- Email: [email protected]
A Challenge from Scotland
250
results are significantly better when transplants are well matched. Secondly, these results justify the delay necessitated by the need for HL-A typing and for preserving and transporting kidneys over considerable distances. The message seems clear: better a well-matched kidney a few hours old than a fresh one mismatched. No deleterious effect was observed after storage under optimum conditions up to fourteen hours. Potentially very valuable information may also come from consideration of the mismatched kidneys which nevertheless did well. This kind of collaboration can explore new approaches, including the role of factors such as antigenic strength, autoenhancement, and immune-response genes in graft survival. The Department of Health and Social Security proposes to establish a new kidney-distribution centre based on the Bristol blood-transfusion service and the National Tissue Typing Reference Laboratory set up two years ago, whose first task was to standardise and distribute the sera used to identify HL-A antigens. It is to be hoped that some way will be found to draw into the Department’s plans the accumulated experience of the London group, which has evidently forged close links with its counterparts elsewhere in Europe. After all, what is needed is an international kidney centre, since new developments in the techniques of organ preservation will soon make it feasible to deliver a well-matched kidney to any part of the globe in a fresh and viable condition.
A Challenge from Scotland CHANGING the
framework of institutions is couple of green-papers, an an Act of Parliament, and the trick off-white-paper, is done. Changing the way institutions operate is, however, a much more formidable task. Hence the interest of the report1 of the joint working-party, headed by Dr. J. H. F. BROTHERSTON, chief medical officer of the Scottish Home and Health Department, on the integration of medical work in the National Health Service. Although addressed to the particular situation of Scotland, the document is of obvious relevance to the rest of Britain. The problem which it examines is crucial to the entire reorganisation plan of Sir KEITH JOSEPH, the Secretary of State for Social Services: the problem of how to turn formal institutional integration into practical working integration in the day-to-day operations of the N.H.S. The Scottish Home and Health Department wisely realised that the implications of organisational change for the working doctor should be worked out well before the introduction of change itself. Here there is surely a lesson for the rest more or
legal
less easy:
a
1. The Integration of Medical Work in the National Health Service. Report of a Joint Working Party appointed by the Secretary of State for Scotland. H.M Stationery Office, 1971.
Again, the composition of the working-party deserves underlining: it is made up entirely of the medical profession, though representing all sections-academics, consultants, general practitioners, and public-health administrators. It is the profession trying to work out its own future by revamping its jobs. Once more, perhaps, there is a of the country.
moral for the rest of the country, where there is a danger that wrangles about details of the consultative document2 may persuade doctors to lose sight of their own opportunities for achieving change as well as resisting it. What, in the view of the working-party, are the main implications for the profession of trying to make a reality of integration ? The starting point for its recommendations is a simple one-so often accepted in principle, so often ignored in practice-scarce manpower skills must be allocated in the most " effective way. Professional sentiment or premust not stand in the way of delegating judice " work, either within the medical profession or to nonmedical staff outside it. In short, although the report is too polite to put it quite so crudely, traditional demarcation lines will have to give way. From this general point, the report makes a number of recommendations about bridging the gap between general practice and hospital specialists. On the one hand, it proposes that (over a period of time) general practitioners should play an increasing role as members of " appropriate specialist teams " in general hospitals. In particular, it suggests that general practitioners could play a bigger part in paediatrics and geriatrics, both inside and outside the hospital, and that with suitable training they would not require to refer too many clinical problems to the general physician. On the other hand, it recommends that specialists should become increasingly concerned in the work of health centres, which, properly supplied both with diagnostic equipment and supported by a community team of social and other paramedical workers, would help to raise standards and diminish the need to refer patients to hospitals. In effect, the report proposes what can only be called a process of professional inter-penetration: a recognition at last of functional interdependence and the need for real continuity of care in looking after chronic conditions with periodic acute episodes and remissions. It is hard to fault this strategy. If the general practitioner is to become anything more than a glorified hospital sifter or gate-keeper, and if N.H.S. resources are to be used to best effect, then he must take a greater share of work in hospital. Indeed, the working-party only spells out the logic of a succession of reports:’ Cohen,3 Gillie,4 and B.M.A. primary-care 2. National Health Service Reorganisation: Consultative Document. Department of Health and Social Security, 1971. 3. Report of the Committee on General Practice within the N.H.S.
4.
Central Health Services Council. H.M. Stationery Office, 1954. on the Field of Work of the Family Doctor. Central Health Services Council. H.M. Stationery Office,
Report of the Sub-committee 1963.
251
study.5 If general practice is not to atrophy, it must be given an enriched role. In turn, this inevitably means that specialists will have to accept what some of them may regard as dilution, though in fact it could rather more correctly be seen to be one more step in the process of allowing specialists to concentrate full-time on the specialisms for which they have been highly and expensively trained-instead of, as so often, being prodigal with their skills on patients who do not need them. This objective has a number of important implications both for the organisation of the Health Service and for the medical profession. The general practitioner would have to delegate some of his existing work to nurses and other members of his healthcentre team. He himself would become the general physician of the future, while today’s general physicians would become tomorrow’s cardiologists, endocrinologists, nephrologists, and immunologists. Acceptance of the Brotherston report would thus mean a much-needed reversal of the historic trends which have always been towards more and more professional monopolies and exclusiveness-in Medicine as in Law. Yet the medical profession would be setting itself against all current trends if it resisted these recommendations: for in an era where it is becoming increasingly accepted that technological skills are in constant need of renewal and that the emphasis has to be on training people for flexibility, it is hard to maintain that the medical profession alone should be immune from the changes implicit in such an approach. Again, the medical profession will have to adjust not only its internal relationships but also those with related professions. In particular, it will have to think seriously about its relations with the new breed of managers which Sir KEITH JOSEPH is proposing to inject into the N.H.S. There is a danger that the medical profession may simply ignore the need for improved management and its own direct responsibilities 6for bringing it about: rather as if the captain of a ship were to refuse to talk to the chief engineer down below. Hence the emphasis in the report on a system of medical advisory committees at all administrative levels to act as a link between the profession and the managers. Here again, though, there is bound to be a period of strain, while traditional attitudes are remoulded and adjusted. During a time of such strain, the role of the medical profession in the administration of the proposed new organisation of the N.H.S. is going to be all the more important. Implicit in the Brotherston recommendations is a new way of looking at the organisation of medical work: on the basis of the needs of the community as a whole as distinct from those of a number of discrete sectors or individual patients. If this view is to be acceptedand unless it is, there cannot be much hope of major 5. 6.
Primary Medical Care. British Medical Association Planning Unit Report no. 4. London, 1970. Logan, R. F. L., Klein, R. E., Ashley, J. S. A. Br. med. J. 1971, ii, 519.
changes
in
working practices-then a major job of to be done. And inevitably the catachange and the prophets of this faith will
conversion has
of be the new breed of medical administrators: the specialists in community medicine-or community physicians.7 Rightly, therefore, the report puts great emphasis on the training of community-medicine specialists, the essential linkmen between clinicians, general practitioners, administrators, and local authorities. The doctrine of the Brotherston report, its advocacy of breaking down professional barriers and moving towards a kind of hybrid general-practitioner/ specialist, is not so very revolutionary. Indeed the fact that much of it sounds almost familiar is a tribute to its chairman, and his success over the years in making his pioneering, ecumenical ideas more widely acceptable. Far more revolutionary is that Scotland is quietly beginning to move in the direction outlined. Equally revolutionary is the spectacle of the medical profession for once anticipating the effects of institutional change: if there had been similar foresight in 1948-instead of an excessive preoccupation with pay and various backward-looking issues-many of the initial failures of the N.H.S., caused by imposing a tight organisational straitjacket on a fast-changing technology, might have been avoided. To praise the Brotherston report is not to underestimate the problems of applying a similar approach in the less homogeneous and less intimate circumstances of the N.H.S. in England and Wales. Given the existing inter-professional disputes8 it seems almost foolhardy to risk aggravating them. Again, it is difficult to devise positive incentives to change: why should the middle-aged general practitioner or consultant, comfortably set in his ways, be expected to change for the greater good not of himself but for that abstraction-the needs of his community ? Is this too altruistic ? To talk of increasing managerial efficiency is easy: to carry out the task of social engineering required to make it a reality is fiendishly difficult. As the report recognises, it would be only too tempting for different sections of the profession to block change-for the general practitioner to take refuge in the " mystique of general practice ", for the specialists to cling on to " the resources which by an accident of history they at present monopolise ", and for both groups to deprive their patients of the benefits which " can accrue from epidemiological analysis of their problems " by the community physician. The report also concludes, however, by ringingly expressing its confidence that the medical profession will meet this challenge positively. That is a faith which the medical profession throughout Britain should seek to justifyfor its own sake.
lysts
7. Morris, J. N. Lancet, 1969, ii, 811. 8. Br. J. Hosp. Med. July, 1971.
results are significantly better when transplants are well matched. Secondly, these results justify the delay necessitated by the need for HL-A typing and for preserving and transporting kidneys over considerable distances. The message seems clear: better a well-matched kidney a few hours old than a fresh one mismatched. No deleterious effect was observed after storage under optimum conditions up to fourteen hours. Potentially very valuable information may also come from consideration of the mismatched kidneys which nevertheless did well. This kind of collaboration can explore new approaches, including the role of factors such as antigenic strength, autoenhancement, and immune-response genes in graft survival. The Department of Health and Social Security proposes to establish a new kidney-distribution centre based on the Bristol blood-transfusion service and the National Tissue Typing Reference Laboratory set up two years ago, whose first task was to standardise and distribute the sera used to identify HL-A antigens. It is to be hoped that some way will be found to draw into the Department’s plans the accumulated experience of the London group, which has evidently forged close links with its counterparts elsewhere in Europe. After all, what is needed is an international kidney centre, since new developments in the techniques of organ preservation will soon make it feasible to deliver a well-matched kidney to any part of the globe in a fresh and viable condition.
A Challenge from Scotland CHANGING the
framework of institutions is couple of green-papers, an an Act of Parliament, and the trick off-white-paper, is done. Changing the way institutions operate is, however, a much more formidable task. Hence the interest of the report1 of the joint working-party, headed by Dr. J. H. F. BROTHERSTON, chief medical officer of the Scottish Home and Health Department, on the integration of medical work in the National Health Service. Although addressed to the particular situation of Scotland, the document is of obvious relevance to the rest of Britain. The problem which it examines is crucial to the entire reorganisation plan of Sir KEITH JOSEPH, the Secretary of State for Social Services: the problem of how to turn formal institutional integration into practical working integration in the day-to-day operations of the N.H.S. The Scottish Home and Health Department wisely realised that the implications of organisational change for the working doctor should be worked out well before the introduction of change itself. Here there is surely a lesson for the rest more or
legal
less easy:
a
1. The Integration of Medical Work in the National Health Service. Report of a Joint Working Party appointed by the Secretary of State for Scotland. H.M Stationery Office, 1971.
Again, the composition of the working-party deserves underlining: it is made up entirely of the medical profession, though representing all sections-academics, consultants, general practitioners, and public-health administrators. It is the profession trying to work out its own future by revamping its jobs. Once more, perhaps, there is a of the country.
moral for the rest of the country, where there is a danger that wrangles about details of the consultative document2 may persuade doctors to lose sight of their own opportunities for achieving change as well as resisting it. What, in the view of the working-party, are the main implications for the profession of trying to make a reality of integration ? The starting point for its recommendations is a simple one-so often accepted in principle, so often ignored in practice-scarce manpower skills must be allocated in the most " effective way. Professional sentiment or premust not stand in the way of delegating judice " work, either within the medical profession or to nonmedical staff outside it. In short, although the report is too polite to put it quite so crudely, traditional demarcation lines will have to give way. From this general point, the report makes a number of recommendations about bridging the gap between general practice and hospital specialists. On the one hand, it proposes that (over a period of time) general practitioners should play an increasing role as members of " appropriate specialist teams " in general hospitals. In particular, it suggests that general practitioners could play a bigger part in paediatrics and geriatrics, both inside and outside the hospital, and that with suitable training they would not require to refer too many clinical problems to the general physician. On the other hand, it recommends that specialists should become increasingly concerned in the work of health centres, which, properly supplied both with diagnostic equipment and supported by a community team of social and other paramedical workers, would help to raise standards and diminish the need to refer patients to hospitals. In effect, the report proposes what can only be called a process of professional inter-penetration: a recognition at last of functional interdependence and the need for real continuity of care in looking after chronic conditions with periodic acute episodes and remissions. It is hard to fault this strategy. If the general practitioner is to become anything more than a glorified hospital sifter or gate-keeper, and if N.H.S. resources are to be used to best effect, then he must take a greater share of work in hospital. Indeed, the working-party only spells out the logic of a succession of reports:’ Cohen,3 Gillie,4 and B.M.A. primary-care 2. National Health Service Reorganisation: Consultative Document. Department of Health and Social Security, 1971. 3. Report of the Committee on General Practice within the N.H.S.
4.
Central Health Services Council. H.M. Stationery Office, 1954. on the Field of Work of the Family Doctor. Central Health Services Council. H.M. Stationery Office,
Report of the Sub-committee 1963.
251
study.5 If general practice is not to atrophy, it must be given an enriched role. In turn, this inevitably means that specialists will have to accept what some of them may regard as dilution, though in fact it could rather more correctly be seen to be one more step in the process of allowing specialists to concentrate full-time on the specialisms for which they have been highly and expensively trained-instead of, as so often, being prodigal with their skills on patients who do not need them. This objective has a number of important implications both for the organisation of the Health Service and for the medical profession. The general practitioner would have to delegate some of his existing work to nurses and other members of his healthcentre team. He himself would become the general physician of the future, while today’s general physicians would become tomorrow’s cardiologists, endocrinologists, nephrologists, and immunologists. Acceptance of the Brotherston report would thus mean a much-needed reversal of the historic trends which have always been towards more and more professional monopolies and exclusiveness-in Medicine as in Law. Yet the medical profession would be setting itself against all current trends if it resisted these recommendations: for in an era where it is becoming increasingly accepted that technological skills are in constant need of renewal and that the emphasis has to be on training people for flexibility, it is hard to maintain that the medical profession alone should be immune from the changes implicit in such an approach. Again, the medical profession will have to adjust not only its internal relationships but also those with related professions. In particular, it will have to think seriously about its relations with the new breed of managers which Sir KEITH JOSEPH is proposing to inject into the N.H.S. There is a danger that the medical profession may simply ignore the need for improved management and its own direct responsibilities 6for bringing it about: rather as if the captain of a ship were to refuse to talk to the chief engineer down below. Hence the emphasis in the report on a system of medical advisory committees at all administrative levels to act as a link between the profession and the managers. Here again, though, there is bound to be a period of strain, while traditional attitudes are remoulded and adjusted. During a time of such strain, the role of the medical profession in the administration of the proposed new organisation of the N.H.S. is going to be all the more important. Implicit in the Brotherston recommendations is a new way of looking at the organisation of medical work: on the basis of the needs of the community as a whole as distinct from those of a number of discrete sectors or individual patients. If this view is to be acceptedand unless it is, there cannot be much hope of major 5. 6.
Primary Medical Care. British Medical Association Planning Unit Report no. 4. London, 1970. Logan, R. F. L., Klein, R. E., Ashley, J. S. A. Br. med. J. 1971, ii, 519.
changes
in
working practices-then a major job of to be done. And inevitably the catachange and the prophets of this faith will
conversion has
of be the new breed of medical administrators: the specialists in community medicine-or community physicians.7 Rightly, therefore, the report puts great emphasis on the training of community-medicine specialists, the essential linkmen between clinicians, general practitioners, administrators, and local authorities. The doctrine of the Brotherston report, its advocacy of breaking down professional barriers and moving towards a kind of hybrid general-practitioner/ specialist, is not so very revolutionary. Indeed the fact that much of it sounds almost familiar is a tribute to its chairman, and his success over the years in making his pioneering, ecumenical ideas more widely acceptable. Far more revolutionary is that Scotland is quietly beginning to move in the direction outlined. Equally revolutionary is the spectacle of the medical profession for once anticipating the effects of institutional change: if there had been similar foresight in 1948-instead of an excessive preoccupation with pay and various backward-looking issues-many of the initial failures of the N.H.S., caused by imposing a tight organisational straitjacket on a fast-changing technology, might have been avoided. To praise the Brotherston report is not to underestimate the problems of applying a similar approach in the less homogeneous and less intimate circumstances of the N.H.S. in England and Wales. Given the existing inter-professional disputes8 it seems almost foolhardy to risk aggravating them. Again, it is difficult to devise positive incentives to change: why should the middle-aged general practitioner or consultant, comfortably set in his ways, be expected to change for the greater good not of himself but for that abstraction-the needs of his community ? Is this too altruistic ? To talk of increasing managerial efficiency is easy: to carry out the task of social engineering required to make it a reality is fiendishly difficult. As the report recognises, it would be only too tempting for different sections of the profession to block change-for the general practitioner to take refuge in the " mystique of general practice ", for the specialists to cling on to " the resources which by an accident of history they at present monopolise ", and for both groups to deprive their patients of the benefits which " can accrue from epidemiological analysis of their problems " by the community physician. The report also concludes, however, by ringingly expressing its confidence that the medical profession will meet this challenge positively. That is a faith which the medical profession throughout Britain should seek to justifyfor its own sake.
lysts
7. Morris, J. N. Lancet, 1969, ii, 811. 8. Br. J. Hosp. Med. July, 1971.