Teamwork and leadership in public health

TEAMWORK AND LEADERSHIP iN PUBLIC

By I A N

HEALTH

*

A. G. M A c Q U E E N ,

M.A., M.D., D.P.H.,

F.R.S.It.

Medical O.[]~cerof Health, ,tberdecn, and lwcturcr in Public lteal;h, Univcrsit), of Aberdeen SIncE doctors, no less than soldicrs, sometimes fall into the error of planning to-morrow's defences to meet yesterday's threats, let me begin by mentioning some rcvolutions of the last two decades and their effects on our services. (I) The Socio-econornic Revolution.--Indisputably the years 1939-59 have wimcssed a considerable levelling of incomes, a great reduction of gross primary poverty and an improvement in nutrition, clothing and cleanliness: the detection and remedy of ma!:~utrition, unsuitable garments and vermin no l o n e r rank among the main functions of child welfare and school health services. The majority of houses are now council-owned or owner-occupied, and the rapid disappearance of the slum landlord and slum tenant in:plies tremendous decline in a formerly important part of the public health inspector's work. There are other changes, less immediately obvious. Increased mobility of population, with less,.'ned possibility of inter-family help, means that the health department often has to take the place of the older generation in advising young parents and of the younger generation in providing support for veterans. In the past prosperous families relied in times of crisis on servants (the 1931 census gave the number of domesticsin England and Wales as 700,000), and nursing homes: today such families have to depend increasingly on the facilities provided by health and welfare departments. Freer movement of social class creates problems of failure, frustration and even success: it is h.ardly surprising that the maintenance of mental health is now regarded as our biggest job. Improved standards of living--better houses, better clothes, better equipment--affect our services: 20 years ago young parents from dismal slums, educated in dingy schools, came for advice to dull, badly-equipped clinics; today their successors expect clinics to measure up to the standards of modem schools and houses. (2) Smaller Families and Surviving Veterans.~The parents of I940--60 are from the first generation of small families--from# generation averaging 2.2 children per family, whereas the parents of 1920--40 were from a generation averaging 4-6. Consequently, young parents of today know little about the developmental needs of children and clamour for advice which the health *Slightly abridged version of Presidential Address to Scottish Branch of Society of the Medical Offmers of Health (Glasgow 5th December, 1959). 244

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department must try to supply. Again, in every I00 people there are now eight I:re-school children, 16 school children and 14 pensioners: our see'ices for old people must come to rival in size the child welfare c,r school health services. (3) The Educational and Cultural Revotution.~All young people of ,~v--,... years have been at school up to the age of 15, and about c.ae in five appreciably longer. ]n two decades we have passed t¥om a relatively uneducated public who would accept a d,':ctor's dogmatic statements to a semi-educated public wflo demand the r.ght ;~" to make their own decisions. Our health education techniques must be re-oriented (and health education is a big part of our future work), persua:on and discussion replacing authoritarianism and lecturing. Problems of leisure exist as never before: men and unmarried women usually work relatively short hours, and housewives have small houses and labour-saving equipment. Incidentally, abundance of leisure and awareness of ignorance about children's developmental needs and behaviour problems have together created an atmosphere very favourable to health education. provided that we think of it as true education (not didactic instruction) and as concerned primarily with emotional and social health (not hygiene and infectious diseases). (4) The Legislative Revolution.--The main Acts on which our functions are based have all become law within the last 15 years. Consider only one point from one Act~the availability of medical treatment without direct charge. Clearly this reduces the need for minor ailment clinics: in operating treatment services we merely do work for which the general practitioner is paid. I have said nothing of sex equality, of the opening of many occupations to women, or of the change from the era of craftsmen and peasants to that of mechanisation and mass production; but, before passing to the biggest revolution, let me gather up some of the implicatiofis for health departments of these four revolutions. Certain aspects of our work are decreasing :---(a) Environmental hygiene is in .a phase :of decline: nuisances become fewer as civilisation advances; the public health inspector has less need to coerce slum landlords; problems of food contamination are lending to become matters for national, rather than local, action; water, drainage and sewerage require maintenance activity on!y, as win food and air in a few years. The P.H.I. may dwindle numerically (asin Sweden), a n d so may the M.O. and HiV. specialised: on infectious diseases. (b) The physical aspects of maternity and child welfare andlschool health services are declining: domiciliary midwifery is slowly dwindling by thewiil of the people: (though an :enormous field ~s opening for the health educat on a n d social counselling:of prospective parents): physical diseases 0f e,hitdren are decreasing; an::otbgr se~ces are such diseases aSl:emain; minor ailment :clinics and head iaspectio~ are on~:~e':way out~ (c)i :On: "a ~more: basis' the home ,ursing:. ~ i ~ may: d~line appr~iablyas the health Of the community improvesi theordy factor at present

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holding the demand for that service level is the increase in the proportion of old people. Other aspecrs of our work arc expanding greatly: .... (a) Promotion of mental health and reduction of maladjustment, delinquency, neurosis and psychosomatic disease consitute a tremendous challenge: the best hope seems to lie in getting relationships and attitudes right in the early formative years; H.Vs. in the home, and M.Os., H.Vs. and health education officers in the ante-natal and child welfare clinic, are in the most favourable position to tackle what is incomparably our biggest job; considerable expansion both of group teaching ;~nd of individual leaching is of pressing urgency. (b) Preservation of the health and well-being of veterans is another.enormous field: every M.O.H. would bc well-advised to re-read Circular 60/1958 of the Department of Health for Scotland, especially the paragraphs about the five main ways in which H.Vs. can help old people and about home nursing and home helps. (c) After-care of those recovering from physical or mental illness and prevention of non-infectious conditions (e.g. home accidents) are other expanding aspects. (5) The Scientific Revolution.--We all recognise the scientific revolution in hospital medicine, e.g. that, instead of the house-surgeon giving the anaesthetic, anaesthesia needs full-time consultants, or that cardiography has become so complicated that one specialist is required to interpret the electrical recordings and another to treat the diseased heart. Most of us recog~~ ~ too, that the bewildering advance in medical knowledge is the real cause of the G.P.'s insecurity: he is reasonably well-paid and no longer over-worked, but is uneasy because he cannot keep pace with the unparalleled output of new diagnostic techniques and new drugs. Many of us are slow to recognise the scientific revolution in preventive and social medicine, although our subject is probably advancing faster than clinical medicine. On the sociological side it is difficult to find time to read important British publications (like Titmus's Essays on the Welfare State and Wootton's Social Science and SocialPathology), to say nothing of American or Scandinavian contributions to knowledge. On health education, my senior health guidance lecturer recently compiled for someone a list of five up-to-date books on the subject: I was humiliated to discover that I had not read even one of them. As |br psychology (since our biggest job is the preservation of mental health) it is important to realise that psychology has developed to the stage where there is no such thing as a general psychologist: there are experts in abnormal psychology of adults (general psychiatrists), in psychopathology of children (child psychiatrists), in the psychology of learning processes (educational psychologists), in that of work (industrial psychologists), in analytical techniques (psycho-analysts), and in human relations (social psychologists), but there is no expert in psychology a s a whole. Just as Bacon was perhaps t h e last scholar who took all science as his province, so some M.O,H. of the 1930s was probably the last health worker

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who could claim to be resonably expert in the whole of public health. It is no longer possible for one person to profess all public health as a specialty, May I cite myself as an example ? I entered public health just before the big changes began; I became an M.O.H. 16 years ago; and I have tried to keep up to date. Yet a good health visitor knows, by reason of her special training and experience, more about a child's emotional and social needs than t do; a good administrative officer can, through his background, leave me behind in office administration and filing methods; a good public health inspector is ahead of me in meat examination; a good health visitor tutor can, from her advanced training in educational psychology and teaching methods, outstrip me in health education. This multiplicity of skills that are not interchangeable necessitates the concept of the public health team. THE

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The main future tasks of the health department are--to improve emotior~at and social health; to preserve the health and well-being of veterans;to support and rehabilitate persons handicapped by physical, mental or social disability; to reduce non-infectious diseases; and to continue to eliminate environmental hazards. For these tasks we need knowledge of--child psychology and social psychology; health education skills; discussion techniques and teaching methods; physiology and disease processes; sociology; epidemiologicai iech niques; hygiene and sanitation; and (since departments are large) staffmanagement and administration. Since no individual can have adequate skill in even half of these, the day of the dictator is past. The old idea of the omniscient M.O.}t., who made all decisions and issued instructions to his staff, must be replaced by the concept of the team and its captain. The M.O.H., the'specialist M.O., the superintendent H.V., the H.V. tutor, the health education officer, the chief dental officer, the C.P.H.I,, the superintendent midwife and the admin, officer eact! possess special skills and unique knowledge. They must work together for th: good of the Department and the community. TEAM

CAPTAIN

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In a refresher course for M.Os. a couple of years ago my colleague,: Miss Lamont, depicted the health and disease services as a football :team (with the hospital services--purely defensive--as goalkeeper, as backs domiciliary consultations and out-patient departments, as centre half tile G~P. flmaked by home nurses and other supportive services, as forwardsthelM,O,H. :in the centre, the M,O..and general purpose H.¥., withthe P.H.L and the specialist H.V, as wingers ; and then converted i n t o a rugby team by addinglnformed Public Opinion as a second line of forwards).::While acc.epfing~that pict:ure, let;me'draw my: analogy from a different game, crickeL The capture, h a mg won the toss;makes a n immediate decision, to put t h e b t h e r s i d e in, and a

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s,.~t'-~nd " decision, to select X as first bowler. Having nlade these decisions, the captain fades temporarily into the background" for that over X places the field, including the captain himself. After X has had a reasonable chance to cope with the situation the captain may decide to rest him and lry Y as bowler. and Y is then in charge for the time being. That exemplifies the difference between a dictator and a team captain. Once the M.O.H. has decided---either singly or in consultation with the section heads-+that a particular problem or situation is best entrusted to, say, the superintendent H.V., he should not interfere with her methods and she should be free to "'place the field". Just as, to take one example, an M.O. must feel that he has full responsibility in a medical l~atter and can say to an H.V. "'Please do not send in for immunisation any child with a cold," so, to give another example, the health education officer must feel that he has fult responsibility in a health education matter a n d can say to a n M.O. "Please tW in future speeches to get a striking beginning and to use some visual aids". This responsibility of section heads, and indeed of all professional staff', is highly important: otherwise decisions are made not on the skills and experience of the team but simply on the limited knowledge of a medical member. The concept of a team of professional colleagues with diverse skills is difficult for doctors to grasp, because 30 years ago public health work was primarily "medical" and the doctor's decision all-important; and tradition lingers. We must constantly remember that, while the M.O. has training and experience that no other officer possesses, exactly the same is true of the dentist, the H.V+, etc. Although some M.Os. are over-authoritative and dictatorial, the worst offender~ are probably some of the older superintendent H.Vs. and superintendent D.Ns. If a superintendent H.V. is a full section head, "directly responsible to the M.O.H." (to quote a phrase from the 1956 Workip..g Party Report that has been included in both the English and Scettish Circulars of 1959), it is equally true that the H.V. is a highly qualified otficer capable of making decisions within her appropriate sphere. The situation is ridiculous if a H.V. has to consult her superintendent before telephoning a client's doctor or communiicating with the home help organiser. Security and the team.--The team concept, essential because no one profession has a monopoly of knowledge, also provides security in a world of empire+builders. Considered in isolation any one health profession could disappear, and only later would the community realise how much it had lost; but so long as the team stands together and fights together, it is invincible, because no empire,builders can suddenly create a rival team. To retain security we must re~Jise that an attack on district nurses is as harmful to us as an attack on M.Os,, that shortage of H.Vs. can be as fatal to us- as shortage o f doctors, that underpayment of a P, H+I+is as dangerous as underpayment o f a n M . O . H . .

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and that closure of an H.V. training school through lack of tutors is at much a threat as closure of a univcr.sitv dept. of social medicine. Status and the Team.--Thc status of the M.O. as team leader depends on the professional reputation of the team. Anyone who belittles the H.Vs." professional competence or suggests that the P.H.I. is a glorified plumber or says the Home Nurse is ovcr-paid, attacks the entire team. Improvements in the status of Directors of Educ~;tion in the last 20 years are not unrelated to their efforts to improve the pre,.,tige of .school teachers and other education staff: while the M.O.H. of ten years ago said, "'That is a good idea; 1'11 m,:truct nay H.Vs. to carry it out," the Director of Education ~id, "That . ~ m s a good idea; 1'I! discuss it with appropriate teachers to get their reaction". In the long run, ofcourse, our salaries depend on the prestige of the team: if (as is now the case) the head of an institution training 60 dental ancillaries receives three times the salary of a Principal H.V. Tutor, we can hardly expect the salaries of public health M.Os. to compare favourably with those of generat dental practitioners. LEADERSItlP

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We, members of the senior profession in the public health team, ate not teadcrs by divine right. We have the longest training, but not by much: a tt.V. tutor's six years of obligatory full-time training, a fully qualified chief nursing officer's six years, and a dental officer's five years approach our own seven. We remain leaders only by proving our continued ability to act as captains. Possible threats to our leadership include :--(a) The Civil Servit.ne pattern of the lay administrator on top--We could find ourselves supplanted by administrative officers or county clerks. (b) Fragmentation through hostility that we have created--Some P.H.Is. have inade spirited efforts to achieve independence, and nowadays nursing organisations are hinting that they often find us unhelpful and even antagonistic (e.g. that they would rather have a G.P. or a consultant than an M.O.H. on the new H.V. Training Body). (c) Fragmentation by persons well-disposed towards our services--With the increasing shortage of H.V. tutors through sheer underpayment, it is only a matter of time before somebody suggests in the public interest passing the training schools to Education Departments and paying the tutors as advanced further education teachers. (d) Empire-building by workers in neighbouring territory.-~Need I mention the Younghusband Report ? Our leadership can remain only if we hold the team together and lead worthily. What qualities should we cultivate in ourselves and seek in our future successors ? Without claiming to know the whole answer, I offer seven points. (I) Giving loyalty to tile entire team.-,.As we demand loyalty from the team, each team member is entitled to expect loyalty and support from us. Often we show up badly here. How many of us raised a voice for the P.H.I.

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~hen he was underpaid ? How many of us have tried to do anything about the present dangerous shortage of lt.V. tutors or the lack of qualified superintendem H.Vs.? How many of us have even publicly drawn attention to the fact that, )'ear after year, Britain is training six H,Vs. for every 11 required annually? When we take part in discussions with hospital staff or G.Ps., de we always refuse to deal with any matter involving home nursing or health visiting until a representative of the profession concerned is present? (2) t2)wouraeing a sense of responsibitit)'.~The commonest cause of failure of a department or section is one person making all the decisions, so that hc (whether departmental head, like M.O.H., or sectional head, like supt. H.V. or senior M.O.) is overworked and has neither time nor knowledge for sound decisions, and his co!leagues, reduced to routine followers of instructions, lose ~heir initiative and enthusiasm. It is essential to work out a broad (though often unwritten) scheme of responsibility, so that each individual~ right down the line--knows v,'hat sorts of decisions he or she can take without consulting team leader or section head. It is not enough simply to give team members full opportunity to make decisions. Many (like most chief nursing officers) have grown up in an authoritarian atmosphere and cannot become self-reliant overnight. We can perfiaps help by deliberately encouraging section heads to make decisions instead of coming to us; by tactfully reminding them that at field level most decisions should be made not by them but by the field-workers, who are, after all, qualified professional staff; by consulting sectional heads on matters of policy before making our decisions; by supporting these officers even when we privately think their decision was unwise; and, in the selection of section ;heads or their deputies, by eschewing alike the "yes-girl" who will just obey orders and the over-dominating individual who will dictate to his section instead of leading it, and by trying to appoint (e.g. as supen, isor of midwives) a woman with the initiative to take decisions, the personality to argue on occasion with the M.O.H., and the sense not to resent it if on occasion one of her midwives argues with her. (3) Providing Conditions Where Re,~ponsibiliO, can be Exercised.~This means far more than ensuring that the nursing officer or health education officer has an office and reasonable privacy. It also means making sure that the immediate team of any leader is small enough for him to know their merits and weaknesses in detail. Graicunas i n ,'The Span o f Control" tries to prove mathematically that efficiency is reduced if the number o f people in close coniact exceeds six; and certainly a team of more than eight:is unsatisfactory. The common diagram of a public health staff i s ~ M . O . H , and deputy, with in the next line perhaps a dozen section heads (senior M;Os. f o r various subjects, superintendent H , V , H.V. tutor, superintendent midwife, C.P.HJ., chief dentaI o(licer; h e a l t h ~ u c a f i o n :officer, administrative officer, etc.). This diagram: looks unworkable, b u t is in: practice made workable by a f u n c .

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~ional distribution of sections between chief and deputy, so that--although both chief and deputy need a general knowledge of the whole D e p a r t m e n t each is normally in close contact with only about half of the section heads and is able to know in detail the qualities, limitations and problems of that half. In some of the sections, however, there may exist a " team '" of impossible dimensions: a superintendent health visitor and her two deputies cannot conceivably co-ordinate and advise 60 H.Vs. All too often the heads of our nursing services are left with rm time to contribute to policy and planning; instead of acting as leaders of the biggest ~ctions in the Department, they merely serve as advisers to individual field-workers, but have to deal with so m a w that their counsel becomes u.seless. We really need what the recent circular on health visiting advocates~a grade of Group Advi.~r, intermediate between H.Vs. on the one hand and superintendents and tutors on the other, and from what has been said above it follows that we should aim at about one Group Adviser for every six H.Vs. Some superintendents will oppose the creation of this grade, because they have themselves acted as group advisers (to a team fi~r too large for one leader) instead of being concerned with policy: it is up to us to show them the light. (4) Proriding Adequate Clerical Assistance.~-How off:on do we review the distribution of clerical staff? Heads of older sections generally have adequate clerical help, but sometimes health education officers and co-ordinating nursing officers have to scribble notes in long-hand. It is bad administration to have a H.V. tutor (with six years of full-time professional training) doing her own filing, and equally bad administration to make no reduction in the clerical staff of a section with dwindling functions. (5) Supplying Inspiration and Encow'agement.--.tf we are real teamleaders, we must stimulate, inspire, encourage, point trie way to future advances, and mould an integrated team. Occasional policy-making meetings of section heads will help, provided that these meetings are not too over-loaded with doctors; and the issue of a quarterly staff bulletin is worth considering. (My own quarterly bulletin is printed and issued also to all members of the town council). (6) Learning to Understand.~In addition to getting to know the talet~t.~, aptitudes and weaknesses of each member o f our team, we must learn enough of their problems and even their technical jargon to understand what they say. We are useless as team leaders if we have to grope for the ;meaning when, at a case conference on a difficult farnily, a :health visitor says. " T h e r e i s acute secondary poverty but no primary poverty", or ~when the health education officer asks. ? ' D o you think: Dr, Black could manage a talk on t h e stage of negativism?" Perhaps some o f us devote {oo m u c h time to reading clinical journals and insufficient time to publications devoted tO social ~ience, :health education and sociaipsychology. (7) Studying Administration :and Teaching.--We a r e rather more

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d ~ t o r s ' ~vc are doctors ~¥ho, after post-graduate training and experience in .,,¢~-iat hcahh and preventive medicine, have become leaders or potential leaders of a ~eam x~ho~ main job is to teach health. The team of qualified professional workers (M.Os. and H.Vs., midwives and P.H.Is., dentists and meat inspectors) is large: therefore we must sludy administration and personnel management. The principal task of the team is to teach heahh to the public: therefore we must familiarise ourselves with learning processes and teaching techniq~,,cs~ 1 have criticised some nursing officers as authoritative and tradilional. May 1 make amends by suggesting one point where we could usefully copy ~hem? The outstanding H.V. who aims to become a teacher of intending ~N H.\,s. has Io take a sixth year of fu'll-time traifiing in teaching before she can ~ paid as a tutor, and the outstanding H,V. who seeks to become an administrator can take a similar sixth year for the certificate in public health nursing ~:~dministration. On the medical side we have as yet nothing comparable (for 71.he D.P.H. year is inevitably a Iraining in social and preventive medicine. corresponding roughly to the H.V. course): perhaps we should try to organise for our profession courses on administrative techniques and teaching metlaods.