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INDUSTRY AND THE HEALTH SERVICE
611
Letters
to
the Editor
INDUSTRY AND THE HEALTH SERVICE
SIR,-Mr Hunter (Sept. 1, p. 495) seems to be saying that industry may have more to learn from health services than the other way round. By industry, of course, he means the boardroom, not the shopfloor; I know of no evidence that boardrooms wish to abdicate any real power, but we have plenty that they wish to extend it to include the Health Service. The Secretary of State for Social Services has now announced all but a few of his appointments to the new English area and regional health authorities. Of 281
appointees named,
78
are
bankers, company directors,
business executives, property developers, and brokers; 39 are doctors; and there are 19 solicitors, 6 accountants, 5 retired Army officers, 3 ex-colonial governors, and 24 other professionals. Representing the sons of toil we have 6 farmers (1 lord and 1 knight), 11 shopkeepers, 10 supervisory staff, 18 full-time trade-union officials, 3 railwaymen, 1 coalminer, and 1 engineer. There are 4 of unstated occupation, and as most of the 53 women are listed as housewives they are difficult to classify; it seems unlikely that many of them have spent months waiting for an outpatient appointment, to spend hours waiting to see an overworked registrar, while a friend tries to cope with 3 children on top of her own. Yet that is the sort of situation into which these company directors and other gentry are supposed to have practical insight; for most management decisions in any social service are social decisions, and even those that are chiefly technical have social implications. Their most important field is, of course, that of indecision; leaving things as they are. Clocking in on time is as important for hospital consultants as for coalminers, as every study of hospital outpatient inefficiency has found: waitinglists can be abolished by consultants who really wish to abolish them, rather than keep them as brakes on referral demand, or incentives to private referral; overworked, short-tempered staffs could be relieved, at least to some extent, if consultants would accept the full quota of new consultant appointments offered by the D.H.S.S.; and the disgracefully low wages obtaining throughout the nonprofessional grades of hospital workers, as well as many of the ancillary professional grades, is well known to be uneconomic as well as unjust. We may depend upon it that no effective action will be justified on these matters by managements of this composition, and the even flow of sherry in the boardrooms will continue undisturbed. If anyone actually challenges the dual power of directors and consultants, as Councillor Teresa Stewart did in Birmingham over the private-beds issue, they will be dropped from the appointments list next time, as she was. Of course there will be real changes in 1974. The power of top doctors to run hospitals as they please, without any enforced responsibility to plan the distribution of resources in relation to measured needs, will now be shared to a much greater extent by the ruling class of businessmen. They will be more conscious of the need for economy in all social services, most particularly those parts of the Health Service which neither they nor their families have to use by normal pathways. What will remain wholly lacking is the expertise and the motivation that the service really needs-namely, shared experience of the common lot, and a determination to improve it even if this does involve
challenges
to
professional despotism.
The situation will change only when local authorities, local and national patients’ groups, national and local
trade unions and trades councils, parents’ associations, and other locally rooted bodies cease to accept this Whiggery as inevitable, and insist on effective local representation. Doctors who are serious about a democratic service will assist in this: the rest is chatter. It is up to all of us to prevent the National Health Service becoming the first instalment of the Corporate State. Glyncorrwg Health Centre, Glamorgan.
JULIAN TUDOR HART.
one who works in industry, and has had some of industrial management, I should like to reinforce the point made by Mr Hunter in his very important letter.
SIR,-As
experience
The organisation and management of the Hospital Service has been so chaotic that it is astonishing that it has not collapsed before, and the reason it has not done so has undoubtedly been the dedication and devotion of all those who work within it. Certainly, I believe that the Health For Service has a great deal to learn from industry. it that a labour-intensive is organisation example, surprising which is the biggest employer of female labour in the country has no proper personnel service and no occupational health service, and it would be a pity if useful techniques of management which have been evolved in industry should be ignored simply because some management techniques are regarded with suspicion.
The basic objective of industry is said to be to achieve the maximum return on capital, and clearly this can never be the objective of the Health Service, which has no economic output. We should view the Health Service in a much more flexible light as an organisation for solving problems of people caused by sickness or illness. Each patient’s problems are individual to himself or herself. If these problems can be isolated, then each member of the Health Service team can bring his expertise towards a solution. This may be by a direct day-to-day contact by a nurse or the back-up facility necessary to provide clean sheets on hospital beds, and to work out this fully and clearly requires an enormous amount of hard thinking about communications and responsibilities. Because we are dealing with individual problems, overall directives from above would be neither appropriate nor necessary. The functions of regional or national organisations would be cybernetic rather than directive. Hierarchical systems are easy to understand and easy organise; in the case of the Health Service I don’t believe they are efficient, an organisation based on a flexible response to problem-solving at the periphery does mean an abandonment of much traditional thinking and acceptance of new and less authoritarian roles, but it would restore the patient to his central position, and that is why most of us came into this business. to
I would not rate Mr Hunter’s chances of changing the world very high if it were not that I think that in general practice today this type of organisation is developing and, once the teething troubles of group practices and health centres are over, it may be that the Hospital Service will follow them into an organisational revolution which could have almost as much effect on medicine as the discovery of
penicillin. Until this happens don’t rail at industry. There is awful lot you can learn from techniques worked out industrial management. East Midlands Gas, P.O. Box 145, De Montfort Street, Leicester LE1 9DB.
an
by
A. R. BUCKLEY, Chief Medical Officer.
Letters
to
the Editor
INDUSTRY AND THE HEALTH SERVICE
SIR,-Mr Hunter (Sept. 1, p. 495) seems to be saying that industry may have more to learn from health services than the other way round. By industry, of course, he means the boardroom, not the shopfloor; I know of no evidence that boardrooms wish to abdicate any real power, but we have plenty that they wish to extend it to include the Health Service. The Secretary of State for Social Services has now announced all but a few of his appointments to the new English area and regional health authorities. Of 281
appointees named,
78
are
bankers, company directors,
business executives, property developers, and brokers; 39 are doctors; and there are 19 solicitors, 6 accountants, 5 retired Army officers, 3 ex-colonial governors, and 24 other professionals. Representing the sons of toil we have 6 farmers (1 lord and 1 knight), 11 shopkeepers, 10 supervisory staff, 18 full-time trade-union officials, 3 railwaymen, 1 coalminer, and 1 engineer. There are 4 of unstated occupation, and as most of the 53 women are listed as housewives they are difficult to classify; it seems unlikely that many of them have spent months waiting for an outpatient appointment, to spend hours waiting to see an overworked registrar, while a friend tries to cope with 3 children on top of her own. Yet that is the sort of situation into which these company directors and other gentry are supposed to have practical insight; for most management decisions in any social service are social decisions, and even those that are chiefly technical have social implications. Their most important field is, of course, that of indecision; leaving things as they are. Clocking in on time is as important for hospital consultants as for coalminers, as every study of hospital outpatient inefficiency has found: waitinglists can be abolished by consultants who really wish to abolish them, rather than keep them as brakes on referral demand, or incentives to private referral; overworked, short-tempered staffs could be relieved, at least to some extent, if consultants would accept the full quota of new consultant appointments offered by the D.H.S.S.; and the disgracefully low wages obtaining throughout the nonprofessional grades of hospital workers, as well as many of the ancillary professional grades, is well known to be uneconomic as well as unjust. We may depend upon it that no effective action will be justified on these matters by managements of this composition, and the even flow of sherry in the boardrooms will continue undisturbed. If anyone actually challenges the dual power of directors and consultants, as Councillor Teresa Stewart did in Birmingham over the private-beds issue, they will be dropped from the appointments list next time, as she was. Of course there will be real changes in 1974. The power of top doctors to run hospitals as they please, without any enforced responsibility to plan the distribution of resources in relation to measured needs, will now be shared to a much greater extent by the ruling class of businessmen. They will be more conscious of the need for economy in all social services, most particularly those parts of the Health Service which neither they nor their families have to use by normal pathways. What will remain wholly lacking is the expertise and the motivation that the service really needs-namely, shared experience of the common lot, and a determination to improve it even if this does involve
challenges
to
professional despotism.
The situation will change only when local authorities, local and national patients’ groups, national and local
trade unions and trades councils, parents’ associations, and other locally rooted bodies cease to accept this Whiggery as inevitable, and insist on effective local representation. Doctors who are serious about a democratic service will assist in this: the rest is chatter. It is up to all of us to prevent the National Health Service becoming the first instalment of the Corporate State. Glyncorrwg Health Centre, Glamorgan.
JULIAN TUDOR HART.
one who works in industry, and has had some of industrial management, I should like to reinforce the point made by Mr Hunter in his very important letter.
SIR,-As
experience
The organisation and management of the Hospital Service has been so chaotic that it is astonishing that it has not collapsed before, and the reason it has not done so has undoubtedly been the dedication and devotion of all those who work within it. Certainly, I believe that the Health For Service has a great deal to learn from industry. it that a labour-intensive is organisation example, surprising which is the biggest employer of female labour in the country has no proper personnel service and no occupational health service, and it would be a pity if useful techniques of management which have been evolved in industry should be ignored simply because some management techniques are regarded with suspicion.
The basic objective of industry is said to be to achieve the maximum return on capital, and clearly this can never be the objective of the Health Service, which has no economic output. We should view the Health Service in a much more flexible light as an organisation for solving problems of people caused by sickness or illness. Each patient’s problems are individual to himself or herself. If these problems can be isolated, then each member of the Health Service team can bring his expertise towards a solution. This may be by a direct day-to-day contact by a nurse or the back-up facility necessary to provide clean sheets on hospital beds, and to work out this fully and clearly requires an enormous amount of hard thinking about communications and responsibilities. Because we are dealing with individual problems, overall directives from above would be neither appropriate nor necessary. The functions of regional or national organisations would be cybernetic rather than directive. Hierarchical systems are easy to understand and easy organise; in the case of the Health Service I don’t believe they are efficient, an organisation based on a flexible response to problem-solving at the periphery does mean an abandonment of much traditional thinking and acceptance of new and less authoritarian roles, but it would restore the patient to his central position, and that is why most of us came into this business. to
I would not rate Mr Hunter’s chances of changing the world very high if it were not that I think that in general practice today this type of organisation is developing and, once the teething troubles of group practices and health centres are over, it may be that the Hospital Service will follow them into an organisational revolution which could have almost as much effect on medicine as the discovery of
penicillin. Until this happens don’t rail at industry. There is awful lot you can learn from techniques worked out industrial management. East Midlands Gas, P.O. Box 145, De Montfort Street, Leicester LE1 9DB.
an
by
A. R. BUCKLEY, Chief Medical Officer.