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GREEN LIGHT ON ADMINISTRATION?
1186
Letters
to
the Editor
GREEN LIGHT ON ADMINISTRATION?
SiR,—The senior medical staff of the Kettering and district hospitals have given very careful consideration to the proposals contained in the outgoing Minister of Health’s green-paper,! and have reached unanimous agreement on the following basic criticisms and alternative proposals which we feel will commend themselves to the great majority of hospital medical staff, and perhaps to many of our colleagues in other fields. For, while agreeing with the declared aims of the greenpaper, we have serious reservations about the means proposed to achieve them. There is a need for change, but is a major
upheaval necessary ? We regret the failure to include the social services, particularly those for the aged, and for mentally disordered and handicapped persons, in the proposed new administrative structure. Some progress has already been made by voluntary cooperation between hospital, local-authority, and executivecouncil services, but if integration is to have any real value these services must be under the control of a single authority. Although the proposed area boards would be less remote from individual hospitals than the present regional hospital boards, they would be more remote from hospitals than hospital management committees. This would seriously reduce the opportunities for local opinion to influence the kind of health service provided in a particular area. Further, the size of population to be included in the ambit of one area board is too large to be effectively served by one authority dealing with all branches; and the limitation of public representation on each board to some fifteen members would reduce public participation to an unacceptable level. On the other hand, the area boards would be too small in relation to their planning function, and the suggested consortia of area boards for this purpose would lead to the uncontrolled growth of a second tier of authority between area boards and the Ministry. We think that it would be preferable to have a two-tier system planned from the beginning with 200-250 area health boards, and about the same number of regional health boards as there are now regional hospital boards. And while most people would agree that it would be sensible for health areas to be as nearly as practicable coterminous with local-health-authority areas, most medical staff in hospitals would, we believe, share our view that the hospital services should not be absorbed into the elective local-government system. The management of hospitals should not be subject to the changing moods of local
region would have sufficient resources to undertake large building and engineering projects; (d) advantage could be taken of the experience gained in making the existing hospitalservice structure work; (e) the need to create an entirely new structure would be avoided; and (f) an integrated administrative structure on the lines suggested could be implemented by relatively simple mergers in a fraction of the time it would take to implement the green-paper proposals. Our colleagues on the medical staff of the Kettering and district hospitals feel that there is a grave danger that comment the green-paper, from the vast number of authorities may be so detailed and diverse that the Minister may have an excuse for saying that in the absence of a consensus he will have to make our minds up for us. We hope, therefore, that, if there is general support for the quite simple basic criticisms and counter-proposals outlined in this letter, members of the medical profession will do what they can to concentrate comments made to the Minister on these lines. I. S. HODGSON-JONES Chairman, Medical Advisory Committee, Kettering and District Hospital Group G. MEDHURST Chairman, Medical Staff Committee, Kettering and District General Hospital. on
concerned,
UNRECORDED DEATHS AFTER DISCHARGE FROM HOSPITAL
SIR,-The article by Dr. Rang and her colleagues (Oct. 26, p. 908), and the letters of Mr. Shepherd (Nov. 16, p. 1085) and Mr. Gruber (last week, p. 1139), make interesting reading to a general practitioner who thought that this follow-up was a self-evident necessity: however, I soon became disillusioned when, having informed my hospital colleagues of our patients’ subsequent fate (corrected diagnoses or death), replies, if any, were mostly of a recriminatory or self-justifying nature. So I now just inform the record office of the hospital concerned, enabling them to close the file and cancel appointments-and I
even
get
a
"
Thank
London N.W.6.
you W. LEVY.
SiR,-For many years in this practice we have informed the records officer of the hospital concerned of the death of any patient registered with that hospital. The form, which we keep in the death-certificate book, simply states :
party politics. We regard it as imperative that any administrative structure for the Health Service must contain built-in safeguards for all professional staff at local level, to ensure that they are not dictated to by professional colleagues at a distance; it is essential that they should have the protection of a local statutory committee with power to obtain some modification of attitudes expressed by a remote area headquarters. We think that the most effective and least disruptive method of integrating the present tripartite system is for the existing regional hospital board and hospital management committee structure to be adapted to cover the administration of all branches of the Health Service. That is to say that a management committee, reconstituted to include, say, five representatives each from hospital management committees, executive councils, and local health authorities in each area, and renamed an area health board, should administer all health services for a population of approximately 250,000 people, and that similarly reconstituted regional health boards, each containing ideally at least one teaching hospital, should undertake the planning function for several area health boards. This plan would have the following advantages: (a) local control would be preserved; (b) each health region would benefit from the presence of a teaching hospital within its boundaries; (c) each -
1. National Health Service: The Administrative Structure of the Medical and Related Services in England and Wales. H.M. Stationery Office, 1968. See Lancet, July 27, 1968, pp. 201, 210.
Writtle, Chelmsford, Essex.
J. TUDOR PEMBLETON.
SIR,-I regret that Dr. Winston (Nov. 23, p. 1139) should interpret my letter (Nov. 16, p. 1085) as showing a heartless attitude on my part. I did not really think it necessary to state that the admission to hospital for terminal nursing, with the possibility that permission might be granted for a necropsy, would never be contemplated without regard for the comfort of the patient and the feelings of the relatives.
Letters
to
the Editor
GREEN LIGHT ON ADMINISTRATION?
SiR,—The senior medical staff of the Kettering and district hospitals have given very careful consideration to the proposals contained in the outgoing Minister of Health’s green-paper,! and have reached unanimous agreement on the following basic criticisms and alternative proposals which we feel will commend themselves to the great majority of hospital medical staff, and perhaps to many of our colleagues in other fields. For, while agreeing with the declared aims of the greenpaper, we have serious reservations about the means proposed to achieve them. There is a need for change, but is a major
upheaval necessary ? We regret the failure to include the social services, particularly those for the aged, and for mentally disordered and handicapped persons, in the proposed new administrative structure. Some progress has already been made by voluntary cooperation between hospital, local-authority, and executivecouncil services, but if integration is to have any real value these services must be under the control of a single authority. Although the proposed area boards would be less remote from individual hospitals than the present regional hospital boards, they would be more remote from hospitals than hospital management committees. This would seriously reduce the opportunities for local opinion to influence the kind of health service provided in a particular area. Further, the size of population to be included in the ambit of one area board is too large to be effectively served by one authority dealing with all branches; and the limitation of public representation on each board to some fifteen members would reduce public participation to an unacceptable level. On the other hand, the area boards would be too small in relation to their planning function, and the suggested consortia of area boards for this purpose would lead to the uncontrolled growth of a second tier of authority between area boards and the Ministry. We think that it would be preferable to have a two-tier system planned from the beginning with 200-250 area health boards, and about the same number of regional health boards as there are now regional hospital boards. And while most people would agree that it would be sensible for health areas to be as nearly as practicable coterminous with local-health-authority areas, most medical staff in hospitals would, we believe, share our view that the hospital services should not be absorbed into the elective local-government system. The management of hospitals should not be subject to the changing moods of local
region would have sufficient resources to undertake large building and engineering projects; (d) advantage could be taken of the experience gained in making the existing hospitalservice structure work; (e) the need to create an entirely new structure would be avoided; and (f) an integrated administrative structure on the lines suggested could be implemented by relatively simple mergers in a fraction of the time it would take to implement the green-paper proposals. Our colleagues on the medical staff of the Kettering and district hospitals feel that there is a grave danger that comment the green-paper, from the vast number of authorities may be so detailed and diverse that the Minister may have an excuse for saying that in the absence of a consensus he will have to make our minds up for us. We hope, therefore, that, if there is general support for the quite simple basic criticisms and counter-proposals outlined in this letter, members of the medical profession will do what they can to concentrate comments made to the Minister on these lines. I. S. HODGSON-JONES Chairman, Medical Advisory Committee, Kettering and District Hospital Group G. MEDHURST Chairman, Medical Staff Committee, Kettering and District General Hospital. on
concerned,
UNRECORDED DEATHS AFTER DISCHARGE FROM HOSPITAL
SIR,-The article by Dr. Rang and her colleagues (Oct. 26, p. 908), and the letters of Mr. Shepherd (Nov. 16, p. 1085) and Mr. Gruber (last week, p. 1139), make interesting reading to a general practitioner who thought that this follow-up was a self-evident necessity: however, I soon became disillusioned when, having informed my hospital colleagues of our patients’ subsequent fate (corrected diagnoses or death), replies, if any, were mostly of a recriminatory or self-justifying nature. So I now just inform the record office of the hospital concerned, enabling them to close the file and cancel appointments-and I
even
get
a
"
Thank
London N.W.6.
you W. LEVY.
SiR,-For many years in this practice we have informed the records officer of the hospital concerned of the death of any patient registered with that hospital. The form, which we keep in the death-certificate book, simply states :
party politics. We regard it as imperative that any administrative structure for the Health Service must contain built-in safeguards for all professional staff at local level, to ensure that they are not dictated to by professional colleagues at a distance; it is essential that they should have the protection of a local statutory committee with power to obtain some modification of attitudes expressed by a remote area headquarters. We think that the most effective and least disruptive method of integrating the present tripartite system is for the existing regional hospital board and hospital management committee structure to be adapted to cover the administration of all branches of the Health Service. That is to say that a management committee, reconstituted to include, say, five representatives each from hospital management committees, executive councils, and local health authorities in each area, and renamed an area health board, should administer all health services for a population of approximately 250,000 people, and that similarly reconstituted regional health boards, each containing ideally at least one teaching hospital, should undertake the planning function for several area health boards. This plan would have the following advantages: (a) local control would be preserved; (b) each health region would benefit from the presence of a teaching hospital within its boundaries; (c) each -
1. National Health Service: The Administrative Structure of the Medical and Related Services in England and Wales. H.M. Stationery Office, 1968. See Lancet, July 27, 1968, pp. 201, 210.
Writtle, Chelmsford, Essex.
J. TUDOR PEMBLETON.
SIR,-I regret that Dr. Winston (Nov. 23, p. 1139) should interpret my letter (Nov. 16, p. 1085) as showing a heartless attitude on my part. I did not really think it necessary to state that the admission to hospital for terminal nursing, with the possibility that permission might be granted for a necropsy, would never be contemplated without regard for the comfort of the patient and the feelings of the relatives.