- Email: [email protected]
A BAD EXAMPLE OF A GOOD IDEA
1130
mended the use of cold-cream for operating-room staff with dry skin, and mineral oil for eyebrows. Bacterial contamination of these shed skin scales was confirmed in experiments by Davies and Noble.6 Techniques for determining mask efficiency have not always considered the methods of mask fitting and how they are worn. Greene and Vesley,however, designed a test chamber which enabled evaluation of masks under actual conditions of use, but they apparently did not encounter a mask wiggler among their test subjects. The results of our study do not show that mask wiggling can cause wound infections, but they do indicate the extent of wound contamination that may occur with this practice. Most wounds contain bacteria at the time of surgical closure,8 and a subsequent infection depends upon several other factors including host defences, tissue trauma, foreign bodies, and the extent of bacterial contamination. The latter would appear to be appreciably increased by mask wiggling.
Dear
Royal Commissioners
This week’s offering for the Royal Commission on the National Health Service returns to the popular subject
of organisation. A BAD EXAMPLE OF A GOOD IDEA
WRITING in The Times recently,’ J. B. Priestley suggested that the State is rapidly becoming an administrative bully, whose bureaucratic machinery grows steadily more daunting to those for whose benefit it is supposedly designed, and whose public services tend to be expensive, clumsy, and ungracious. Whether or not you agree with his opinion will depend mainly I suppose upon your politics, but there are many people of all political persuasions, concerned in or with the provision of health care in Britian, who, if they are honest, will undoubtedly feel that at least part of what Mr Priestley says is applicable to the reorganised National Health Service. For reorganisation in practice, as distinct from reorganisation in theory, seems to me to be a prime example of a bad example of a good idea. Its aims are admirable; its attempt to implement them regrettable. Administratively speaking, we have produced an intricately woven magic carpet that just won’t fly. In an attempt to improve our priorities of provision by better planning and control, we have put the Service into an administrative strait-jacket. Where we should have a sensitive, flexible form of management we have a cumbersome and stultifying bureaucracy. The first of April, 1974, in other words, was a D-day on which the D really did stand for disorganisation, and only a further radical administrative restructuring will I believe bring sensible order out of the present frustrating chaos. These are strong words, but there are several reasons why I feel able to state my opinion in such terms. To start with I am a dedicated N.H.S. man who, like the late Baroness Mary Stocks, considers the Health Service as "the greatest, most imaginative and most widely beneficent of all our social services." In addition, despite 1. Times,
Oct. 16, 1976.
Measures to reduce the extent of contamination from this practice could include a surgical scrub of the face or application of facial creams. However, these recommendations might be difficult to enforce, and would probably not afford protection during a long surgical procedure. A better suggestion is that mask wigglers should be made aware of their habit and change to a different kind of mask-i.e., a softer type which extends beneath the chin and does not constrain the face, as does the moulded mask. REFERENCES
Ford, C. R., Peterson, D. E., Mitchell, C. R. Am. J. Surg. 1967, 113, 787. Madsen, P. O., Madsen, R E. ibid. 1967, 114, 431. 3. Nicholes, P. S. Surgery, Gynec. Obstet. 1964, 118, 579. 4. Prioleau, W. H Am. Surg. 1969, 35, 599. 5. Poth, E. J. Sth. Surg. 1941, 10, 810. 6 Davies, R. R., Noble, W. C. Lancet, 1962, ii, 1295. 7. Greene, V. W., Vesley, D. J. Bact. 1962, 83, 663. 8. Wise, R. I., Sweeney, F. J., Jr., Haupt, G. J., Waddell, M. A Ann. Surg 1959, 149, 30.
1. 2.
house governor of change, a I have a longer specialist postgraduate teaching hospital, and more direct experience of the organisation of reorganisation than most. As well as having to keep, in mv present job, a close liaison with the new administration at all four of its levels, I was for more than a year before April, 1974, secretary of a joint liaison committee, and for several months after that date acting administrator of probably the largest of the new area health authorities (teaching). Also as an ex-rugby football correspondent of a national newspaper, I obviously believe that the man on the sidelines sees more of the game than those who play it. And finally and perhaps most important of all, after 2years in the Service and 2yyears of experience of its new structure, I can honestly say that never before have I known staff morale to be lower, staff relationships poorer, time spent in meetings longer, administration more complex, money scarcer, and life generally more frustrating and difficult than it is now. Not that reorganisation is the sole cause of the present discontents. We have after all yet another national economic crisis on our hands, and industrial relations and its involved legislation clogs and complicates management in the Health Service just as much as it does elsewhere. Yet the new administrative structure must clearly be held responsible for some of the basic problems that now confound us-especially in England. For we have in Britain, let me remind you, not one N.H S. but six, and only in the English version have we introduced two administrative authorities-regional and area health authorities-between the central Health Department and the health districts. Neither must we in Britain overlook the price that we shall have to pay for being first in this particular administrative field. NL, other democratic country has taken so large and firm a step towards an integrated and comprehensive health service as we have. Inevitably, therefore, it is we who will suffer the difficulties and confusion of innovators and must try to learn from them. And the first thing we should learn is that administering health services is not the same as providing that that integrated health care does not necessarily nov
my
apparently unique vantage-point
of one of those islands of reaction in
as
a sea
1131
naturally from integrated administration. Without wishing to undervalue the work that I and others like me do, I sincerely believe that the restructured service has
pinned far too much faith on administration. It has concerned itself deeply in the way that health care is organised and paid far too little attention to the impact of that organisation on those who provide the care, the clinicians of all kinds-doctors, nurses, and other therapists. We have introduced into a Service that should be essentially personal, humane, and speedy in its action, a strong element of administrative remote control, which is expensive, clumsy, and slow and therefore highly frustrating to the clinicians, and consequently potentially damaging to the patients. The designers of the new administrative structure seem in fact to have overlooked for some inexplicable reason what I would see as four simple but fundamental principles of health-care management. These are that patients come to health services to be treated and not administered; that the N.H.S. is basically no more than an organisation designed to deliver care and treatment as swiftly and effectively as possible to sick people; that management must be the servant of the Service and not its master; and that the prime function of the administrator is to enable the clinicians to achieve their full potential in caring for the sick. But though I obviously cavil at the form of the new administration, its style-interprofessional, consesus team management-seems logical to me when health care itself has become a team exercise. The form of the structure, however, especially in England with its additional regional tier, is an administrative horse of a very different colour. Theoretically based on the simple administrative principle of maximum delegation downward and maximum accountability upward each tier in practice seems more intent in some misguided spirit of self-justification on controlling rather than just working with the one below it; a situation in my view which is bound to sound the death knell of good adminstration. I cannot, of course, pretend to have a guaranteed answer to the problem, but at least I have some possible solutions which I am prepared, obvious though they may be, to put before you. Firstly, if we really do believe in the fundamental management principle of delegation with accountability, then surely we should start practising rather than just preaching it. This means as far as I am concerned the concentration of the maximum possible authority and responsibility in the health districts, for that is where the Service actually meets the sick. It also means removing as many as possible of the administrative barriers that exist between the districts and the central providers of funds at the D.H.S.S. Sad though it may be for those who have toiled so hard to try to make the new system work, this will inevitably involve the dismantling of most of the present structure of regional and area health authorities. But dismantled in one way or another they must be. Whether all but the 34 single district areas should go, leaving the 14 regions intact; or whether the existing regions and areas should in some way be amalgamated into a very much smaller number of new area health boards, as suggested last year by Professor Warren, is 2 Warren M. D. Br.
med. J. 1975, iv,
183.
a matter of opinion and for investigation. I prefer the former arrangement, because fewer authorities are involved, but either way as long as those which stand between the Department and the districts stick religiously to their strategic planning and allocating roles I shall be content. What I want to see, however, is the introduction of small district health authorities responsible for the provision of comprehensive care to the population of their districts, with each closely linked to its existing community health council, and either singly or jointly to its local authority and especially the social services department (which ideally ought to be administered directly by the district health authority anyway). This, I believe, would provide as much coterminosity as is needed, for unless health care is actually to be handed over to the local authorities I cannot see this principle as ever being fully workable in practice. I also realise that my proposed rearrangement will involve the family-practitioner committees, but, like Professor Warren, I believe that these could be reorganised to fit in with the new arrangements either at regional/area board or even at district health authority level. What I see as more important is the need for district health authorities to be small, concerned solely with the management of their districts, be constituted of people with relevant knowledge and ability and-most important-free from the ideological political bickering that has certainly riddled some of the existing A.H.A.s. It is time in fact that the N.H.S. at all levels stopped being the butt of party politics and became instead an interparty responsibility in the interest of the nation as a
whole. The only other point I would make about the members of my district health authorities (and this applies even more to their consultant and G.P. colleagues on the district management teams) is that they should regularly be provided with some kind of education for the task they have to do-a singular omission of the present service. And, finally, a word on service planning-a key function of the reorganised N.H.S. Without wishing to denigrate what I accept as a key task, I cannot help doubting the existence of appropriate data in a useable form and more particularly our ability to use the data even when we are provided with it. Appraising and comparing the effectiveness of what we do has certainly up to now proved to be what Sherlock Holmes would have called "a 3-pipe problem", and I cannot see it being easily solved in the forseeable future. So, while I support our continued efforts to do so and in particular the continued use of health-care planning teams in this respect, there is, I believe, an essential need for these teams to be like their masters, the district health authorities. In other words they should remain small enough to do a practical and useful job effectively. Let them not (anyway at this stage of the game) spend their time on long-term planning of ideal services that we cannot afford, but rather on shorter-term schemes likely to be of direct and foreseeable benefit to patients. It is the patients after all who, to use a nasty but expressive modern cliche, are what the N.H.S. is supposedly all about. Bethlem Royal Hospital and Maudsley Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX
L. H. W. PAINE House Governor and
Secretary
mended the use of cold-cream for operating-room staff with dry skin, and mineral oil for eyebrows. Bacterial contamination of these shed skin scales was confirmed in experiments by Davies and Noble.6 Techniques for determining mask efficiency have not always considered the methods of mask fitting and how they are worn. Greene and Vesley,however, designed a test chamber which enabled evaluation of masks under actual conditions of use, but they apparently did not encounter a mask wiggler among their test subjects. The results of our study do not show that mask wiggling can cause wound infections, but they do indicate the extent of wound contamination that may occur with this practice. Most wounds contain bacteria at the time of surgical closure,8 and a subsequent infection depends upon several other factors including host defences, tissue trauma, foreign bodies, and the extent of bacterial contamination. The latter would appear to be appreciably increased by mask wiggling.
Dear
Royal Commissioners
This week’s offering for the Royal Commission on the National Health Service returns to the popular subject
of organisation. A BAD EXAMPLE OF A GOOD IDEA
WRITING in The Times recently,’ J. B. Priestley suggested that the State is rapidly becoming an administrative bully, whose bureaucratic machinery grows steadily more daunting to those for whose benefit it is supposedly designed, and whose public services tend to be expensive, clumsy, and ungracious. Whether or not you agree with his opinion will depend mainly I suppose upon your politics, but there are many people of all political persuasions, concerned in or with the provision of health care in Britian, who, if they are honest, will undoubtedly feel that at least part of what Mr Priestley says is applicable to the reorganised National Health Service. For reorganisation in practice, as distinct from reorganisation in theory, seems to me to be a prime example of a bad example of a good idea. Its aims are admirable; its attempt to implement them regrettable. Administratively speaking, we have produced an intricately woven magic carpet that just won’t fly. In an attempt to improve our priorities of provision by better planning and control, we have put the Service into an administrative strait-jacket. Where we should have a sensitive, flexible form of management we have a cumbersome and stultifying bureaucracy. The first of April, 1974, in other words, was a D-day on which the D really did stand for disorganisation, and only a further radical administrative restructuring will I believe bring sensible order out of the present frustrating chaos. These are strong words, but there are several reasons why I feel able to state my opinion in such terms. To start with I am a dedicated N.H.S. man who, like the late Baroness Mary Stocks, considers the Health Service as "the greatest, most imaginative and most widely beneficent of all our social services." In addition, despite 1. Times,
Oct. 16, 1976.
Measures to reduce the extent of contamination from this practice could include a surgical scrub of the face or application of facial creams. However, these recommendations might be difficult to enforce, and would probably not afford protection during a long surgical procedure. A better suggestion is that mask wigglers should be made aware of their habit and change to a different kind of mask-i.e., a softer type which extends beneath the chin and does not constrain the face, as does the moulded mask. REFERENCES
Ford, C. R., Peterson, D. E., Mitchell, C. R. Am. J. Surg. 1967, 113, 787. Madsen, P. O., Madsen, R E. ibid. 1967, 114, 431. 3. Nicholes, P. S. Surgery, Gynec. Obstet. 1964, 118, 579. 4. Prioleau, W. H Am. Surg. 1969, 35, 599. 5. Poth, E. J. Sth. Surg. 1941, 10, 810. 6 Davies, R. R., Noble, W. C. Lancet, 1962, ii, 1295. 7. Greene, V. W., Vesley, D. J. Bact. 1962, 83, 663. 8. Wise, R. I., Sweeney, F. J., Jr., Haupt, G. J., Waddell, M. A Ann. Surg 1959, 149, 30.
1. 2.
house governor of change, a I have a longer specialist postgraduate teaching hospital, and more direct experience of the organisation of reorganisation than most. As well as having to keep, in mv present job, a close liaison with the new administration at all four of its levels, I was for more than a year before April, 1974, secretary of a joint liaison committee, and for several months after that date acting administrator of probably the largest of the new area health authorities (teaching). Also as an ex-rugby football correspondent of a national newspaper, I obviously believe that the man on the sidelines sees more of the game than those who play it. And finally and perhaps most important of all, after 2years in the Service and 2yyears of experience of its new structure, I can honestly say that never before have I known staff morale to be lower, staff relationships poorer, time spent in meetings longer, administration more complex, money scarcer, and life generally more frustrating and difficult than it is now. Not that reorganisation is the sole cause of the present discontents. We have after all yet another national economic crisis on our hands, and industrial relations and its involved legislation clogs and complicates management in the Health Service just as much as it does elsewhere. Yet the new administrative structure must clearly be held responsible for some of the basic problems that now confound us-especially in England. For we have in Britain, let me remind you, not one N.H S. but six, and only in the English version have we introduced two administrative authorities-regional and area health authorities-between the central Health Department and the health districts. Neither must we in Britain overlook the price that we shall have to pay for being first in this particular administrative field. NL, other democratic country has taken so large and firm a step towards an integrated and comprehensive health service as we have. Inevitably, therefore, it is we who will suffer the difficulties and confusion of innovators and must try to learn from them. And the first thing we should learn is that administering health services is not the same as providing that that integrated health care does not necessarily nov
my
apparently unique vantage-point
of one of those islands of reaction in
as
a sea
1131
naturally from integrated administration. Without wishing to undervalue the work that I and others like me do, I sincerely believe that the restructured service has
pinned far too much faith on administration. It has concerned itself deeply in the way that health care is organised and paid far too little attention to the impact of that organisation on those who provide the care, the clinicians of all kinds-doctors, nurses, and other therapists. We have introduced into a Service that should be essentially personal, humane, and speedy in its action, a strong element of administrative remote control, which is expensive, clumsy, and slow and therefore highly frustrating to the clinicians, and consequently potentially damaging to the patients. The designers of the new administrative structure seem in fact to have overlooked for some inexplicable reason what I would see as four simple but fundamental principles of health-care management. These are that patients come to health services to be treated and not administered; that the N.H.S. is basically no more than an organisation designed to deliver care and treatment as swiftly and effectively as possible to sick people; that management must be the servant of the Service and not its master; and that the prime function of the administrator is to enable the clinicians to achieve their full potential in caring for the sick. But though I obviously cavil at the form of the new administration, its style-interprofessional, consesus team management-seems logical to me when health care itself has become a team exercise. The form of the structure, however, especially in England with its additional regional tier, is an administrative horse of a very different colour. Theoretically based on the simple administrative principle of maximum delegation downward and maximum accountability upward each tier in practice seems more intent in some misguided spirit of self-justification on controlling rather than just working with the one below it; a situation in my view which is bound to sound the death knell of good adminstration. I cannot, of course, pretend to have a guaranteed answer to the problem, but at least I have some possible solutions which I am prepared, obvious though they may be, to put before you. Firstly, if we really do believe in the fundamental management principle of delegation with accountability, then surely we should start practising rather than just preaching it. This means as far as I am concerned the concentration of the maximum possible authority and responsibility in the health districts, for that is where the Service actually meets the sick. It also means removing as many as possible of the administrative barriers that exist between the districts and the central providers of funds at the D.H.S.S. Sad though it may be for those who have toiled so hard to try to make the new system work, this will inevitably involve the dismantling of most of the present structure of regional and area health authorities. But dismantled in one way or another they must be. Whether all but the 34 single district areas should go, leaving the 14 regions intact; or whether the existing regions and areas should in some way be amalgamated into a very much smaller number of new area health boards, as suggested last year by Professor Warren, is 2 Warren M. D. Br.
med. J. 1975, iv,
183.
a matter of opinion and for investigation. I prefer the former arrangement, because fewer authorities are involved, but either way as long as those which stand between the Department and the districts stick religiously to their strategic planning and allocating roles I shall be content. What I want to see, however, is the introduction of small district health authorities responsible for the provision of comprehensive care to the population of their districts, with each closely linked to its existing community health council, and either singly or jointly to its local authority and especially the social services department (which ideally ought to be administered directly by the district health authority anyway). This, I believe, would provide as much coterminosity as is needed, for unless health care is actually to be handed over to the local authorities I cannot see this principle as ever being fully workable in practice. I also realise that my proposed rearrangement will involve the family-practitioner committees, but, like Professor Warren, I believe that these could be reorganised to fit in with the new arrangements either at regional/area board or even at district health authority level. What I see as more important is the need for district health authorities to be small, concerned solely with the management of their districts, be constituted of people with relevant knowledge and ability and-most important-free from the ideological political bickering that has certainly riddled some of the existing A.H.A.s. It is time in fact that the N.H.S. at all levels stopped being the butt of party politics and became instead an interparty responsibility in the interest of the nation as a
whole. The only other point I would make about the members of my district health authorities (and this applies even more to their consultant and G.P. colleagues on the district management teams) is that they should regularly be provided with some kind of education for the task they have to do-a singular omission of the present service. And, finally, a word on service planning-a key function of the reorganised N.H.S. Without wishing to denigrate what I accept as a key task, I cannot help doubting the existence of appropriate data in a useable form and more particularly our ability to use the data even when we are provided with it. Appraising and comparing the effectiveness of what we do has certainly up to now proved to be what Sherlock Holmes would have called "a 3-pipe problem", and I cannot see it being easily solved in the forseeable future. So, while I support our continued efforts to do so and in particular the continued use of health-care planning teams in this respect, there is, I believe, an essential need for these teams to be like their masters, the district health authorities. In other words they should remain small enough to do a practical and useful job effectively. Let them not (anyway at this stage of the game) spend their time on long-term planning of ideal services that we cannot afford, but rather on shorter-term schemes likely to be of direct and foreseeable benefit to patients. It is the patients after all who, to use a nasty but expressive modern cliche, are what the N.H.S. is supposedly all about. Bethlem Royal Hospital and Maudsley Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX
L. H. W. PAINE House Governor and
Secretary