PRIORITIES FOR HEALTH

790 United States MURDERERS IN

Dear

THE COMMUNITY

Many people here continue to be concerned about the ease and rapidity with which persons committed to institutions after murdering someone are returned to the community, where they may live without adequate surveillance or control. Once loose, they sometimes commit another murder or series of murders. Just where the responsibility lies for such premature releases from custodial care is not easily determined, nor has the community had any say in the matter or any effective means of protest. In April, 1975 a young man, diagnosed as schizophrenic, hacked his healthy mother to death with an axe and one month later, not denying his crime, he was found, after a non-jury trial, to be innocent of murder by reason of insanity, testified to by two local psychiatrists. He was turned over by the law to the care of the State mental hygiene service, to be kept in hospital till such time as he might be sufficiently recovered to resume life in society. 14 months later a final review panel of a psychiatrist, a psychologist, and a psychiatric social worker adjudged him fit to be returned to his local community, with some form of "structured facility" to take care of him and contain his noted behavioural peculiarities, his "obsessive and compulsive personality", and his freakish food habits. No such local facility exists, but the panel does not seem to have known about this, or even to have inquired about it. The local community and a vigilant district attorney energetically fought the decision, and judicial rulings led to the appearance before the court of the State commissioner of mental hygiene to explain the decision. An elaborate system of checks by review panels of increasing independence of the patient’s care was described, which revealed that while the final panel might be independent, it was also shockingly ignorant of the patient and seemed very gullible in accepting what he told them. Indeed, a dreadful series of bureaucratic omissions came to light: the details of the actual murder were not known to the panel, being unrecorded in the patient’s mental hospital notes; no transcript of the trial had been asked for or sent to the mental hygiene department, which never, it seems, asked for such information, even though it was available. The members of the panel all knew that the patient had committed a murder, but the social worker thought the murder weapon was a bat used in the mercy killing of a mother with cancer, the psychologist thought a club or a bat had been used, and the psychiatrist thought a chair had been used. None knew the details of the murder; none knew that the patient’s sister and her children had gone in fear of their lives till the patient was detained. The panel’s diagnosis was "latent schizophrenia", while the diagnosis of a court-appointed psychiatrist was chronic schizophrenia in a gaunt, emaciated individual who was considered a potential danger to himself and others, an individual who found it difficult to concentrate, who felt insecure under stress had no insight into the motivation behind the murder, and told inconsistent stories about it. The panel members agreed that had they known the full facts their decisions would have been different; the commissioner withdrew his recommendation and the judge, very properly, remanded the patient once more to custodial care. New regulations have been promulgated to tighten up review procedures in the hope of preventing such a scandal from recurring. The community is relieved and grateful to its D.A. and his staff, for an important blow has been struck for the restoration of some rights to the community. Perhaps, too, psychiatrists have been taught a lesson. It was firmly denied that lack of finance or inadequate facilities had any influence on the release decision, but the panel members had been influenced, it was said, by the current trends towards cutting down custodial and institutional care and returning sufferers from mental disorders to their communities. Laudable as this may be, it seems no warrant for returning potentially dangerous individuals to the community and just hoping that they will not prove to be still dangerous.

series of spontaneous offerings to the Commission on the National Health Service.

We continue

Royal

Royal Commissioners

our

PRIORITIES FOR HEALTH A Manipulative Document? IN one sense this commentary upon the "consultative" document1 on Priorities for Health and Personal Social Services in England is a technical review, but its conclusions raise wider issues. The document itself is a confused and, in round terms, a harmful paper, not so much because of the recommendations which it puts forward, but because it trivialises and devalues the process of consultation. This criticism is based on the claim that the main premises on which the discussion proceeds are false. These observations are developed below, although the intricacies of the confusions within the paper inhibit comprehensive analysis. The implications of interest to the Royal Commission arise from a contemplation of how such a paper came to be constructed and how such events might be prevented in the future. OBFUSCATIONS, OMISSIONS, AND FALSE ANTITHESES

Even chaos

seems

susceptible

to

the

art

of classifica-

tion, and these three types of muddle may be helpful headings. Examples in each class, sufficient probably to establish the charge that the basis of the discussion is false, follow (references are given to appropriate sections of the document). False Antitheses A false antithesis, used subsequently to choose between alternative priorities, is reflected in the headings and subject matters of sections m-ix. Two alternative dimensions of a taxonomy of health-care services are hopelessly mixed up. Sections III and iv (general practice and hospitals) are concerned with institutions, whereas sections v-ix (services for the elderly, physicallv

handicapped, mentally handicapped, mentally ill, children) are defined in terms of client groups. The conclusion is that certain client groups are to be favoured at the expense of certain institutions (1.11; 4.28; 4.29. In one place the comparison is deformed into an entirely non-commensurate relationship--"people before buildings" (1.7). These absurdities are recognised elsewhere; over half of the admissions to general hospitals are in fact elderly people; but the difficulty is not resolved. A second false antithesis is set up in the form of an implied choice between different institutions. This takes the form of adjacent discussions of primary-care general-practice services on the one hand and general acute/maternity hospital services on the other. Unfortunately, the issue is set upon disparate foundations. That is, the growth of general-practitioner services is presented as a prediction while the growth of hospital services is set as a target. Intentions of interfering wuh the first are disavowed while interference with the 1. Priorities for Health and Personal Social Services Document. Department of Health and Social Office London, 1976.

England a Consultative Security. H. M. Stationery

in

791

second is in fact proposed. The commentary

the the services is bland, I1çral-practitioner commentary n the hospitals is censorious. An alleged slowness in r3tionalising certain aspects of the (acute) hospital seruce is by implication attributed to resistance rather than, as may be nearer the truth, to lack of the necessary investment with which to implement desirable changes. No evidence on this particular issue is supplied, there is no reference to the relative effectiveness of general and specialist services, and the question of the balance between the two is evidently not up for discussion; it is preempted, and rational discussion is prejudiced rather than assisted (1.22 ; 3.5; 3.11; 4.12; 4.19; on

4.20; 4.21). Another inconsistent basis is presented for deciding pnonties between different client groups. First, the discussion is almost limited to groups for which resources B1111 be increased, and apart from the maternity services 4.25) fails to mention those from which resources will be taken away (women with prolapse; women with breast lumps; manual workers with inguinal hernias; adults with duodenal ulcer, diabetes, or chronic bronchitis). Second, even for the groups which it does discuss, the document adopts different premises. The chapter on children’s services sets targets in terms of medical-care objectives (e.g., neonatal care in hospitals, care and prevention of delinquency) while the sections on the mentally handicapped, the mentally ill, and the elderly set their targets mainly in terms of financial inputs. For the last group, a specific socially valued objective, to keep elderly people in the community, is added. fhe recommendations of two sections (mentally ill and mentally handicapped) are based upon the recommendations of Government white-papers, while the others have different formats. 0;o the declaration in the foreword that an important purpose of the document is to "provide the detailed information that will enable the right choices to be made," there are extensive and serious omissions. Except for a series of clinical procedures associated with the acute hospital service there is little reference

Despite

effectiveness or efficiency. Certainly they are not applied in discussions of the services whose growth-rates are to be adjusted. There is no reference to customer satisfaction. Standards are mentioned (1.7 ; 1.9 ; 5.25), but only in a loose sense, and there is no reference to the to

problem of their definition,

or their measurement, or the of assessing or enforcing conformity with defined standards. There is no discussion of the effectiveness of listing planning and decision-making mechanisms or any reference to the failure of existing means of formulating priorities, which the very existence of the docu-

means

ment

implies.

Fhe main false omission from the document, however, a a clear declaration of the units in which projected


are

specified. They

simply expressed Paper of living index? Pounds

unit costs for local authority residential and in future be held constant". At face value day we must suppose that by "growth", a reduction might be implied. This ambiguity alone is sufficient to destroy confidence that the document could contain a real basis for consultation. The document does not present staffing constraints realistically. For example "the Government place a very high priority on the achievement of a medical school student intake of some 4000 a year by 1980" (2.9); but the mechanisms and resources for reaching this target, and its practicality, are not discussed. The same applies to a projected "growth of 6 per cent per year for home nurses and health visitors" (3.9); their source is not discussed, nor the question whether they are to be obtained through withdrawals from the hospital service. "Community hospitals" are discussed without reference to their staffing problems (4.2; 4.5): whether they are to be staffed by general practitioners, or by whom. The clear implication that they are euphemisms for low-cost lowstandard accommodation for disabled, geriatric, and demented patients is at variance with demands for improved, if undefined, standards (1.9). Nucleus hospitals (1.7) are mentioned but neither defined nor discussed. that

current

care can

Obfuscations points-although of relaimportance-is the reference to phasing out of pay-beds in N.H.S. hospitals (1.12) and the statement that this will increase the scope for using acute beds for the elderly. This is the nearest approach to deception by design in the whole book. Can we believe that the concomitant transfer of demand, by patients who had occupied these beds, escaped attention through inadvertence? A much more important confusion arises from the explicit linking (p. 1) of the priorities discussion with the Government white-paper on public expenditure. The question of what to spend on health-care services, and the question of how best to deploy the resources made available, must be decided in different The

tively

most

obvious of these

minor

The

decision

areas must interact, but the of required responses, the terms of urgencies alternative policies, the administrative mechcomparing anisms through which they are argued, and the professional standards which are applied, all differ in the two fields. There is a danger that the traditional political premises of conflict and confrontation-appropriate, or at least operative, in the first field--could, through

terms.

two

relative

transfer to the second field, destroy the prevailing premises of inquiry, interpretation of evidence, and consensus. So long as these two issues remain mixed, profes-

sional readers will suspect that the purpose of the report is manipulative rather than consultative and that the possibilities of genuine consultation in the future have been sacrificed to provide a smoke-screen to hide the nature of the operation.

are

percent. Percent what? Pound notes? Dollar bills?

"icney adjusted by the cost ousted by salary increases of Health Services staffs? !’:unds adjusted by increases in the size and structure of population? There are few clues, but here and there nds are mentioned (1.7; 1.8; 1.16; 4.31), while in "’ncx-2 reference is made to "two sensitive assump... that there will be no further wage drift and

VIRTUES AND NECESSITIES

Despite This

its

faults, the document is

statement can

also be

supported

not on

totally bad. three main

grounds. The Recommendations The recommendations made in the paper

on

dlfferen-

792 tial growth-rates in different parts of the N.H.S. may under appropriate conditions be desirable. None of the issues raised is new. They have been discussed in extenso over many years and there has even been some research on which a policy might be partially based. The imbalances of the present service are widely recognised and the manner in which they might be corrected during a period of real growth are widely, if not universally, agreed. If the main proposals of the document could be disentangled from its false issues and false premises it might be possible to discuss the consequences of a period of restricted growth, or zero growth, or contractionwhatever the truth might in the event turn out to be. Value Systems

Any explicit priority-deciding mechanism requires a declaration of the value judgments which it uses. This is quite separate from the numerical studies of needs, demands, population structures, budgets, manpower, material resources, and adopted standards, which also steer administrative decisions. If the value system is not explicit, then the basis of the priority decisions is not explicit; and the consultative document, to its credit, makes some attempts in this direction. It is arguable how this should be done; politicians may be in no better position to assess public desires than are the professionals involved in the service. It is also arguable whether some of the value judgments proposed in the document would be universally acceptable or would survive direct presentation to the public; the imperative to keep elderly people at home, rather than admit them to hospitals, might not always be received enthusiastically by those who would be affected by it! It is unarguable, however, that value judgments are necessary if priority decisions are to be rational, that some degree of national consistency should be sought, and that it is probably desirable that they be made public. In these respects, therefore, the consultative document does supply at least one valid major issue for discussion.

Inconsistency and Imposition These two are the Scylla and Charybdis of any process of moderate complexity requiring the aggregation of individual preferences. Avoidance of both is in most circumstances impossible. This is not a question of human fallibility, of inefficient committees, of woolly objectives, of inadequate research, or of inappropriate methods of representation or government. It is intrinsic, unavoidable, and mathematically demonstrable. Arrow2 has shown that the problem springs from the fundamental nature of individual preference relationships, and the process of assembling them into sets.

Arrow’s theorem-2 can be paraphrased in the terms that "the only consistent arrangement of the preferences of a group of people is one which is imposed". This theorem deserves to be more widely studied, despite the unwelcome character of its implications. These points are made here in order to emphasise that, despite the criticisms made above, a certain amount of inconsistency is necessarily present in any document produced by a group of people. In practical terms a demand for absolute consistency would preclude the possibilities of discussion and consensus. We cannot 2. Arrow, K

J Social

Choice and Individual Values. New York, 1963

have both, and one we are

must

prepared

how much of the the other.

eventually decide to

sacrifice

to

WHAT SHOULD BE DONE

At the most immediate level the answer is simple. I h, document does not supply a suitable basis for discussing priorities, and, despite the considerable effort alreadl spent on it by N.H.S. authorities and staffs, it should be rejected for this purpose. It is first and foremost a manipulative document and should be seen as such. It is a matter for regret that the document has not up to now elicited a definitive and precise response of this kind. Its lingering presence cannot help the mutual responses of D.H.S.S. and N.H.S. to each other. It is becoming a matter of interpretation whether this consultative document represents a recognition of the fadure of the normal consultative and planning mechanisms envisaged for the reorganised N.H.S., or whether It is an implement of their destruction. The paper’s rejection is not, however, sufficient. We now face the problem of the reinstatement or redesign of policy-formulating mechanisms which will render adventures such as this redundant. These must be matters of acute concern to the Royal Commission. Perhaps more than anything else the present exercise underlines the fact-surprising to most people unconnected with the Health Services-that the N.H.S. has no indigenous head office. In this respect it is quite unlike most of the nationalised industries where response lities for policy and long-term planning and results are vested in a Board holding a general brief from the Government. The Board is subject to the pressures of Government departments, but the departments can be authoritively advised regarding the consequences of such pressures and the mechanism provides a one-to-one relationship for discussions between the Government and the industry. The industry is thus protected in its day-today activities from detailed intervention. The N.H.S., bv contrast, must rely for its central "staff work" upon a Government department and the N.H.S. itself has no single central voice. The division between the D.H.S.S. and the N.H.S. extends to staffing and to career structures ; there is no natural process of promotion or interchange between the two organisations, and D.H.S.S, staffs often have closer relationships with other Government departments than with the N.H.S. It is not suggested that further reorganisation of tb N.H.S. will solve all the problems; indeed, as 113 pointed out, some of them are inescapable. Nevertheless the absence of a central unit identified directly with th N.H.S. and sufficiently protected from ad-hoc pohuca incursions, is a serious defect. There are many dineren ways in which this defect might be ameliorated ani many ways in which existing resources at D.H.S.S., ani

perhaps at regional-health-authority headquanermight be redeployed to meet such a need, and thu create a mechanism capable of relating needs, resource: operational efficiencies, standards, and value 1udgmem service-wide basis. These suggestions are for the longer term. In tt meantime some grounds for confidence might be re tored if the main problems were disentangled, rostra tured, and presented for discussion as separate issues. on a

Department of Social Medicine, University of Birmingham

E. G. KNOX