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Government in Public?
31
LEADING ARTICLES
the centre; and the distribution of accountability between the Ministry (or Department) and the boards is tacitly wrapped in a convenient haze which the green-paper does little to dispel. Then again, while the green-paper outlines methods for dealing with complaints, it does not recognise the need for an administration which (like that of a sound business undertaking) is alert and responsive to public mood.
THE LANCET LONDON
4
JANUARY
1969
Government in Public? THE Ministries of Social Security and of Health have been unified at a time when both were subject to ripples from the post-war surge in social legislation. In Social Security the Beveridge ideal of keeping personal poverty at bay through equal benefits from equal contributions is now widely seen as unattainable: with benefits in kind there are still formidable arguments for equality in distribution ; but with benefits in cash the only immediate hope of bringing adequate help to the poor is to weight their receipts at the expense of the more well-to-do. Already increases in family allowances have been related to income-tax; and a forthcoming white-paper seems likely to extend this principle to contributions. All this is a far cry from 1946. In the National Health Service, on the other hand, the practicability of the Act of 1946 has been clearly vindicated. But that Act, for all its strength, was also a patchwork of compromises-with local authorities, with hospitals, and, not least, with professional groups. The effects of these compromises are evident in the administrative structure of the Service, which has now been brought under official scrutiny in the Government’s green-paper.
Mr. CROSSMAN3 hopes that the green-paper will act stimulus and that some action can be taken in the life of the present Parliament. But no acceptable decision on the size and constitution of any new bodies to administer the Health Service can be reached without considering local government; and the Royal Commission on Local Government has yet to report, and Mr. CROSSMAN does not expect action on its findings in less than five years.3 The gains to be sought from administrative reform of the N.H.S. are great. They include increased local participation; an end to the tripartite structure; and a single hospital planning authority for each area. (This journal has for years called for such as a
unification; and
some
teaching hospitals, intent
on
becoming real university hospitals, now see that this may serve their interests no less than those of the surrounding regional hospitals.) But these and other gains are not to be snatched through reform shaped by random discussion of a document which everyone-except presumably its anonymous author-seems eager to disown. Many more ideas are around than are to be found in the green-paper. The alternatives should be displayed and argued; and this applies especially to the public-health service in view of the Seebohm report. It is not too late for Mr. CROSSMAN to set up a small high-powered group to spend most of their next twelve months taking evidence and preparing a report. By then the findings of the Royal Commission on Local Government will be known; and we shall have learned whether action is feasible in the life of the present Government.
The history of the green-paper is an unhappy one. Both the former Minister of Health and Mr. RICHARD CROSSMAN, as Secretary of State in charge of the unified Department, have denied that they are tied by its terms. Indeed why should they be ? With its main proposal for area health boards, it leaves too much unanswered. The suggested 50 area boards are too many for each to act as a coherent planning body, but too few to avoid some sort of second tier. How is this dilemma to be resolved ? Should at least some members of the new bodies be elected, and even (as the more searching Scottish counterpart report2 suggests) be paid? The existing regional hospital boards bear the stamp of conformist similarity which is to be expected with appointment from
If in administration we seem to be threatened with action uninformed by a full public exchange, almost the opposite situation exists with regard to numbers of doctors. Shortage was becoming manifest long before the Royal Commission on Medical Education was set up in 1965. The Royal Commission did not skimp its home-work. It issued an interim report in 1966, and its final report appeared last April;and the Government is expected to announce its response soon.33 Neither the threatened hastiness in amending administration of the N.H.S. nor the long delay in responding fully to an increasing dearth of doctors to man the Service would have faced the country if the Ministry of Health had been sustained by expert, lively, and impartial advice. Mr. CROSSMAN’s recognition3 of the need for better-founded decisions on priorities is welcome ; but it is to be hoped that he will go further. The
1. National Health Service: Administrative Structure of the Medical and Related Services in England and Wales. H.M. Stationery Office, 1968. See Lancet, 1968, ii, 210. 2. Scottish Home and Health Department: Administrative Reorganisation of the Scottish Health Services. H.M. Stationery Office, Edinburgh, 1968. See Lancet, 1968, ii, 1353.
3. See Lancet, 1968, ii, 1389. 4. Report of the Committee on Local Authority and Allied Personal Social Services. Cmnd. 3703. H.M. Stationery Office, 1968. See Lancet, 1968, ii, 201. 5. Royal Commission on Medical Education. Cmnd. 3569. H.M. Stationery Office, 1968. See Lancet, 1968, i, 797, 809.
32
National Health Service is unique among the social services, not only in uncertainty about priorities, but also in the speed of change in the demands on it, and to a lesser degree in its ability to meet these demands. The new Department, like the old Ministry, is not geared to operate a swiftly evolving Service; and it is illuminating that a group from the National Institutes of Health at Bethesda6 has referred to the " unexpected finding that the centralised administration of the National Health Service has not developed an effective planning mechanism in 20 years." With a strong internal planning mechanism, prodded by an independent external group, the green-paper would never have seen the light of day, at least in the form it has taken; and the Ministry would long ago have acknowledged, and clamoured for action on, the threatening situation in medical manpower. There is a strong case for a standing, broad-based commission, independent of the executive and concerned mainly with evaluating the organisation and performance of existing services, and with reviewing the evidence, as a kind of institutional ombudsman, on policies which are not exclusively political. Mr. CROSSMAN is still apparently unconvinced of the need for any such external group (and a Minister and his attendant Civil Servants might be less than human if they did not fear becoming thralls of technocrats by allowing a Department’s activities to be monitored by outsiders). Nor can much cheer be drawn from past experience, ranging from the Central Health Services- Council to the Minister of Health’s Long-term Study Group. This Group is in itself a government of all the talents, which could be said to have sunk without trace if it had even once risen from oblivion. It was not for nothing that the 1946 Act included, in the Central Health Services Council, provision for outside advice; but so far both the main political parties have been curiously indifferent to the failure of this mechanism to come to life. There is no mystery about the cause of the inertia: the mechanism has always been too close to the Ministry of Health. To be effective, the advisory body must be independent, must have a tough no-man for chairman, preferably should have its own secretariat, and should operate in the open. Mr. CROSSMAN has already sought to bring light into dark Departmental corners by sponsoring the idea of parliamentary expert committees. The National Health Service needs in addition (as the 1946 Act acknowledges) to be guided by a group which stands apart from Parliament and from the Civil Service, and which operates freely and openly. After all, the United Kingdom claims to be a democracy; and democratic Government is best conducted, with few exceptions, in public. The formation of the new Department of Health and Social Security offers a convenient opportunity to repair this large and flaw at the centre the of National Health long-lasting in the and Mr. CROSSMAN Service; Department has a chief with both the courage and the stature for the task. 6.
Bierman,
P.
et
al. Milbank meml. Fund g. Bull. 1968,
46,
77.
Hyaline-membrane Disease, Oxygen, Pulmonary Fibroplasia
and
THE treatment of hyaline-membrane disease is intensive supportive care including, when necessary, assisted respiration.1 This approach has modified the natural history of the condition and several reports 2-5 have appeared of late pulmonary sequelae in some of the survivors. The problem is whether to ascribe these changes to the treatment or to the disease; and certainly " an iatrogenic factor is implied by such terms as res" or ".6 pirator lung " pulmonary respirator syndrome The pathological features of hyaline-membrane disease are known to change with the duration of the illness. Before the typical membranes form, the cells lining the affected air spaces degenerate. This nuclear debris, together with the membrane, is then removed while a new epithelium forms between the fragmenting membrane and lamina propria, and the respiratory bronchioles acquire a metaplasic lining.7 This process takes some four or five days, and it is rare to find any membranes after this time. In contrast, the lungs of infants kept alive by a respirator for a week or more showed slower healing and persistent membranes for as long as ten days, followed by mucosal metaplasia, histiocytic invasion, and fibrosis.3 Patchy fibrosis, thickening of the alveolar wall, and distortion of the alveolar architecture have been the characteristic findings in lung biopsy specimens 25 and necropsy material4 from infants requiring respirator therapy. The clinical course follows a familiar pattern. A few hours after birth, increasing respiratory distress, ground-glass opacification of the lung fields on X-ray examination, and a falling arterial oxygen tension, despite high oxygen concentrations in the incubator, indicate severe disease. The infant has attacks of apncea and eventually requires resuscitation by intubation and endotracheal oxygen by intermittent positive pressure. Despite rapid improvement in the general condition, attempts to withdraw assisted respiration fail, and mechanical ventilation follows in order to support life. Initially, nearly normal blood-gas tensions can often be maintained by moderate pressures and inspired-oxygen concentrations, but unless respirator treatment can soon be stopped, both lung expansion and the correction of hypoxia may become more difficult. Many infants succumb at this stage, but a few are eventually weaned from the respirator, only to remain dependent on a high environmental oxygen concentration for many more days and sometimes weeks. At this stage, the typical radiological appearances are diffuse coarse markings in both lung fields and many small sponge-like areas of inter1. 2.
Lancet, 1965, ii, 1227. Robertson, B., Tunell, R., Rudhe, U. Acta pœdiat., Stockh. 1964, 53,
433. 3. Northway, W. H., Rosan, R. C., Porter, L. Y. New Engl. J. Med. 1967, 276, 357. 4. Hawker, J. M., Reynolds, E. O. R., Taghizadeh, A. Lancet, 1967, ii, 75. 5. Shepard, F. M., Johnston, R. B., Klatte, E. C., Burko, H., Stahlman, M. New Engl. J. Med. 1968, 279, 1064. 6. Lancet, 1967, i, 992. 7. Barter, R. A., Byrne, M. J., Carter, R. F. Archs Dis. Childh. 1966, 41, 489.
LEADING ARTICLES
the centre; and the distribution of accountability between the Ministry (or Department) and the boards is tacitly wrapped in a convenient haze which the green-paper does little to dispel. Then again, while the green-paper outlines methods for dealing with complaints, it does not recognise the need for an administration which (like that of a sound business undertaking) is alert and responsive to public mood.
THE LANCET LONDON
4
JANUARY
1969
Government in Public? THE Ministries of Social Security and of Health have been unified at a time when both were subject to ripples from the post-war surge in social legislation. In Social Security the Beveridge ideal of keeping personal poverty at bay through equal benefits from equal contributions is now widely seen as unattainable: with benefits in kind there are still formidable arguments for equality in distribution ; but with benefits in cash the only immediate hope of bringing adequate help to the poor is to weight their receipts at the expense of the more well-to-do. Already increases in family allowances have been related to income-tax; and a forthcoming white-paper seems likely to extend this principle to contributions. All this is a far cry from 1946. In the National Health Service, on the other hand, the practicability of the Act of 1946 has been clearly vindicated. But that Act, for all its strength, was also a patchwork of compromises-with local authorities, with hospitals, and, not least, with professional groups. The effects of these compromises are evident in the administrative structure of the Service, which has now been brought under official scrutiny in the Government’s green-paper.
Mr. CROSSMAN3 hopes that the green-paper will act stimulus and that some action can be taken in the life of the present Parliament. But no acceptable decision on the size and constitution of any new bodies to administer the Health Service can be reached without considering local government; and the Royal Commission on Local Government has yet to report, and Mr. CROSSMAN does not expect action on its findings in less than five years.3 The gains to be sought from administrative reform of the N.H.S. are great. They include increased local participation; an end to the tripartite structure; and a single hospital planning authority for each area. (This journal has for years called for such as a
unification; and
some
teaching hospitals, intent
on
becoming real university hospitals, now see that this may serve their interests no less than those of the surrounding regional hospitals.) But these and other gains are not to be snatched through reform shaped by random discussion of a document which everyone-except presumably its anonymous author-seems eager to disown. Many more ideas are around than are to be found in the green-paper. The alternatives should be displayed and argued; and this applies especially to the public-health service in view of the Seebohm report. It is not too late for Mr. CROSSMAN to set up a small high-powered group to spend most of their next twelve months taking evidence and preparing a report. By then the findings of the Royal Commission on Local Government will be known; and we shall have learned whether action is feasible in the life of the present Government.
The history of the green-paper is an unhappy one. Both the former Minister of Health and Mr. RICHARD CROSSMAN, as Secretary of State in charge of the unified Department, have denied that they are tied by its terms. Indeed why should they be ? With its main proposal for area health boards, it leaves too much unanswered. The suggested 50 area boards are too many for each to act as a coherent planning body, but too few to avoid some sort of second tier. How is this dilemma to be resolved ? Should at least some members of the new bodies be elected, and even (as the more searching Scottish counterpart report2 suggests) be paid? The existing regional hospital boards bear the stamp of conformist similarity which is to be expected with appointment from
If in administration we seem to be threatened with action uninformed by a full public exchange, almost the opposite situation exists with regard to numbers of doctors. Shortage was becoming manifest long before the Royal Commission on Medical Education was set up in 1965. The Royal Commission did not skimp its home-work. It issued an interim report in 1966, and its final report appeared last April;and the Government is expected to announce its response soon.33 Neither the threatened hastiness in amending administration of the N.H.S. nor the long delay in responding fully to an increasing dearth of doctors to man the Service would have faced the country if the Ministry of Health had been sustained by expert, lively, and impartial advice. Mr. CROSSMAN’s recognition3 of the need for better-founded decisions on priorities is welcome ; but it is to be hoped that he will go further. The
1. National Health Service: Administrative Structure of the Medical and Related Services in England and Wales. H.M. Stationery Office, 1968. See Lancet, 1968, ii, 210. 2. Scottish Home and Health Department: Administrative Reorganisation of the Scottish Health Services. H.M. Stationery Office, Edinburgh, 1968. See Lancet, 1968, ii, 1353.
3. See Lancet, 1968, ii, 1389. 4. Report of the Committee on Local Authority and Allied Personal Social Services. Cmnd. 3703. H.M. Stationery Office, 1968. See Lancet, 1968, ii, 201. 5. Royal Commission on Medical Education. Cmnd. 3569. H.M. Stationery Office, 1968. See Lancet, 1968, i, 797, 809.
32
National Health Service is unique among the social services, not only in uncertainty about priorities, but also in the speed of change in the demands on it, and to a lesser degree in its ability to meet these demands. The new Department, like the old Ministry, is not geared to operate a swiftly evolving Service; and it is illuminating that a group from the National Institutes of Health at Bethesda6 has referred to the " unexpected finding that the centralised administration of the National Health Service has not developed an effective planning mechanism in 20 years." With a strong internal planning mechanism, prodded by an independent external group, the green-paper would never have seen the light of day, at least in the form it has taken; and the Ministry would long ago have acknowledged, and clamoured for action on, the threatening situation in medical manpower. There is a strong case for a standing, broad-based commission, independent of the executive and concerned mainly with evaluating the organisation and performance of existing services, and with reviewing the evidence, as a kind of institutional ombudsman, on policies which are not exclusively political. Mr. CROSSMAN is still apparently unconvinced of the need for any such external group (and a Minister and his attendant Civil Servants might be less than human if they did not fear becoming thralls of technocrats by allowing a Department’s activities to be monitored by outsiders). Nor can much cheer be drawn from past experience, ranging from the Central Health Services- Council to the Minister of Health’s Long-term Study Group. This Group is in itself a government of all the talents, which could be said to have sunk without trace if it had even once risen from oblivion. It was not for nothing that the 1946 Act included, in the Central Health Services Council, provision for outside advice; but so far both the main political parties have been curiously indifferent to the failure of this mechanism to come to life. There is no mystery about the cause of the inertia: the mechanism has always been too close to the Ministry of Health. To be effective, the advisory body must be independent, must have a tough no-man for chairman, preferably should have its own secretariat, and should operate in the open. Mr. CROSSMAN has already sought to bring light into dark Departmental corners by sponsoring the idea of parliamentary expert committees. The National Health Service needs in addition (as the 1946 Act acknowledges) to be guided by a group which stands apart from Parliament and from the Civil Service, and which operates freely and openly. After all, the United Kingdom claims to be a democracy; and democratic Government is best conducted, with few exceptions, in public. The formation of the new Department of Health and Social Security offers a convenient opportunity to repair this large and flaw at the centre the of National Health long-lasting in the and Mr. CROSSMAN Service; Department has a chief with both the courage and the stature for the task. 6.
Bierman,
P.
et
al. Milbank meml. Fund g. Bull. 1968,
46,
77.
Hyaline-membrane Disease, Oxygen, Pulmonary Fibroplasia
and
THE treatment of hyaline-membrane disease is intensive supportive care including, when necessary, assisted respiration.1 This approach has modified the natural history of the condition and several reports 2-5 have appeared of late pulmonary sequelae in some of the survivors. The problem is whether to ascribe these changes to the treatment or to the disease; and certainly " an iatrogenic factor is implied by such terms as res" or ".6 pirator lung " pulmonary respirator syndrome The pathological features of hyaline-membrane disease are known to change with the duration of the illness. Before the typical membranes form, the cells lining the affected air spaces degenerate. This nuclear debris, together with the membrane, is then removed while a new epithelium forms between the fragmenting membrane and lamina propria, and the respiratory bronchioles acquire a metaplasic lining.7 This process takes some four or five days, and it is rare to find any membranes after this time. In contrast, the lungs of infants kept alive by a respirator for a week or more showed slower healing and persistent membranes for as long as ten days, followed by mucosal metaplasia, histiocytic invasion, and fibrosis.3 Patchy fibrosis, thickening of the alveolar wall, and distortion of the alveolar architecture have been the characteristic findings in lung biopsy specimens 25 and necropsy material4 from infants requiring respirator therapy. The clinical course follows a familiar pattern. A few hours after birth, increasing respiratory distress, ground-glass opacification of the lung fields on X-ray examination, and a falling arterial oxygen tension, despite high oxygen concentrations in the incubator, indicate severe disease. The infant has attacks of apncea and eventually requires resuscitation by intubation and endotracheal oxygen by intermittent positive pressure. Despite rapid improvement in the general condition, attempts to withdraw assisted respiration fail, and mechanical ventilation follows in order to support life. Initially, nearly normal blood-gas tensions can often be maintained by moderate pressures and inspired-oxygen concentrations, but unless respirator treatment can soon be stopped, both lung expansion and the correction of hypoxia may become more difficult. Many infants succumb at this stage, but a few are eventually weaned from the respirator, only to remain dependent on a high environmental oxygen concentration for many more days and sometimes weeks. At this stage, the typical radiological appearances are diffuse coarse markings in both lung fields and many small sponge-like areas of inter1. 2.
Lancet, 1965, ii, 1227. Robertson, B., Tunell, R., Rudhe, U. Acta pœdiat., Stockh. 1964, 53,
433. 3. Northway, W. H., Rosan, R. C., Porter, L. Y. New Engl. J. Med. 1967, 276, 357. 4. Hawker, J. M., Reynolds, E. O. R., Taghizadeh, A. Lancet, 1967, ii, 75. 5. Shepard, F. M., Johnston, R. B., Klatte, E. C., Burko, H., Stahlman, M. New Engl. J. Med. 1968, 279, 1064. 6. Lancet, 1967, i, 992. 7. Barter, R. A., Byrne, M. J., Carter, R. F. Archs Dis. Childh. 1966, 41, 489.