Medical administration: The appropriate forms of training

MEDICAL ADMINISTRATION: THE APPROPRIATE FORMS OF TRAINING* By R.

C. W O F I N D E N,

M.D., D.P.tt., D.P.A.

Medical Officer of Health, Bristol C.B. CLEARLY one cannot consider the appropriate forms of training for medical administration without some preliminary discussion of such questions as what is medical administration; why this newly awakened interest in it; who are medical administrators and what training have they had or should they get ? In the 20 years I have worked in the public health services I have had the impression that, with few exceptions our branch of the profession has fought shy of being labelled as medical administrators. Moreover, post-graduate training in public health as typified by D.P.H., courses or higher University degrees has never deliberately aimed at training medical or public health administrators. One reason for aversion to this title is clear enough--the fear that if the public health service ever came to be regarded as primarily, or worse still wholly, concerned with administration, our role as doctors might be forfeited. We should be regarded purely as Local Government Officers. The gap between us and our clinical colleagues would widen and we should suffer even greater disparity in financial reward. I N C R E A S I N G I N T E R E S T IN M E D I C A L A D M I N I S T R A T I O N There seem to be signs, however, of increasing interest in and support for medical administration. At a recent European Conference on the role of the hospital in the community there was considerable support not only for hospital medical administration but also for the setting up of special courses of training. Brussels University has recently instituted such a course; the London School of Hygiene is at present organising a course on hospital medical administration at the request of Regional Hospital Boards with the full support of the Ministry of Health. Further, the Henderson Committee (1957) 1 in Scotland has reaffirmed, cautiously but none the less firmly, the value of medical administrators (i.e. superintendents) in hospitals. Now I find public health doctors becoming more self-consciously interested in medical administration. My distinguished predecessor, Dr. R. H. Parry, appeared to blow hot and cold on this subject. In 1942", when considering post-war planning, he wrote: "We cannot lay too much stress upon the importance of the medical administrator: the Poor Law Service killed itself by ignoring the expert administrator and by becoming a prey to the lay administrator who failed * Paper given to a meeting of the Teaching Group of the Society of Medical Officers of Health, at the Ciba Foundation, London, on Saturday, 31st January, 1959. 343

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to see the wood for the trees. Administration became the ' be all and end all' in the heyday of the old guardians. May we be saved from a local civil service of lay administration. If we do not want this to happen in the future of medical service, we must select suitable doctors from amongst our best young men and train them in administration--there is scope for such persons not only in the public health service but also as medical superintendents in municipal, and I sincerely hope also in the voluntary hospitals of the future". All this was in prenational health service days and he was thinking in terms of the larger local authorities. However, in 1948 :~ he wrote: "Surely it ought to be possible for the routine administration of the health department to be carried on by someone with or without medical qualifications who need not necessarily have specialised in public health under the supervision of the M.O.H . . . . I would earnestly advocate that his function as adviser rather than as executive officer should be greatly emphasised . . . I appeal to my colleagues in the public health services once and for all, let us cut the Gordian Knot of administration that is strangling our initiative". These quotations from his papers are not so inconsistent as would appear at first sight. The latter was an expression of his growing fear that under the National Health Service the medical officer of health would become overburdened with a mass of administrative detail to the detriment of his raison d'Otre, i.e. to safeguard the public heahh with all that this implies from the point of view of "ascertaining", and "advising" without being hampered with day-to-day routine. Parry's real plea was for the medical officer of health to concern himself less with the O. and M. side of administration rather than to foreswear administration altogether. However, in stressing the M.O.H.'s advisory function, and minimising his administrative and executive function, we may be lending support to the sort of system which Simon and Newsholme, amongst some of our distinguished predecessors, found so grossly unsatisfactory. I cannot help wondering whether this increasing interest in medical administration, apart from being an expression of doubt as to the rightness of our present hospital and general practice administration, is the first sign of a new desire to place medical administration in a more respectable position. Is it in fact an expression of a desire for a fundamental change in medical organisation--perhaps for a regionalised health service embracing all aspects of organised medicine, a service in which we see ourselves in a new role as medical administrators of all aspects of the National Health Service ? WHAT

IS

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ADM

l N ISTRATION

9.

There are, at present, no rccognised or formal courses in medical administration so the question of the appropriate forms of training is wide open to discussion.

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ADMINISTRATION

It is an interesting comment that in Great Britain no book entitled "medical administration" has ever been published and there are few original papers on it in our literature. The nearest text-book approach I have seen is Haven Emmerson's book o n " Administrative Medi~,ine" and this refers to the U.S.A. This immediately poses the question what is the difference, if any, between "medical administration" and "administrative medicine"? Irvine (1954) 4, one o f the few public health doctors to have written on this subject, thinks there is a shade of difference between them. He says that "administrative medicine" suggests a phase of medicine which is administrative whereas "medical administration" suggests a phase of administration which is medical. After some further discussion Irvine devised his own definition o f medical administration as: "That phase of public administration which is concerned with the provision by the community o f health care for the individual or the community as a whole and which is based on medical science and skill". Most modern text-books o f public health cover much o f the ground (at least from a factual point of view) envisaged by Irvine's definition. You may think this is a good description o f what medical administration should be but I am not sure that it defines accurately what medical administration is doing to-day or indeed what it may do in the future. Let me try to explain what I mean by referring to our own field of public health. PUBLIC

HEALTH

:

SOCIAL

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SCIENCE

Nowadays the term "public health" is not so respectable as it was and is often replaced by the term "social medicine". Justification is claimed on the grounds that medicine, public health and social science have many spheres o f mutual interest and "social medicine" represents a marriage of medicine and the social sciences. The old public health doctors were experts in the effects of the physical environment on health. It is being realised more and more, however, that a sound knowledge o f soc.~ology, anthropology, and psychology is essential for a fuller understanding of many present-day factors in the causation o f physical and mental ill-health. It is worth raising the question of whether the newer public health doctors, in spite of reorganised D.P.H. courses are being placed in an increasingly unfavourable position vis-a-vis the social scientists for the public health doctor cannot keep abreast of all the newer knowledge emerging from the social sciences. Irvine recognises this difficulty and says "for that reason sociology must increasingly take its place among medical studies". He then goes on to say there is " . . . need for medical direction of workers not in themselves medical but trained in a science or skill subserving the end o f medicine". I have no doubt we would all agree with him. A case could be made that almost any physical, mental, cultural, social or even spiritual phenomenon can have good or bad effects on physical or mental health. Naturally we then

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think in terms of administrations which accept the same view so that health administrations would be the primary units with social components within them playing an important but subservient role. The medical administrator, as manager so to speak, then fulfils his duties through delegation of the appropriate work to those with the appropriate training. I am not sure, however, that many people other than ourselves are convinced that this will be the future pattern. One of the great difficulties confronting the public health doctor to-day is the fact that he is increasingly out of step with this age of medical specialisation. Society loves and demands medical specialists and is prepared to pay them accordingly. While specialisation increases apace and explores narrower fields in greater depth the public health doctor has to acquire an ever-broadening spectrum of knowledge and try to apply this to the community so that mankind can derive the benefit. The public health doctor can never hope to acquire the detail of much of this specialised knowledge; increasingly he becomes Jack-ofall-trades and master of none. In a lesser degree the same applies to the general medical practitioner and the health visitor who are equally out of step with this modern trend. Here, I think, lies part of our dilemma--are wein future goingto be narrow administrators and executives in a limited health field or broad advisers relieved of detailed administration? As knowledge increases further it may become increasingly difficult to do both. In my view with increasing knowledge of the social sciences, so much of which is of considerable health importance, the social scientist will no longer be content to forego his place in the sun and to play a subservient role. The separation of welfare and children's services from health administrations (direction being increasingly by the newer social scientists) is symptomatic of this change. The emerging pattern may be represented in the two approaches: "Health and Social Services" (or health and social administration) and "Social Services" (or social administration), the latter term implicitly accepting health services as part of the social services. Indeed, unless we put our house in order, we may find ourselves in the future playing at the worst a subservient executive role within social administrations or at best acting as advisers to them. Direction of services in any system of Government or organisation carries with it status, prestige and the appropriate financial reward and if we wish to retain direction then somehow or other we have to convince our Governors, centrally and locally, not only of the relevance of the social sciences to health but also of the overriding need for medical direction. Whenever the question has been raised, or the issue put to the test, of whether the doctor (as administrator) should have to execute his own advice (i.e. the policy accepted by his governing body) in order to get the best results, the answer has always been in the affirmative. Otherwise, as has been shown in the past (and as happens sometimes to-day where the M.O.H. is adviser only to a Welfare Committee) there is a danger that the advice will be ignored and so never put into action. To have the best of both worlds therefore we must expect in the future to have to delegate on an increasing scale.

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INITIATIVE

It has sometimes been said that local autonomy and initiative is steadily declining being undermined by central control and direction. If such control and direction ever became absolute, really effective medical administration at the local level might disappear. We all know that medical advice has been available to Central Government Departments for over a century. It may well be that but for the strong bulwark of local semi-autonomous administrations with their professional advisers and administrators that an attempt might have been made, and may still be made in the future for local implementation of national policy through lay administrators. In spite of having medical administrators to Regional Hospital Boards I am not sure that this hasn't already happened to some extent in the hospital service. If ever such a view of the public health service gained the day it would lead to a sorry state of affairs in medicine. At present the local implementation of broad central public health policies can be, and is, achieved in an almost infinite variety of ways to suit varying local circumstances. Indeed, one of the most useful features of local health administrations (as opposed to local hospital or general practitioner administration) which never ceases to puzzle the foreign visitor is the tremendous variation in pattern even though they are all being provided within a national legislative framework. This is part of our national genius, a feature of our democratic way of life allowing for change and progress and not easily understood by those who visit us from other countries nor easily transportable elsewhere. I believe that this rich variety of pattern arises largely from the varying degrees of perspicacity, imaginative interpretation and ingenuity displayed by the local medical administrator in the person of the medical officer of health. His first love is the well-being of humanity and he is prepared to adapt the administration (and what is more important he is allowed to adapt to a far greater extent than in the hospital service) to serve this objective. If the public health doctor is ever deprived of this opportunity he will run the danger of being replaced by a local lay administrator who will be subject to, and in a weaker position to resist, a far greater degree of central direction. There is no doubt that the British health services would be the poorer for it. It is my firm view that at the local level he could never be effectively replaced by a managerial lay administrator to whom he would act as medical adviser. So often health services at the local level are conceived and developed by local medical administration in spite of, rather than because of, central and local lay administrators. FORMS

OF

TRAINING

So far I have said little about the appropriate forms of training for medical administration, but these random reflections may have been useful if only to stimulate thought on a subject which seems to have been discussed remarkably little. The present pattern of medical administration is reasonably clear;

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medical officers in central government departments; medical officers o f health; senior assistant medical officers; the few remaining medical superintendents in hospitals and certain medical officers in the armed forces and the Colonial Medical Service can all be regarded in greater or lesser degree as medical administrators. The immediate question to discuss is whether the existing D.P.H. training is inadequate and whether there should be specialised training for such posts. In considering this question account must be taken of the changed pattern o f medical service during the past 10 years. Since local authorities were relieved of responsibility for hospital administration, Regional Hospital Boards can no longer look to them as a field of recruitment of medical administrators with hospital experience. For these reasons thought must be given to other forms o f training and the ones which I would like to consider are: 1. A modified D.P.H. Course. 2. An ad hoe course of shorter or longer duration. 3. A completely new course leading to an academic qualification--say, a D.M.A. (Diploma in Medical Administration) or because this abbreviation is already used for a Diploma in Municipal Administration, say, a D.H.A. (i.e. Diploma in Health Administration).

A Modified D.P.H. Course In recent years there has been much discussion on the nature and content o f D.P.H. courses. The C.P.H., introduced immediately after the war in the interests of clinicians working within the public health service, was rapidly outmoded by the 1948 change in the organisation of medical services. Indeed, it was out of step with the times almost before it got under way. I don't think anyone regretted its passing. Under the new G.M.C. rules, however, no new clear pattern o f training has emerged which can confidently be expected to take care of the needs of future medical administrators, particularly in the hospital field. The D.P.H. course and qualification was designed originally, and remains, as the only real and recognised post-graduate entry into public health. The changing medical and social scene has necessitated changes in content. In particular, health education, sociology and social psychology now figure much more prominently in syllabuses. With the introduction of more part-time courses, which are spread over a longer period, a greater degree of apprenticeship comes into the picture than was, or is, the case with a full-time academic course. Whichever way it is organised, there is so much new medical, scientific, and technical knowledge to be taught that there is little time to be covering subjects which might be considered more helpful to those wishing to pursue a purely medical administrative career. This raises the controversial issue of academic versus vocational courses in universities and generally universities are rather averse to sponsoring the latter. In my view, the D.P.H. course always has been a largely vocational

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course so this aspect does not worry me unduly. If, however, it is accepted as a vocational course it seems wrong that the newly qualified D.P.H. student has to go back into clinical work, often for very many years, where he sees and practises very little of what he has been taught, before he can take up a post as a public health administrator. It would not be quite so anomalous if the D.P.H. course taught the student the kind of clinical work he would have to do in clinical public health practice but in fact it does not. There would seem to be more wisdom in the student having his clinical experience behind rather than in front of him, before he embarks on a D.P.H. course. Most of us have gone through these stages. Several years after m y D.P.H. training and on leaving the clinical for the medical administrative field, I felt very acutely the gaps in m y knowledge. Part of the answer seemed to lie in the course leading to a Diploma in Public Administration. I never regretted pursuing this study and indeed I think the knowledge gained has been as useful to me in m y career as a medical administrator as has m y D.P.H. training. On the other hand it could not have replaced the D.P.H. training; but it was essentially complementary to it. What did I learn ? Public finance, economics, constitutional law, central and local government, political economy, sociology and social history. Nearly 20 years ago those subjects seemed a far cry from medicine. With the emergence of social medicine, however, I must say that the knowledge and orientation I gained helped enormously to bridge the gap between the medical and social sciences and to gain a better understanding o f the working o f our social, political and economic systems within the broad framework of history. D.P.H. courses, both past and present, make some attempt to cover these subjects but to nothing like the extent desirable. It can be argued that the D.P.H. graduate, assuming he has the right personal qualities, will pick up enough knowledge and experience by his in-service training as a senior assistant or a deputy to fit him for a managerial post in public health administration. This often does happen but he would be better equipped if he had a wider background of academic knowledge. It has also been argued that medical (or any other) administrators are born, not made. I am not impressed with this trite observation, nor with the proposition that by self-selection (because o f certain innate qualities and attitudes of mind a man possesses) there is some insurance against getting the wrong men into medical administration. The fact is that public health is a very wide field and when a man thinks o f making it his career he probably has no very clear idea of what kind of work he might ultimately have to be responsible for. In the post-war years there have been too m a n y pieces of driftwood coming into the public health service. I believe that existing D.P.H. courses could be modified or amplified so as to orientate them more deliberately towards training public health or medical administrators. It would be necessary, however, either to cut out some of the present subject matter or to lengthen the course. Both these suggestions are

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fraught with difficulty; the first because one would be reluctant to jettison very much of the present subject matter and the second because in the absence of student grants, of the even greater deterrent to future good candidates a lengthened training would be fikely to prove. The Henderson Report on "Medical Superintendents and Medical Staff Committees" gives its blessing to a modified D.P.H. course as a basic training for hospital medical administrators. Some of the conclusions of this committee in regard to hospital medical administration appear to me to be reasonably sound and cannot be dissociated from public health administration, e.g., 1. The need to broaden the career possibilities in medical administration. This, they said, might be done by facilitating movement from medical superintendent posts to medical administration posts at Board of Management, Regional Board and Department of Health levels. While the administrative situation in Scotland differs from that in England and Wales I think there is much wisdom in the principle of easier transferability from one groove to another of the National Health Service. 2. The need to improve salaries so as to attract the right kind of people. Few thinking people would disagree with this aim if our future health services are to be administered efficiently and economically. 3. The need for some form of training "on the job" as well as for some form of systematic training suited to the needs of medical administration. The Henderson Committee thought the former "more important since administrative ability tends to grow out of experience in handling administrative problems rather than in the assimilation of theoretical knowledge". 4. The creation of trainee posts in hospitals. I have already mentioned the difficulties arising out of the long time lapSe between D.P.H. qualification and starting practice in medical administration. It might be worth considering whether, in the public health service, there might be a case for trainee posts at administrative level in large local health authorities, which would be filled by recently qualified D.P.H. candidates. To attract the right men the candidates should be subsidised while taking the course either by the local health authority, the Ministry of Health or the local education authority. This suggestion would cut across our present system of promotion from the clinical field. It would also raise the problem of formulating selection criteria but that need not deter us. If, in the future, most of the clinical work at present undertaken in public health departments is undertaken by general practitioners, as it probably will be, such a system might be needed. It is clear that in such an eventuality the number to be trained would be considerably smaller than it is at present. Ad hoc Courses of Short Duration Professor Walton, of the London School of Hygiene and Tropical Medicine has been kind enough to give me the details of a two-months' course on Hospital

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Administration which he is organising for senior assistant medical officers in co-operation with Regional Hospital Board and with the support of the Ministry of Health. Doubtless he will give us first-hand information of this interesting development but I would fike to make one or two observations on the principle of short ad hoc courses. Local health authorities have hitherto been the main recruiting ground for medical administrators to Regional Hospital Board and the Ministry of Health and this has proved of great value. It is possible that future recruits to Regional Hospital Board administrative posts will have no D.P.H. background training or local health authority experience. For such recruits this short course would be of some value in outlining the work of local health authorities in addition to the more specialised work in hospital. I doubt, however, whether it would be anything like enough to imbue them with all the necessary knowledge and insight to improve the co-ordination of local health authority-hospital-general practitioner services which is so badly needed. Narrow specialised courses in hospital administration are fraught potentially with this sort of danger. Such difficulties and dangers might be alleviated by greater ease of movement by administrative doctors between the three main branches of the health service. If movement by appointment gets any worse, as it may do if such short courses are organised and recruitment to the hospital field is directly from the clinical field, co-operation will deteriorate and co-ordination suffer. However, even without movement by appointment it ought to be possible to arrange short periods of secondment of intermediate grade medical officers from one branch of the service to another. What a good thing it would be if new recruits to the Ministry of Health who have had little or no local health authority experience could be seconded to a County Borough and a County Council for a short period of training; equally local health authority or hospital medical administrators could profit from a short spell of work in the Ministry of Health. It would be interesting to speculate on the content of a course on medical administration, particularly in the absence of any systematised British text-book on medical administration. Doubtless existing D.P.H. courses cover the major principles of public administration, which are equally valid in the field of medical administration. Students could also read with profit Parkinson's Law and Microcosmographia Academica. In an idle moment, however, I tried to get down what might be regarded as some of the working principles which seem to have emerged from my own brief experience in this field. Not all of these principles are original, they are by no means comprehensive, and I apologise in advance for their slightly cynical orientation: 1. That administration is but a means to an end and not an end in itself. 2. That he who pays the piper calls the tune. 3. That help and assistance should be given with the objective of fostering self-help and not dependency.

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4. That he who works in an organisation should know his function and purpose in relation to the whole. 5. That some overlapping of function may be no bad thing in order to avoid gaps. 6. That "prevention" has small sales value except in times o f grave threat or emergency. 7. That you will only half convince a lay committee and rarely convince a medical committee that one case prevented may be worth two successfully treated. 8. That wise delegation of work (but never abrogation o f responsibility) is essential to the success of any medical administrator. 9. That a medical administrator should not interfere with the doctorpatient relationship. 10. That the order of batting on a committee agenda is at least as important as the order of batting in a test match. 11. That the description of one human case often "sells" better than a scientific report based on the statistical evidence of 1,000 cases with controls. 12. That "little policies" within "big policies" are, or should be the offspring of the medical administrator's mind rather than that of his committees. 13. That some of the most useful qualities a medical administrator can possess are : A love of and an ability to manage human beings; patience and tolerance; the resilience of steel; imagination, and a grasshopper mind; the optimism of a euphoric disseminated sclerotic; and an iron-shod gluteus-maximus. 14. That only medical men can clearly interpret medical issues. 15. That medical administration, particularly in the public health field, consists largely of salesmanship. First he must sell himself; then he must sell his ideas to committees; then he must sell his medical services to the public and convince them they are getting good value for their money. 16. That when you have had about as much of it as you can stand ; Go into Parliament; take a job with WHO, or get an academic job in a university and teach administration.

A Diploma in Medical Administration I do not consider the provision of a new Diploma in Medical Administration with any great seriousness at the present stage of development of the health services but with any substantial reorganisation (which is almost bound t o happen sometime in the future) the need for such a course might become apparent. In the meantime it might be worthwhile giving this proposal some thought, particularly having regard to events and developments in allied fields. For example, in The Times Educational Supplement for Friday, 5th December,

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19585, there is an article by Dr. Paul Halmos, Lecturer in Psychology and Education, University College of North Staffs, on the need for an interprofessional tripos for the training of administrators. A three years' honours course is suggested which would include education, social work and public health and would lead to an honours degree in, say, " Welfare Theory and Administration". Dr. Halmos does not indicate at what level it would be proposed to employ such administrators in the health and welfare state but he does say : " ' . . . he would acquire a qualification to plan and administer the helping services of a welfare state and would bring to this task a comprehensive point of view and a many-sided experience". CONCLUSION

In the time at nay disposal I have ranged over a fairly wide field without formulating any firm conclusions. M y main object has been to stimulate thought and discussii~n. No doubt the Henderson Committee is right in saying that administration must ultimately be learnt on the spot, during a period of apprenticeship or in-service training. This is undoubtedly the time during which one must develop an almost instinctive appreciation of situations, a time when one must learn by experience how people think and work and why they do certain things but not others and what is practicable and what is not. With increasing experience it is hoped one develops the necessary wisdom and capacity for judgement which lays the foundations of ultimate success in administration. Even so, the time is ripe to reconsider the whole question of the fundamental academic training on which in-service training schemes might be based. The Teaching G r o u p o f the Society has an interesting, if difficult, task before it.

1MEDICAL

REFERENCES SUPERINTENDENTS AND M E D I C A L

STAFF COMMITTEES.

(1957). H.M.S.O., Edinburgh. 2pA R g Y, R. H. (1942). "Post-war Medical Planning". Public Health, Feb. 3 . (1948). " Some thoughts on the future of Public Health and of the Medical Officer of Health". Ibid., Mar. 41 R v 1 N E, E. D. (1954). "Medical Administration". Public Health, August. 5H A L MO S, P A V L. (1958). "Interprofessional Tripos, Training the Administrator." The Times Education Supplement, Dec. 5th.