THE SECOND GREEN-PAPER

33

Points of View THE SECOND GREEN-PAPER N. F. COGHILL West Middlesex

J. S. STEWART

Hospital, Isleworth, Middlesex

principal purpose of the second green-paper is unify the three main parts of the National Health Service. This reorganisation offers an opportunity to improve communications, on which the efficiency of the integrated service will greatly depend, but it seems likely that some of the proposals would make THE

to

them

worse. CENTRAL CONTROL

The

green-paper’s proposals are designed to give a decentralised service, but the emphasis on greater central control of finance, and the lack of powers of the district committees (D.c.s) suggest the opposite effect. It is proposed to increase local participation by inclusion of people from the community and the local health services on the D.C.S. We believe that local participation, already at a minimum, will not be increased by the green-paper’s proposals. It is unlikely that the medical profession will happily accept a more centralised service with less local participation, and the more powerful bureaucracy that would inevitably result. The reasons implied for more surveillance and control of money spent on the service are that money has hitherto been spent on the wrong things and that priorities have been ill-chosen. However much truth there is in such charges, and we agree that more money needs spending on mental health, mental deficiency services, and the chronic sick, it would be a retrograde step to increase the central powers of administration of the N.H.S. There are other ways of dealing with these problems. As in the past, the Department can earmark funds for specific purposes, and boards must comply. But what is desperately needed to make better housekeepers of the people running the service is not more Ministerial financial direction, but less Treasury control. The lowest money-spending echelons in the service must be allowed to carry over savings from one year to the next; and flexibility could be introduced by allowing these bodies more latitude in spending their money within the Department’s general policy directives. Financial and operational audit post hoc, with suitable sanctions when necessary, would keep managing bodies on their toes. Those which failed to be good stewards could revert, for a period, to more rigid forms of budgeting and control. LOCAL CONTROL

Although it is agreed that the N.H.S. will not be administered by local government, its administration is to be " closely associated with local authorities ". One suspects that this is an attempt to introduce an element of " democratic control" into the health service, a concept that many people support. Unfortunately, as the example of education shows, and past medical experience confirms, this is not the best way to protect people’s rights when they are receiving a service (as

parents and pupils on the one hand, the N.H.S.). It is mainly for this

or as

patients in

that the medical profession has resolutely set its face against the N.H.S. being administered by local government. The best assurance of a humane and efficient Health Service lies in the attitudes of the people providing it (attitudes governed by tradition, professional ethics and standards, appropriate training, and opportunities for innovation) and by the provision of means for redressing the grievances of those ministered to, no less than of those ministering. We believe that studies of the attitudes of people working in the service, and of the factors forming these attitudes, are a vital step in the promotion of the kind of health service we need. We see the appointment of a Health Commissioner and the setting up of a Hospital Advisory Service as important steps in providing machinery for redress and innovation. One of the best safeguards for a service is the willingness of professional people running it to speak up. This is fostered by providing an authority for appointing and employing the professional workers, higher in the hierarchy than that concerned with directly administering the service. We must avoid the deadening effect noticed in education where the teachers are employed by the Local Education Authority who also run the schools. We therefore urge that consultants, and matrons and sisters, be employed by Regional Health Councils, so as to avoid local political and administrative pressures. It is proposed in the green-paper that up to one third of the members of area health authorities (A.H.A.S) shall be local councillors. These people will already be fairly fully occupied with their jobs and with sitting on Council committees; and whether Councillors or not, these members will be political appointments. Inevitably their attitude to services tends to be formed by considerations of local party politics. This step is being suggested at a time when there is, for example, a move away from such appointments to the governing bodies of schools.’ By all means, have some Councillors on hospital governing bodies, to provide a link with local government, but is there a need for them to constitute as much as a third Whatever the number finally of their members ? decided upon, they must have the time necessary for the intricate detail of a unified health service. reason

DISTRICT COMMITTEES

One of the great problems with the present administrative organisation of the Health Service is the lack of channels of communication between the periphery and the centre. If the Health Service is reorganised according to the suggestions in the green-paper there would be still greater separation of the hospitals from their governing bodies. The 90 A.H.A.S will be too remote to become involved in day-to-day administration of hospitals or groups of hospitals. Indeed, this is recognised in the green-paper, which proposes that D.c.s should be set up to be concerned with a hospital, or a group of hospitals, apparently in much the same way as hospital management committees (H.M.C.S) are now. However, it is specifically stated that D.C.S shall have no statutory powers, although " it is intended that the A.H.A. which establishes these com-

34

mittees will use them to supervise the running of services at district levels ". It is proposed that half the membership of the D.C. should be appointed by and drawn from the A.H.A., and the other half from elsewhere (including a number of local people). Many of the members of D.c.s, being also members of the A.H.A. (apart from all their other commitments) will be too busy to work effectively at The lack of powers of D.c.s will not attract D.c. level. other people of good calibre. In Local Education Authorities where schools’ governing bodies contain many members of the Council, the governing bodies may seldom meet, usually have few powers, and are often ineffective. The Council members are already very busy and prefer to discuss school matters in the Education Committee and the Council rather than in the meetings of the governing body. The insertion of a feeble administrative layer (D.C.) between hospital and A.H.A. means that consultants will have even less access to the seat of power than they have with the present poor communication links with the hierarchy. We believe that other workers in the service-general practitioners and nurses, for example-would find themselves similarly isolated. How are powerless committees (however many local people there are on them), and" powerless workers in the service, going to be able to plan, administer and provide for the comprehensive health needs of every citizen " ? How can a committee supervise the running of a district hospital, as well as G.P. services, if it has no powers-that is, powers to spend money and to manage its affairs with some freedom ? The proposals for D.c.s are unacceptable. People of the kind the service needs will never sit on that sort of committee. AREA HEALTH AUTHORITIES

to secure the services of able with time to master the complexity people of hospital administration and to play an active role in it. The problem is only a little less acute at board level. We suggest that to overcome this defect the chairman, vice-chairman, and perhaps one or two other members of A.H.A.s should be full-time and be really adequately paid. The majority of the members of these committees would remain unpaid. (We believe this system has worked well for electricity

It has

proved difficult

on H.M.c.s

boards.) There has been

a

good deal

of talk recently about We must pay more than lip-

public participation.2 service to this important concept. Consultation implies the simultaneous giving and taking of advice, but if we are to sustain high standards in the professions of medicine, nursing, and administration, not only must there be satisfactory channels through which advice may be sought and given, there must also be the the people in the service being able to influence events. This possibility will inevitably recede unless close relationships are carefully developed between those who work in the service and those who administer it.3J There is nothing in the second green-paper which suggests that the Department wishes to change or interfere with the divisional system. Nevertheless, the proposals would in practice make serious difficulties for its full development. We believe the

possibility of

divisional machinery should provide the main source for new ideas in hospitals. Our experience4 is that divisional committees are good places for pinpointing administrative problems and working out acceptable solutions because they are relatively small working groups whose members tend to share similar problems and aims, so that direct clash of opposing interests is uncommon. Our divisions have little difficulty in carrying the medical committee with them in their recommendations. The blocks come higher up the administrative chain. We wonder if it is in recognition of this that it is proposed that one-third of the members of A.H.A.s should be professional people (doctors, nurses, &c.). Would this device be any more successful than the existing organisation ? The answer lies in recognising that at present some H.M.C.S and boards achieve better communications than others with their hospitals. This happens because on the one hand people on committees necessary for developing spend time on the communications, and on the other because administrators apply modern methods of management in a

groundwork

professional setting. In the absence of real knowledge of patient need the three factions comprising the A.H.A.s-drawn from local authorities, the professions, and nominees of the Secretary of State-with their opposing interests, might not pull together. The prime sources of this knowledge should be the hospital divisions, the general practitioners, the medical officers of health, and the medical social workers. Whatever the final constitution of A.H.A.S, we do not believe that good communications, on which good administration so greatly depends, will just happen because these bodies contain numbers of interested parties. Recent studies 5,6 suggest that the hospital service is not making full use of the talents of its professional staff at their working level. The same may well be true of doctors, nurses, and others outside hospitals. It is vital that any new administrative arrangement should open up organic links with bodies of professional workers in the service. Administrative divorce of hospitals from A.H.A.s, implicit in the green-paper, would prevent this. REORGANISATION NOT ENOUGH

Our problem is to devise practical means of realising these ideas. Any attempt to formulate a new administrative structure for the Health Service in the present state of our ignorance must be to some extent a theoretical exercise. We suspect it may simply not be possible to do it successfully without experiment. Some A.H.A.s could, for example, be variously constituted, some members being paid (as suggested), or members being drawn from different sources. However, organised careful monitoring is essential so that defects and advantages of different systems are quickly discovered. Why should not the A.H.A.s be responsible for this, perhaps with the coordinating help of the proposed Hospital Advisory Service? The A.H.A. will certainly have to conduct research into its spending practices (normal process of audit), and it will be expected to support research into technical and clinical problems. What is more natural than that it should critically observe its own workings, and its managerial effectiveness ?

35

It would be a tragedy for medicine if any reorganisation of the N.H.S. jeopardised the scientific training of medical students, but we see no reason why this should happen in a unified service where the hospitals mainly

teaching undergraduates will be administered by the same authority as other hospitals. Most large hospitals now teach medical students or postgraduates or both, and we believe that all will benefit from being brought under, one umbrella. Academic standards for teaching and research should be maintained by adequate supervision and/or finance from universities, Royal Colleges, and the Medical

responsible

for

Research Council. To convert a tripartite system to a unitary one obviously requires administrative and physical changes in organisation. But there are other imperfections in the service, for example: inefficient management at all levels, lack of policy directives, isolation of peripheral workers in the service, separatism between departments and groups (particularly nurses and doctors), and committee amateurism. These are in urgent need of remedy, but it would be dangerous to assume that reorganisation alone will correct them. People’s attitudes and methods of work also need changing. This is a much more difficult task than effecting mere organisational change, which is presum-

Views of General Practice

the reason why it is usually avoided; but it is the vital obverse of the reorganisation coin. Without it, when the dust has settled the same familiar attitudes will be found in the same (or similar) positions-the plus fa change syndrome-and no radical improvement in the working of the service will be evident, with inevitable consequences to morale. The problems of all professional people in the N.H.S. are fundamentally similar. In attempting to maintain high standards and flexible conditions for innovation, a degree of participation is required, not less, but greater than at present. This is what the next green, or white, paper must offer.

ably

REFERENCES 1. Baron, G., Howell, D. A. School Management and Government: Evidence to the Royal Commission on Local Government in England. The Research Unit on School Management and Government, University of London (Institute of Education). Research Studies no. 6. H.M. Stationery Office, London, 1968. 2. People and Planning. Report of the Committee on Public Participation in Planning. Ministry of Housing and Local Government, Scottish Development Department, Welsh Office. H.M. Stationery Office, London, 1969. 3. Coghill, N. F. Lancet, 1969, ii, 1058. 4. Stewart, J. S. Br. med. J. 1969, iv, 420. 5. Revans, R. W., Coghill, N. F. A Study of Para-clinical Attitudes Among Consultants. in Changing Hospitals; vol. II: The Hospital Internal Communications Project seen from Within (edited by R. W. Revans). London (in the press). 6. Revans, R. W., Coghill, N. F., Ulyatt, K., Ulyatt, M. F. Unpublished.

in their practices, attention of these patients.

was

given

to

the manage-

ment

THE PSYCHIATRIC COMPONENT IN GENERAL PRACTICE* H.

J. WALTON University Department of Psychiatry, Royal Edinburgh Hospital

general practitioner is the main provider of psychiatric treatment in Britain. He refers only 1 in 20 of his psychiatrically ill patients to a psychiatrist.’ In the United States, also, a large part of the psychiatric workload falls on doctors other than psychiatrists. A national survey2 showed that 29% of those who felt the need of professional help for personal problems approached doctors other than psychiatrists; 18% consulted psychiatrists and psychologists; and 13% went to social agencies or marriage-guidance clinics. It was found in a survey in Monroe County, N.Y., where 58 doctors reported on over 11,000 patients seen during the course of a month (about 17% of the white adult population are seen annually), that about 17% of patients had a mental or emotional disorder.3 Only a third of the patients so diagnosed had come to the doctor complaining of psychiatric disorder-a demonstration of the responsibility imposed on the doctor to identify psychiatric illness when the patient’s primary complaint is somatic. A British survey of 46 London practices found that 14% of patients present with psychiatric illness in a year.4 As the evidence accumulated that general practitioners maintain large numbers of psychiatric patients THE

*

a paper read at the World Psychiatric Association Symposium on " Uses and Abuses of Psychiatry ", held at the Royal College of Physicians in London, Nov. 17-19,

Section of

1969.

REFERRAL

The general practitioner may act along physical rather than psychiatric lines-for example, referring the patient with non-organic disorder to a physician or surgeon: a large proportion of patients at general medical and surgical clinics suffer primarily from psychiatric disorders.4,5 The general practitioner, in making the inappropriate referral, may hope the patient will benefit from being reassured by a consultant that no physical disease is present. Older patients, when ill with a psychiatric disorder, are less likely to be aware of the nature of their disorder than younger patients. In one survey, while threequarters of patients under 65 recognised their condition, almost half of those over 65 did not realise that their illness was psychiatric.3 Older patients are less willing to accept a psychiatric diagnosis, and more prone to deny psychiatric disorder.Ample documentation exists that another non-medical consideration, the social class of psychiatric patients, powerfully influences the treatment provided.7 The general practitioner primarily determines how much psychiatric illness gets recognised. He decides which patients get to see a psychiatrist; his attitude to psychiatry and psychiatrists influences how many and what types of patient he will refer.8 Patients rarely have the right of self-referral, direct approach being available only in a few special instances to such groups as students at some universities 9 and to some industrial workers.10 General practitioners refer their men patients to psychiatrists more often than they do their women patients, and their younger rather than their older patients. Although twice as many women as men con-