100 newborn babies die each year because of inadequate specialist care. Please do not grudge us our fair share of the resources we need, and to which we have a right. West House, Wylam, Northumberland NE41 8AW
JEAN K. B. MCCALLUM
HEALTH SERVICES BOARD
SiR,—Your Oct. 20 summary of the Trades Union Congress conference about the Royal Commission on the N.H.S. describes me as a "Self-confessed redundant member of the Health Services Board". I actually described myself as a "soon to be redundant member of the Health Services Board". The difference is important. Until the Government enacts legislation abolishing the Health Services Board I shall continue to perform my statutory duties under the law. Indeed, only a few days after your report appeared I was pleased to be one of the signatories to a report withdrawing a further 179 pay beds which, as he observed in the House of Commons, Mr Patrick Jenkin is obliged to carry out. National Union of Public Civic House, Aberdeen Terrace, London SE3 0QY
Employees, BERNARD DIX, Secretary
Assistant General
Priorities
for
Health
and The Way the allocation of resources between the various sectors-acute, geriatric, community, mental illness, mental subnormality, maternity and children-but they have no force. Nor can they have: the tiers of health authorities make their own decisions. Was Owen correct, then, in referring to "a centralised bureaucracy that was stifling effectiveness" and in asserting that "administration must be streamlined and decision making made quicker and more decisive"? Decision making about what? Financial allocations? Planning permissions? Terms and conditions of service? The truth is that the NHS is not centrally controlled except with respect to the functions defined above. This explains why there is little animus against the DHSS and the RHAs. The opposition is to the AHAs, which _ were the child of the 1974 reorganisation. Duplication is open to the same objections in the operational sphere as it is in the upper tiers, but much of the criticism of structure is levelled as much at single district as at multidistrict AHAs. What was genuinely new in 1974 was the introduction of management into the NHS-the management, that is, of the health care of defined populations and of the whole range of health services. The previous concept of a Hospital Service, dominated by the acute sector and the consultants who work in it and divorced from the community health and social services, with small hospital management committees and administrators who were the servants of the health professions, carrying out their will, was abolished. Are the professions and the politicians now at cross-purposes, the former believing that a net of unitary district health authorities will put the clock back, the latter, that such a net will advance the clock still further? Behind the impulse for further reorganisation are three assumptions. The first is that the bureaucratic suprastructure is hugely expensive. Where is the evidence? I understand that the administrative corps is the smallest of any developed country and, with 6% of the NHS labour force, it is smaller than those of the nationalised and larger private industries in the U.K. The second assumption is that by its non-executive activity the DHSS is running the show (and stifling it). The responsibility for so-called monitoring by the RHAs comes into this category. This assumption causes great confusion among those, not employed in the NHS, who engage in its reorganisation. The third assumption, made explicitly by the Royal Commission, is that planning and operational functions are distinct. Planning can only mean capital planning (function 8). This requires capital resource decisions, but otherwise it is a technical problem for architects and engineers. The real planning, the planning that matters in the Health Service, takes place at the operational level and refers to clinical policies and the distribution and strength of the various specialties and sectors providing for the local population. This is the crucial issue. None of this is to deny Owen’s prescription, only his diagnosis. The elimination of bureaucratic suprastructure and of unnecessary administrative jobs (and there are some) is welcome. But the result will be greater centralisation of functions 1, 2, and 3 and, possibly, of 8 and 9 as well, and a redeployment of administrators to the operational level will bring them directly under the influence of professional forces which may not share his views about objectives.
ning issues,
as
Care
Forward, give the Secretary of State’s views
Avon Area Health
on
Authority (T),
Greyfriars, Lewin’s Mead, Bristol BS1 2EE
A. H. SNAITH
VOICE FROM THE NORTH member of a community health council I am reyour Nov. 3 editorial on N.H.S. funding in which you say "Rather less is heard from those parts of the country which gain from redistribution. Is the additional money being put to good use? Or are acutely ill patients dying in London in order that mentally ill patients in the North of England should have lockers by their beds?" Posed in this dramatic way the question is heavily biased towards the needs of the acutely ill but as you have not apparently heard much from the far North I would like to tell you of some of our concerns. In this area we have two big mental handicap hospitals. One of them is one of the largest in the U.K. and serves a population of 1.2 million. Both of these hospitals are very near the bottom of the national "league table" of costs of nursing care per inpatient day and total cost per patient per inpatient day. We accept that someone has to be at the bottom of the pile; the point which most concerns us, however is, the differential in resources available between hospitals around the country. The relatively wealthy mental handicap hospitals are in some cases receiving twice as much money per patient per inpatient day as do those in our area. This means that, despite great
SIR,-As
sponding
a
to
efforts to reduce overcrowding and to discharge able patients, the remaining patients, many of whom are severely handicapped, are nursed in a situation where it is difficult to offer more than custodial care. It is not possible to develop community psychiatric nursing services when hospital staff are so stretched and many initiatives in treatment and training must be frustrated. Last year our area health- authority devoted most of its betterment monies to funding 14 additional nurses in these hospitals-that was wonderful, but we need over a 100 more to attain minimum standards. RAWP’s recommendations do not apply to psychiatric hospitals but, taking the national average budget for psychiatric hospitals as a baseline, one of those on our patch is over 1 million underfunded per annum. The debt we owe to devoted staff is enormous, managers and others alike. Choosing priorities is a painful task in these hard times, but in the underfunded regions and areas you may be sure that every penny of the betterment monies is turned over and over before it is finally allocated. Acutely ill patients may die here too as a result of lack of resources; why is London so special? In my local paper today there is an article stating that the Northern Region is the only region without a comprehensive neonatal intensive-care unit and that more than 100 newborn babies die each year because of inadequate specialist care. Please do not grudge us our fair share of the resources we need, and to which we have a right. West House, Wylam, Northumberland NE41 8AW
JEAN K. B. MCCALLUM
HEALTH SERVICES BOARD
SiR,—Your Oct. 20 summary of the Trades Union Congress conference about the Royal Commission on the N.H.S. describes me as a "Self-confessed redundant member of the Health Services Board". I actually described myself as a "soon to be redundant member of the Health Services Board". The difference is important. Until the Government enacts legislation abolishing the Health Services Board I shall continue to perform my statutory duties under the law. Indeed, only a few days after your report appeared I was pleased to be one of the signatories to a report withdrawing a further 179 pay beds which, as he observed in the House of Commons, Mr Patrick Jenkin is obliged to carry out. National Union of Public Civic House, Aberdeen Terrace, London SE3 0QY
Employees, BERNARD DIX, Secretary
Assistant General