The society of medical officers of health eleventh annual symposium the unity of medicine—the theory and practice of integration

Pttbl. tthh, Lomt. (1972) 86, 258-285

S e s s i o n Ii. T h e Practicalities Introduction by the Chairman, Dr D, Cullington, County Medical Officer, Berkshire I wot~.D like just briefly to introduce all,three Speakers for this session to you now. Firstly Dr. Hampson, who is Area Pathologist at Reading. Dr. H a m p s o n is a member o f the Central Health Services Cotmcil and the Standing Medical Advisor3' Committee. He is, also on the Steering Committee For the N.H.S: Management Re-organization that Mr Lee was referring to this morning. Perhaps o f even greater immediate interest to us is lt~e fact that he has been a m e m b e r of the H u n t e r C o m m i t t e e , and I know him well locally in his capacity as Chairman of the Medical Executive Committee of the Reading Cogwheel organizatiom M r Alien. who will speak second, is Consultant Ophthalmologist in the Farnham Group o f Hospitals, and he will o f course be very intimately connected with the new Frimley "Best Buy" Hospilal. He is Chairman of their Medical Advisory.Committee, though I gather from him that they have not, as yet, got a Cogwheel in the sense that Reading has. Dr. Forbes, who will speak third, has been a general practitioner in the Bicester area but now has the challenging and interesting post o f Senior Lecturer in C o m m u n i t y Medicine at the new medical school in the University o f Southampton.

F. HAMPSON M,A., D,M.~, B.CH,~ F~C.PATH.

Area Pathologist, Reading I S~U}ULD be speaking less than the truth if 1 did not admit at the beginning that: I have looked on my task today with some misgivings. [ think I must establish m y amateur status at once. Let me say therefore that I have no real qualifications to speak about this subject at all. Furthermore. I have been told that I have to be practical. It is something o f an impertinence for me to talk about a subject which is not my own to an audience of experts who would not be here if they did not possess a knowledge and experience of medical administration much greater than m y own. My excuse must be that [ was invited. I am going to be deprived of an aid which I would normally employ i f [ was talking on m y own subject, a series o f illustrations which at least would take people's minds off what l was saying! I should add one m o r e to these preliminary remarks. 1 am, Mr. Chairman, or I have been, as you care to read it, a m e m b e r o f the Hunter Working Parry on Medical Administration, and 9f the Working Party on Collaboration with Local Authorities, so I must make it completely clear that what follows represent m y own views and nothing more. It does not necessarily reflect the opinions of either o f these bodies. If you fi|'.:t any merit in what 1 say, it will have arisen out of m y experience on them, but the errors and shortcomings are wholly mine. S o m e b o d y once said that there is no subject which at f r s t sight seems difficult and complex, whicl-, after deeper thou/~ht and more careful study doesn't appear m o r e difficult and complex still. Oscar Wilde expressed the same idea when he said that the truth was seldom pure and never simple. ! hope that what I am going to say will be pure enough but the issues are certainly not simple, and 1 expect to ask m o r e questions than I m~swer.

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To begin with, for our present purposes we must be quite clear about what is given about the situation and which we have to regard as fixed. No doubt each section of the profession, general practitioners, hospital doctors, and community doctors, could have produced a scheme for integration differing From the one we have been given and. in their opinion an improvemen! on it. No doubt too our masters the planners will be reasonably happy if they find each section complaining a little, and none strikingly m o r e than another. So what then is given ? Instead of the tripartite organization of the profession, we are to have a unified integrated Health Service. Regional Boards are to be replaced by a new form of regiona, organization with somewhat different functions, except in Wales which will have none. Hospital Management Committees are to disappear and an entirely new structure, the Area Health Authority, is to be introduced. Local committees concerned with some arrangements t\~r general practice are to remain, but with a rather altered role. My purpose today is solely to consider how these exchanges will affect us as doctors, of whatever description, and in particular to attempt some tentative steps in the exploration of the role and function of what in some ways is a new kind of doctor, the c o m m u n i t y physicians. F r o m the vast amount of material which one could have chosen to talk about, I have decided to divide m y subject matter into three parts, each of them posing a question. How are we to work m o r e closely t o g e t h e r - - a n d by "we" of course I m e a n the three branches? Flow are wc to influence the bodies responsible for medical services? How are we to effect a painless, ! hope, integration between a traditionally non-hierarchical organization of clinical medicine and a hierarchical pattern of medical administration ? None of these tl~ree can be considered in isolation, but I hope that we shall find that the concept of the community physician will have a bearing on each of these three questions, and that it will to a large extent form a connecting link between them. I am deliberately not going to attempt a definition o f the c o m m u n i t y physician; too m a n y people have attempted too m a n y definitions already and for m y present purposes may I say that I a m more than content to accept Alex Gatherer's admirably lucid definition which he set out

in Challengefor Change. You will no doubt find nay remarks are hospital biased, and perhaps this is inevitable in view of m y background, but 1 hope that m y own prejudices will not be too obtrusive. and even if they are I a m quite sure I can rely on other speakers to adjust the balance. H o w then are we to work m o r e closely together? I think this should not in practice present insuperable problems since in m a n y ways we are used to doing exactly tb.is already and there is surely no question of uniting three warring groups. So far as hospital doctors and tamily doctors are concerned, what are required are certain shifts in emphasis. The role of the c o m m u n i t y physician needs a new approach. The process of further integration between specialist and generalist will clearly have to be achieved by two general measures, by getting t2mlily doctors m o r e and m o r e into the hospital, and by taking hospital doctors m o r e and m o r e outside. I can see no other way. no other general principle by which this matter can be approached. The sharp break which occurs when a patient is admitted to hospital has occasioned difficulties in the past, and is perhaps the commonest cause o f complaint by general practitioners regarding their role and their status. M y v~ews about this are not going to be universally supported, but I must give them. [ believe that in our present state of evolution the general practitioner has two roles in the hospital i if he is interested in a specialty, there should be ample opportunities for him to pursue that interest, first as a clinical assistant, and then in appropriate higher grades. I would go further and say there ~nust be no barrier between the general practitioner and the consultant grade other than the acquiring

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o f suitable experience and qualifications. There is o f course none now in any absolute sense, but the change is seldom made. The second role I see for him is that he shall be in charge of his own patients in his own hospital, or at least in his own beds. In m y own region we already have a unit consisting of one ward which has been handed over to local general practitioners for their use as a pilot scheme. Final assessment of this would be p r e m a t u r e - - i t has been running for little m o r e than a y e a r m b u t the unit is the Subject o f close study by the Regius Professor's Department in Oxford, and to a m u c h less extent by ourselves. At this stage I am sure we would all be prepared to say that the results are encouraging. We need a lot m o r e information and the first year has been to some extent one of finding out just Mlat m o r e information we do need. We want to k n o w about how these patients are setecled, about their length of stay, their rate of transfer to acute beds, and the frequency with which consultant opinions have been sought. We also need an assessment of how m a n y o f them would not have been admitted to hospitN at all if this unit did not exist, and an assessment o f how we!l they fare in this unit as compared with a control group, if one could be organized, in art .acute general hospital. The situation is not altogether typical, I should say, because it has been facilitated by the fact that the area concerned is served entirely by one large general practice. The doctors are enthusiastic and I can foresee an extension o f this arrangement as soon as circumstances will allow; the next step will almost certainly be a day hospital. 1 hope there will be little disagreement about these two roles for the general practitioner in hospital. The other possible role is m o r e difficult. Should he have charge of his own patients in acute wards in district general hospitals? The Scottish Report on doctors in an integrated service envisages the G.P. going far to replace the general physician in this respect, biat personally 1 doubt it. The authors of that Report refer quite correctly to the tendency to replace general physicians by specialist physicians, but is this to go the whole w a y ? Must every physician be a specialist ? In the same Report the point is made that the consultant general physician developed because a man's colleagues recognized his particular gifts and came to value his opinion. Is this then.to cease? Equal we m a y be, but are we all as equal as that ? Is a general practitioner, with all his other concerns, to be expected to be as good in general medicine as one who has no other professional interests ? These questions 1 leave with you, but personally I do not see the demise o f the general physician just yet. So m y answer to the question o f whether or n o t the G.P. should have beds in acute hospitals is therefore " N o " but 1 am willing to be convinced otherwise. So much for the general practitioner in hospital. Now what about the reverse ? We are up against practical difficulties when we try to extend consultant w o r k outside the hospital though it has to be done. Travel becomes ever m o r e difficult and it makes more sense to collect a n u m b e r o f similar patients~and bring them to a doctor than to take the doctor to a n u m b e r o f patients dispersed over half a county. Lines exist already, by way of domiciliary consultations, and I think ! can see at least two more. One is by liaison in c o m m u n i t y hospitals, where in a more relaxed atmosphere the consultant and general practitioner can get together, and the other is via health centres. In some specialties, though certainly not in all, it m a y well be t}mt it ~,ill be entirely reasonable, to arrange consultant/ general practitioner discussions ie b,e~!th tenures, to the benefit of all concerned. A n o t h e r most important way in which t~ese two groups can come together is in educational activities. The rapid development of postgraduate medical centres does provide a framework for this and in m a n y parts of the country the good effects o f their introduction are already 0eing felt. N o r need the intellectual traffic in these centres be one way only.

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1 would hope that they will be true meeting places, and not simply buildings where general practitioners attend tbr instruction. The extension of the "Co~vheel'" structure to a district rath.er than limiting it to a district general hospital, otters another and. I think, m o s t important way of integrating the general practitioner's work and the consultant's work. I would like to say more about this when ! discuss how we can inflt, ence managing bodies, but potentially I am sure tl~is is an important inlegraiive force. So much tk>r th.e comparatively easy part. The new consideration to be taken account oi is the advent of the community ph.ysican. 1 hope you d o not expect me to make any really preci.se suggestions about his role, since others will be going into more detail arid in any case much of it must be allowed ~o grow and develop. There was a l'amons London leaching hospital which was considering lhe question of appointing a thoracic surgeon, and when everybody had said his say, the senior surgical consultant on the stat:f said he really could see no reason t\~r such an appointment because he always dealt with empyema cases himselE I have no doubt lhat similar views will be expressed about the c o m m u n i t y physicians and Hint time will show them to be just as wide of the mark as was that general surgeon's comment. In later sections I will try to look at die. formal role of the c o m m u n i t y physician in the new structure, but th.is is perhaps the place to suggest one or two ways in. which he might be integrated at what one might call "'shop floor" level. Flexibility, especially in the earty days, is vital, and the fact that different patterns will develop in different places is all to the good, but some functio.qs do suggest themselves readily. The comprehensive children's units which are now being advocated indicate an obvious role, and so do the whole fields of geriatric and psychiatric services. Within these fields the c o m m u n i t y physician's function as link man is obvious, since there must be close relation between the medical and social serx, ices and in child health with the educational services too. These are only instances and obviously his role must be far wider: with a concern extending outside the hospital as well as in. it. The Scottish report which 1 have already mentioned is clear arid helpful in deIining some of the special activities o f the c o m m u n i t y physician. It says that he wilt assemble and interpret data. relating to health service needs, population trends, and effectiveness of existing services. l-.le cannot hope to do these things in isolation; he will have to w o r k closely with clinicians. It goes on to say that he will collaborate with those responsible for broadening the service and ensuring that resources are used to the best elTect, and that he will play his part. in planning and initiating new services. Clearly this implies working together in a very real sense. It says that he will help each clinical division to assess its work and to relate it to the wider field of the community. In the same paragraph it discusses his role in managernent but I will leave that for a few minutes. Finally it speaks of his role in collaborating with the social services and environmental health departments and here too a close relationship with clinical colleagues is essential. i firmly believe that a post which includes duties of this kind, and there are m a n y others one could list, will enable a doctor to find full professional satisfaction in the same way that other doctors find it in their fields. 1 know that I am describing what is in some respects a new kind of doctor, but l think it would be unrealistic to imagine that the changes that are contemplated can be introduced without cutting across some of the neat and tidy categories of doctors to which we have become accustomed. In summa/T then, I ~ee no basic difficulty in working closely together, and t see the c o m m u n i t y physician as the catalyst. M y new point was, how are we going to influence policy making and managing bodies ? I must rc.,,st the temptation to c o m m e n t on what is already decided, and i will assume that

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medical representation, by which l mean actual membership o f the bodies concerned, is going to be as poor as it looks like being.+lf this proves to be so, doctors are going to have to seek to influence policy rather by proffering advice than by taking an active part in the decision making process itself, and clearly there are two lines for the transmission of this advice, t]rst advice by professional medical administrators who will be in a strong position both at area and at regional level, artd second by medical advisory machinery ralher simil~Hto, but not necessarily the same as, t h a t xvhich now exists, I hope that 1 am not going to confuse either myself or you in this section, bt~t it is, not going to be easy to avoid it, because difficulty arises because o1"this new tier, the area health authority, about which I should dearly like to c o m m e n t but will not. My problem to date arises because at district level we have developed, or are developing, an effective machinery for giving advice or participating in management, but it seems that there is to be no statutoi3' body at that level for us to advise .or assist. At area level, on the other hand, a statutory body will exist, but no structure for organizing medical advice or participation, oth.er lhan the few medical members of ttte authority, has yet been devised. So t will t~3~ to be as clear as I can but a certain a m o u n t o f jumping from one level to the other is going to be tinavoidable, as so m u c h is still unknown. The position is made the m o r e complicated because the level at which machinery does exist--the district---is a management level only. Policy is to be determined at a level where there is still no machinery. AI this stage i must annourice myself as a strong supporter of ~.he Cogwheel system, and say that I see in its development not only a means of influencing policy and management. but perhaps the most effective single way of bringing about real integration. At district level 1 think there are few real difficulties, except the difficulties of size in producing an integrated C o ~ , h e e l arrangement. Size is important, and I think was never better considered than it was by Sir James Howie in his paper last'year called "Democratic Dirt.~tion". He produced good reasons there for deciding that twelve was about the maximum size l~r a committee which is to engage in deliberative discussion as distinct fi'om general discussion, and t h i s b r i n g s us face to face at once with a problem in the formation of a Cogwheel executive. The Cogwheel system in nay own hospital, which at present does not include an-,, but hospital representation, operates through a medica} executive committee of nine, and it was not easy to keep the n u m b e r down to that. If we are :o aim at an integrated Cogwheel, then not only will it be necessary to include a division o f c o m m u n i t y medicine and divisions of general practice, b o t h to be represented on the executive committee, but it will be equally necessary to ensure that it is not overwhelmingly hospital based, t think there is a real problem here and a good deal more thought is necessary. There will certainly be a division o f c o m m u n i t y medicine and I hope that such a division will include doctors other than c o m m u n i t y doctors; that it will include general prectitioners, geriatricians, paediatricians and whoever else may be closely concerned. So I can see no real difficulty about the inclusion of a community medicine division in Cogwheel. General practice is obviously a great deal m o r e difficult. The development o f health centres might m a k e it easier and it may be possible to group a n u m b e r o f health centres together to form a division but clearly it will ~ot suffice if one division o f general practice is found a m o n g ten or a dozen other divisions. Howe-~er, I think it is perhaps premature to try and discuss this further. Apart from size, two other considerations remain and to some extent it has been doubt about their practicability which has influenced a m l m b e r o f hospitals in deciding not 1o implement Cogwheel. Both o f these considerations are fundamental. First a large group of doctors must be willing to allow a smaller group, chosen by themselves, t.o act on their

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behalf and to make decisions which will alTecl their work. Second, the .,,mall grnup constituting the executive committee must be composed of people who are able lo la5 aside their specialist loyalties and to act ol!jectively. In some ways the tirst of these conditions is foreign to our tradition, and the :~econd may seem to go against human nalure. But t think they are both essential at present and will be just as much so in an expanded district Cogwheel. M a n y doctors afler atl are totally uninterested in administration and wh.y n o t ? This i,~ not why lhey became doctors, We have to convince them that even if so far as lhey arc concerned administration is an irrelevance, it is not so for the body politic of doclor~. One difficulty we can look ti)r~vard to with assurance is lhat fhe doctors with no particular interest in administration arc the ones w h o wilt have most fault io lind with the arrangements which are made and lhe decisions which are taken. As [ said at the beginning, di£ticult problems become more difficult as one explores them, and this applies to administrative problems as lntlch as to any others. 11" one can., so to speak, exlrapolale backwards, then one can see that for doctors with neither km~wledgc of nor inieresl in administration at all~ the problems cease to exist. A man with neither knowledge nol interest will see no reason whalever why there could be any possible advanlage 'in altering his own arrangements. Contrariwise, and just as important, there is a danger that a medical administrator, recognizing the need, and wishing to do something about it, will not sufticiently explain to others what seems to him to be a self-evident proposition. Indeed t think this has been one of the great defects so far in the integration proposals. l h e r e has not been nearly enough, information given to the non-expert, and 1 underline that, of the ills wh.ich the changes were,in.tended to remedy. This I am sure, has been one of the ti/ctors. wilh pr~udice and conservatism being two others, which have been responsible for a reaction which al local level has often varied between, hostility and a sort of despairing resignation, Having decided that a lnodilied form of CoDvheel would in my opinion be realizable at district level, a large question remains unanswered and that is, w h o m is it to advise? One of the great advantages of the system at the moment is the direct link, through Cogwheel, between the most junior member o f the medical staff, w h o arrived not dry behind the ears last week, and the chairman o f the hospital management committee, l-~uI managernent committees are to cease to be, and we do not know what wilt replace them. I do m,r th.ink it will be satisfactory if the medical executive committee of Cogwheel is able to advise only permanent officials at district level. This introduces more stages between doctors and decision makers than are acceptable, in my opinion. I can see that the system could continue to work, though perhaps less effectively--and this is where i am going to j u m p from district to area---if by some means or other district Cogwheels were able to maintain a direct line of communication to area authorities, btit I can see a lot of difficulties. In the first place, an area ,authority is going to be a more remote body than a hospital management committee. It will not have the intimate knowiledge of conditions at local level which a hospita~ management committee does have, and it will be concerned with the whole field and not merely hospitals. 1 think it Will be hard to achieve the close relationship of partnership which exists now where an active Cogwheel system is working along with a well-informed and well-disposed hospital management committee. Another problem arises because of the fact that it looks as though medical membership of these bodies is going to be so poor, and medical links with ci,atricts rather tenuous, and yet another one because at area level there wilt presumably be a strong team-of professional medical administrators. It cannot be expected that they, any more than the authority itselt; will have the intimate knowledge of conditions at local level which a medical executive committee will have if it is doing its j o b properly.

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With weak professional representatio~ on tl~e authority it would seem [o be a reasonable fear thai medical advice will be gained by tl~e authority rather from its professional administrative staff than via the Cogwhect machinery, if indeed it provc,~ possible to operate any form of area Cogwtleet at all. The danger irt this, I think, is that if Cogwheel linds itself becoming less and less influential, the interest in working it will 13!1 correspondingly. At the end I will try to suggest a possible answer to the qttesiion of whom the district Cogwheels may advise. Ctea"ly one approach to the problem of giving effective advice or participating in management will have to be made via the strong medical advi,;orv machiner~ which the Consultative D o c u m e n t promises us, and let us assume for a moment, ~hat. Imwever it may be set tip, it i:~ going to be something quite distinct from Cogwheel. \\"hat are the difficulties going to b e ? Regional Boards have been concerned with a comparaiively large number of hospimt management committees and the greater this number the easier it has been for n medicat advisory committee to be objective, in fulure, ho~-ever, parlicularly in the two-disirict area, the members of the medical advisory committee, bc they hospital men, general practitioners, or community doctors, will have an allegiance to one or other of the dis~riciy. Perhaps it will be making impossible demands on them to suggest ~hat the members fron~ one district shou[d see the need for something or other as clearly :n a di,~trict which is m~l their own as in one that is. This will be particularly true in instances whicl~ arc certainty going to arise where two districts, with no natural links, are joined together, t):ven ti,,e appointment of medical a d v i s o w committees in these cases is going to pose serious problems, If they are to be nominated by the Area Authority, the authority uill no d o u b t aim at approximately equal numbers from each district. ;If they are elected by doctors, then either each group o f doctors will elect onty members from its own district, m which case a conflict situation is built in, el: all doctors in the area will choose members of the Advisory Commilie~: in which case people will be voting for or against candidates w h o m they hardly know. However appointed, local authorities will remain strong and perhaps excessi~.ely so. So far m this discussion on how we may influence statutory bodies, 1 have made no reference to the community physician. If he is going to be based, or partly based, at district level, though with a clear place amongst the area stall" as well. I can see him being put in a dill}cult position. He may well find that his co-equal colleagues in the district wish t0 recommend a certain course with which he may welt agree. If his hierarchical superiors at Area level do not share this opinion, what is the poor man to d o ? He is in danger of being caught with one toot on the boat and the other foot on the shore. 1 think that however this is going to be done, and l know it is difficult, some way has to be found of" ensuring thai the doctors I am thinking of, devoting time and trouble to working medical advisory systems, or trying to help in management, must continue to feel that they are running something m o r e than a talk shop, that they are in a very real way able to exert an influence on the policy making body, whether they do this directly at the area level through some machinery yet to be devised, or wh.ether they work through district Cogwheels. H o w this is to be done is one of the big question marks in my own mind, and it is easier to see how it cannot be done than how it can. M y final section is to say a little a b o u t the question, a very important one, of the interface between hierarchical medical administration and the rest of medicine. The long traditions o f the profession are based on the individtlal responsibilities of'a doctor to his patient, on a direct lace-to-face relationship, and inevitably from this kind of arrangement has grown a structure which, apart fl:om the junior ranks, is non-hierarchical. A general practitioI~er ranks neither higher nor lower---the terms do not mean anything--than a consultant, and the same applies to senior doctors in the public health field. But the very notion of manage-

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do not yet k n o ~ cxact]x ~vhal '~villbc proix~,cd, huii!. ~olHd >ecru IikeI\ their there r,n,i~ hc at the di,~tFictlevel a ¢omn~unil.v ph>sician wh.,~ to .~omc cxtenl at Ic~i,,lnm,. be r¢,,p~m~ii~[c [oa chief medical olTiccr in an area. So the di,~cu~,ion on the interiacc theFc!orc ~ ~.'r>~harpI> f,..~cu.,seson ~his n e w kind oF doctor, the con~mulnit~, phy.qck~n. ] I-llIl~1 be CCll'C['tI] ll('~[to ~ccill [o iillticip~:llC tile IepoF[ of the l.ln~ler (.'cm'o~i{(c.c.~ind to ns>ure you aeain that whal I a m saying c]b()tllthis ix el}l.hc!) ~ll;ll I ~ h m k ~h,,,~l it.,II ~hcrc is ;.in',c<)l'renpondcilce or lailurc of correnl'~orldcncc, het',veen ~b.at I anl ,~a>in.~ lli'~\,..LIII~.I ,,\hal m a y eventually emerge, this is coincidence.

I lhink lhe po,,ilion oF the comi?.uniiy physician in the il nclllc ih;.I! mu~1 bc grn~ped, if w e arc ~,.oing Io cFe~te whal i;- to son3e cx!cn~, a nc~v kind ~,I a ~ m a l . then I think ,.~e m~sI ,q(q expect, to be ~ible to llt jlhn neati\ into an cxb, iin~ medical xh,I. and he ~ ill I~:ive t(~ wei,.rtwo Il~Is. W h a I I do believe (.o be I'und:imentai to hi,,nile. if hc i~ lo acl a,, a lorcc m a k i n g ('or real integration~ and beyond tha! it he i',!o c:onlinuc to v,ork uscIulIv wi!hin an intc~rated service, is that his sin|us mux~, bc ~uch a~ x\ill ph~vc hinl on equal tern> ~ifl~ the con~ultam or with the pri[~cipal in gcner-~l praclicc, lie ;nu'~tc.:~rr>1he ~.:me re~ponxibiIitie~ and h.c must enjoy the s a m e p.rivilegcs.

ll" thi> is to bc so, then merely lal~ellhlg this man as ol'consultan~ sla~u~ will n,>l <~t i!,,elI sulticc+ I do not ;xant to becoir~c involved no\x in questions of tlainin 7 and quatititalicms. but the pFi,,..Tpte tl-~tlst he tluc lhat if clinical consultanls l the cotlllY~.tlniiy physician to show that t~is work does depend cm the practice <~t" it~ O~tlt particule
But a point that I do w a n t to m a k e quite clear is my o w n strongly held belief that ;t would not be at all a good a r r a n g e m e n t for tile communit>, physician at district level Io he art agent o f the area autl~ority in the sense that tim i m p l e m e n t a t i o n of its policies ~-outd hc his peculiar responsibility, and o n l y his. l--le must have a share in this, a,, I will sa$ in a m o m e n t , but I d o n o t see a role for t~im as a general manager o f services at tt:e district lc.,-cl.

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t f he, and he alone, were to be the implementer of the area's policies in this way, he would very rapidly become, in the eyes of his cli~lical colleagues, one o f them, and not one o f us. And by whatever n a m e he became known we should have created a de facto medical superintendent. 1 understand that our friends north o f the border are quite happy about this, but 1 think one can say that this would not l~e so in England. To have a professional manager at district level would, 1 feel, be all too tit~ely to result in tile weakening, or even the death, o f clinical participation in management, which in m a n y places, though still in its infancy, is thriving. " Y o u job is to manage," they might say; "'O.K. get on with it!" And this is absolutely not what we are looking lbr. What then is to be his role in management, for surely he must have o n e ? I think the answer is to be found in the concept o f the district management team, a team composed o f a c o m m u n i t y pllysiciaa, an administrative officer, a chief nursing officer, the chairman of Cogwh.eel, if there is a Cogwheel,;certainly, I would say, one other doctor of whatever allegiance, and p e r h a p s ~ t h i s I think is for the f u t u r e - - a finance oJfieer, this depending on the sort of administrative an'a~gements that are going to be proposed. I think that this concept o f a team would solve a n u m b e r of problems and I would like to see a corporate responsibility placed u p o n it, to see the team rather than an individual acting as the agent of an area board. If this upsets anyone's neat and tidy ideas of delegation downwards, and accountability upwards, 1 am lmrepentant, becm~se in any case 1 think it is all too easy to attach the wrong significance to that phrase w i t h its implications about what is up and what is down, since as doctors we should be placing the patient at lhe apex of the pyramid a n d ' n o t at the base. If a team like this is formed then 1 think ! have to some extent answered the question of w h o m the district Cogwheel is to advise. It will advise the district management team, and furthermore some of its members will, I hope, be members of that team. If they are this should certainly mean that its advice will not go unheeded, lfow it is to influence the area board directly is 1 think still an open question. Most of what 1 have had to say about this interface has concerned the c o m m u n i t y physician. This is no accident. He is the essential bridge builder. We know something of the concept of m a n a g e m e n t as applied to the health services, but there are many things that we are not clear about yet, and for these we are going to rely on the community physician. At the fundamental level ot" the assessment of priorities and the formulation of new objectives, surely it m u s t be true that there is no role whatever for a manager unless he is either a doctor or has ready access to expert medical advice, so I therefore see the c o m m u n i t y physician as a catalyst again, not just insofar as working together is concerned, but in bridging this gap between the hierarchical and non-hierarchical parts of medicine. I am very conscious of loose ends and unresolved problems, i hope, however, that I have demonstrated a role and a status of the new c o m m u n i t y physician. None of us can t o o k into the future, save through a glass darkly, and it m a y well be that the matters 1 have discussed will n o t loom as large as I now think they will. Indeed I shall be surprised perhaps if this is not so, as l have long held it to be true that any non-trivial decision will have consequences which no one could have predicted. I should like to end with another question, and I hope it will give nO offence. It appears that in the integrated N.tt.S. there are going to be in England and Wales two Departments, some 15 regional boards (the figures may not be quite right), about 95 Area HeaIth Authorities, and about 165 Districts outside London. ls there an adequate n u m b e r o f people hi c o m m u n i t y medicine w i t h the right training and the right b a c k g r o u n d to staff all these posts ? In particular, are there going to be enough of these people, not in five or ten years time, but in 1974 ? I think this is a crucial question.

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The level at which the service must become effective, if it is going to work at all, is lhc district level. It is likely that if management teams, or something like them, come lo exist, by that time the consultants concerned, and to some extent---depending on the arrangemenls .... to some extertt the general practitioners too, wilt be people with considerable interest in and experience of medical administralion. Can they be matched by community physicians of like calibre in 19747 Integratioa at districl level cannot be effective without a strong cadre of these people, and I think we have a two-fold proposition: no good service without good people, and no good people without a good service. I hope that those concerned are goillg to see to it that in the vitally important early years of integration the districts get their proper share of the best people. If integration does n o t happen at district level it will not happen at all, and we should then have no more than a merely administrative transformation.

P. L. ALLEN M.R,C.S,~ L.R.C.P,; 1).O,M.S.

(~ms'Mtant ()pJl//~a]l~l/c gllrgc'ol~, ]"arltham MR, C:HMI
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hospitals would provide the longer slay beds and their enlarged industrial zones, the laundl2¢ and Central Sterile Supplies I)epartment. ~he layout is important; the hospital is a rectang,Hat two storey building with a continuous ward band divided iI~to bays round three sides ul~the upper ftoor. The ground floor accommodates the Out-Patient Department, Accident and Emergency unit, the Isolation Unit, Administration, Medical Records and on opposite sides of the building the psychiatric and geriatric wards with their associated Day Hospitals. The rectangle contains lhe diagnostic a~d therapeutic departments-~X-ray, Pathology, Theatres, Labour wards, Intensive Therapy and coronary care traits, also the Day and l:!mergency Beds with the central lreatment rooms, are on the upper itoor. The central treatment rooms are a new feature where in-patients needing aseptic procedures i'ormerty carried out on lhe wards will be brought in their beds for treatmerd., They will also be used by General Practitioners for ireatment of their patients who require n~inor surgical procedures beyond lhe scope of d~cir surgeries or llealth Centres. llaving brielly set the scene in which the new concepts of care are i.o work, these must be examiued. "The ~ew methods presuppose th.e need to bring the G~P. team, consisting of attached m~rses, heallh visitors and sometimes midwives and socia[ workers into a closer rdalionsi~ip with the hospital, Ih.us enabling the patient to l~e discharged from the hospilat earlier than has been lhe custom." In many cases, it will be possible to avoid admitting a palient Io hospital by use of the Day beds for minor surgery or investigaiions. Five stiitably staffed day beds at Farnham ]tospital have dealt wiih 650 patients in a year. If admission is necessary, especially where associated with planned early discharge, the primary care t e a m nlttst be informed. The patient's social con.dilions will be known ~.o his doctor and te~m~ and lhey can advise what supporting service will be needed on his return home. Such assessments have beer~ made in the past for maternity patien.ts and there is already a close liaison between the Geriatric Department and the weVare services, ]'he in-patient care will be affected by the layout of tb,c wards and ~.t~eorganiz~,don of {he nursing stall'. The continuotls ward band is designed to allow the flexible use of beds; a system tl'~at has operaied at Farnham Hospital ~k)r at least twenty years. Beds are not allocated to individual consultants in a department and at times of pressure patienls are admitted io wards of a diftiarent discipline. Nursing will be arranged to give progressive patient care will, high, medium and tow dependency areas with appropriate staffing levels. The high dependency areas wilt be situated near tlm llt.lrse stations, Support .from a ward housekeeping service is expected Io relieve the nurses of many duties th.ey now undertake; whelber ~t will be possible to work this scheme in an area where l{ght industry provides good wages /'or convenient hours of work will depend upon a satisfactory wage structure. With ha..tee~sive use of the hospitai and a national shortage of nm'ses, their skills must not be abused. It is also ltoped that the number of nt3rses will be related to work toad an.d not to a national norm related to mlmbers of beds, The Student Nurse Training School will have a special syllabus whici~ will allow, by Day Release to a Technical College, study for "O" or " A " level work in Sociology and there will be periods of integrated training in the commun.ity. The tinal examinations will give a qualification which includes a District Nursing Certificate. It was stated that good medical management under a divisional system would ensure eflicient use of beds, thus increasing turnover per bed. Art extension of Parkinson's Law states that patients will be found to til! all avaiiable beds and undoubtedly pressure from long waiting lists and a scarcity of beds reduces the length of stay m~d the turnover interval. A permanent shortage of beds which are used flexibly can lead to the very undesi table result lhat padems booked for admission are turned away because the expected bed has bem~ filled by an emergency case. This rebuffto a nervous patient who has made detailed domestic arrangements to allow for his stay in hospital does great harm. The shortage may of itsell

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lead to less efficient use of beds where the .surgeon, to protect his patiem from disappomlment, may hold up a discharge until the day before his ne×t operating ses.',ion. The reaction to the proposals in a Group which had been, since the start of lt~e Health Service. ~,horl of beds and finance was one of sceplical approval. It was thought that the population estimate:, kvere wrong and that has been confirmed by tt~e 1971 census in which the 1975 prqjeclion has ah'eady been exceeded by 11,000. The revised prqjection tbr 1980 is 256,000 making il necessary ~o plan for new buitdil~g or the retch|ion of hospitals due for closure. The exisling group comprises one mai~ hospital of 280 beds and eight small hospitals, five u i t h operaling theatres and two \villi general practitioner midwifery unit~. All general practitioners have access U) beds wilhin two or fl~ree miles ~!" their surgerie~ bul not in the main hospilal. The mnjorily of beds in lhe hospitals wilh theatres are used by co.13~,uttants. 'rhis active in,,,olvemem fl~roughout the group o f G.P.'s in fi~e hospital care of their palier, ts has pro&:ced 9.rong pressure and general agreement that s~.~ch access .,,hou!d conlirme in !t!lure in spile of closure of :some of the small h.ospilals. How this can be achieved ;.~I *he l)istrict General Hosphul ir~ the comext of unallocaled beds is the subject of much discus,don. II has. h(~wever, been m~Me plain (hat G.P.'s will not ,eplace resident junior doch:~rs i:~ the continuotts cqre o f patients admitted 1oy consultants, 1"o deal wJ~h the probiem~ it was decided to relaip, (he existing Medical Advisory Comnlh.tee where all co~tsuhanl.', can atteml and where all lhe .,,m?ll hospitals have G.I'. repre:,entation: the long term aim bciug a divisional system. A Gene:-al P,aclitioncr lategration ('ommittee was ibrmed: also a multii-d;sciplinary Liaison Commitlce wb.ich included reprc.~,entativcs fro'n ~he corlstlllg.lllt stal}, the G.P. Integration Committee, the Group AdmMistrati~e stall" all(I Matron, als(~ the COU!'tl.y Medical Oilicers of I-leaith of Surrey and Hampshire wifft ~,heir ('hief Nur'ql;g Oliicers a~d member':; frc, m the \,Vdfa,e Services. The l)eparlment of Health arm Social Seem'by and tt~e Regional Ho:q,ital Board who seJ qp the Commitlee are represented. Finally a team nnder Professor Walter Holland of St. Thomas' Hospital Deparlmen~ of Social Medicine agreed with the Dcparlment io undertake research proiects. The lerms of rel~rence included the tormulation ,)f advice on co-ordination and changes in the ser,,ice and the character of the research programme. One result has been a fully validated study on hospital utilization irl the caichmenl area which produced fig',;res on referrais similar to those of other studies but also gave a measure of the G.IL invo!ven:ent in ',he care of patients in the Group. 'The figures being an involvement with 32 "~,'.-~;ot" all h~...patient cases and 14 ;',;:, of all out-pafier:{s, the lat(er category being in tt~e minor casualty services. A randomized controlled trial of planned early discharge surgery for hernias and varicose veirts is also being conducted. Without waiting | o r the report it is apparent that apprehensior~s of a large increase in. work either for G.P.'s or the supporting services were ill fonnded. The study will be concerned not only with morbidity trod demands upon ihe supporting services but will also measure the 1rue cost of care in hospital for long and short stay cases in tl~e study. It will also measure the economic and social effecls on ~.lle patient and his household for both categories of patients. The usual hospital costing, based triton the average cost of all paden'.:s per day in hospital., is quite unrealistic when applied to an uncomplicated surgical case who makes little demand beyond hotel care in the pre-disd~arge convalescent period~ Discharge from hospital at two weeks of patients following surgery for fractured neck o f femur is starting and will be likely to call for more support from the primary care services. An unvalidated study within Farnham Hospital sh.owect that ~1 o, of patients over 60 years of age disdlarged fiom hospital .needed help from the Social Services, the biggest demand being for home helps, home nursing or welfare home places. Discharge was delayed in 6"~; of cases because of lack o f st.lch support. These figures may be open to question but it is

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proving extremely difficult to provide reliable estimates o1" the future demands upon th.e social services. An extension of the present small but active Geriatric Department backed by adequate beds and Day Hospitals at Frimley and Farnham will undoubtedly uncover a demand which is at present suppressed. The G.P. Integration Committee are trying to devise ways in wilich the potential demands can be measured. A serious complication for the future is the Bill now before Parliament which has abandoned th.e proposals of tile White Paper on Local Government Bourrdaries. The White Paper recommended that the local conurbation should be placed under one Authority and would cover the catchment area by one Area Heatth Board. The Bill will split the Group between ttampshire and Surrey by retaining the existing boundaries and will leave the two major hospitals t, nder the Surrey Area Health Board and more than ball" the population under the Wessex Area Health Board. 1f the principle in the Consultative Document on Health Services that local government and health areas are to be coterminous is relaxed to allow a Health district to cover the catchment area, the situation would be improved. "'Marmgement" appears to be tim watchword of the sevenlies, tn the case of the Nursing Service, it has been a straight adoption of an. hierarchical organization on busilless management lines. In the Salmon Report on Nursing, 'sapientat' and ~structurat' authority are dealt with at length and a four page glossary is needed to explain the terms used. Hospitat doctors and general practitiofiers reject the hierarchical approach and agree with Thomas Jefferson "that all men are created equal and independent". Medical Superintendents in general hospitals in England have disappeared and tile one universally agreed point about the recommendations of the Cogwheel Report has been ~he rejection of the appointed Executive Ch.airman in faw)ur of one elected by his peers tbr a fixed term. There is a~ essential conflict for the consultant between his clinical and management functions. In relation wilh his patient, he is concerned with giving the best advice for treatment without immediaie regard to the overall disposition of resources..His advice has a management consequence but it must be distinguished from the management responsibility he incurs when sitting on a committee considering resources. He wishes to retain his clinical freedom, and that no doubt acco,mts for the high attendance at committees where his collea,gues may wish to reduce or alter his ~:hare of the resources. We all accept restraints but such a committee can only function by consensus with the possibility that an individual may still refuse to conform. That system is unlikely to commend itself to the business efficiency expert or 1o a planner detached from the clinical situation. With the probable number of con suitan.ts limited to 30-35 artd few registrars, time spent during the day on the detailed admirtistration suggested in the report could only be at the expense of clinical work. It is. therefore, likely that evening meetings will continue and a modified involvement for most consultants will restflt unless there is a marked reduction in their present work load. One cart look to tools of management for a greatly improved flow of inIbrmation upon which reasoned decisions can be made. At present, Hospi~'.al Activity Analysis being based upon. a central computer is stow and cumbersome providing statistical information in. an outmoded form and clinical information of largely historical interest because of the long delay. Whatever form the management structure of the integrated service takes at District revel, there ,must be an information service which is quick and capable of producing figures upon which decisions can be taken. The clinicians at Frimtey will next year be operating a hospital conceived on the basis of integration but in advance of the management structure necessary to apportion the resources in ail branches needed for success; for these we shall rely on the co-operation that has already been established. The success of the operation will be judged, by the patients to whom we expect to give a higher standard of care in. hospital and at home than has been possible before.

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3. A. FORBES M,A., M.D.

ScJlien Lecturer b~ Community Medichu,, Nol~tha/~tptoP,

1 1tAVE tried in what I am going to say, to gel right down to field level and to con.centratc on problems at source. 1 would like to begin with some personal reminiscences i think that this is relevant and not merely a nostalgic exercise-.--and to i~-~lloxv this by a look at family practice in general, tZrorn th.ere ! shall focus on a few particular aspect.~ of inicgratiOll which seem to me 1o be of special importance, and perhaps suitabte l ) r discussion. I first went into general practice in a market town in Oxfi>rdshire in the Fifties. first as an assistant and subsequently as a partner to a single-handed praclitioner, The praclice xea~, housed in lwo modestly sized rooms in my partner's Georgian house. We had n o socl-clarieb or receptionists, and 1 communicaled about once a fortnight with the district nurse, usually by telephone, and generally with a request to carry out some nursing procedure. We earl'ted out what ante-natal care there was independently and I saw a health visitor about once a formigh.t. There was no access to pathology or X-ray services. Life really was rather primitive. 1 was in parin.ership wilh a man wh.o was about 20 years eider ~han 1 was, a delightiiil man, all Edinburgh. graduate, one of those astute and almost intuitive clinicians, but appailingly disorganized. We had only one consulting room and I had an in-tray artd he had an in-tray. Of course we had no secretary or receptionist, and all the letters, including hospital letters came in. to b_is in-tray and just accumnlaled, erie dab' afler i had been there for about six or eight weeks I came in one M o n d a y morning and. i-.utting his hand on my sh.oulder h.e said "'You know, a dreadful thing happened last. night. I decided 1 would really have to file some of" these letters, and 1 took the in-tray through to the siitiqgroonl and [ sat down in front o f the fire. and I was tk'eting rather tired, and I had a large whisky--el was sitting in front of the open log fires and I fell asleep and the in-tray and its contents.just seemed to slip. I didn*t realise what had happened, and the next thing I knew there was just a blaze", 1 believed this and I was terribly upset about it, " W h a t can we do ? .... There's n.othing we can do, we don't know who the letters rel~rred to. We can't ask the hospital to send us copies o f a/l their letters for the last eight weeks". So we f'orgot this but, believe il or not, six weeks later one M o n d a y morning ! came in and he said " Y o u know, [ am terrible sorry, there was an awf'ul accident last night . . . . ". It was a marvellous tiling system.' But by the time l left practice in 1969 three partners were practising from purpose-buill premises with attached---I mean gentdnety attached-nurses and health visitors each with lheir own a c c o m m o d a t i o n in the practice building. We had the equivalent o f tive tidl-time secretaries and receptionists. We had direct access to the local pathology and X-ray services. A pathoh)gy technician visited once a week to do routine blood examinations, and was prepared to visit a patient ia his home if necessary. In association with the local aulhority ambulance service and the local hospital car service, we had developed an efficient syslem for conveying specimens to the laboratory daily. We had an eleven-bed general practitioner maternity unit where all ante-natal care in the area was carried ore. Local atithority midwives worked in the unit which of course was Regional Board Hospital Management, side by side with hospital midwives. A consultant obstetrician attended once weekly and so did a physiotherapist to w h o m we had direct access. The local doctors were responsible ]'or the local infant welfare clinics and took part in the School Health Service. We had established a geriatric clinic in. the practice which was run by doctors, health visitors and nurses, and finally in 1965 the practice became associated with the OMord Record Linkage

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Study and the Nuffield Department of Medicine in Oxford, which in turn led to further co-operation both from ~he point of view crf records systems and relationship with hospital staff. I have given these examples, not because I want you to think that everything was rnar~retlous in North Oxfordshire, but that at least in some areas, seen from the general practice viewpoint, a substantial measure of integration had taken place, so perhaps we might look and perhaps learn a little from some of the difficulties that we faced. T h o u g h I have described this process of part integration in a few minutes, in fact each step was pathetically slow. For example, ! thought that the integration of the local authority midwives into the Regional Board maternity unit would never happert. It was rather like doing the breast stroke in a swimming pool full of porridge. One got the impression that one was going on and on and getting nowhere but 1 do not think anyone was to b l a m e ~ certainly not the medical officer of health, or the Regional Board, or the general practitioners. It was just that the administrative structure was not devised to cope with a relatively simple situation like this. And of course, as one previous speaker has said. cash and resources--always in short s u p p l y ~ w e r e controlled by different organizations, the money was in different kitties, and there was no mechanism to get money fi'om the kitty into another. The other troable of course was that general practitioners, are independent contractors. It is bad enough to get any group of doctors to decide on a policy and adhere to it, but to get six or eight or ten general practitioners all to agree that they are going to follow some particular course of action over a period of a year and to stick to that decision, is somethin~ that is extremely difficult in fact. We have been hearing a lot about hierarchy today. General practitioners of course are non~hierarchical~in fact they are anti-hierarchical. I am not saying that this is a good thing or a bad thing, but it remains extremely difficult to get practitioners with a c o m m o n policy and common, project which the majority have agreed is desirable. What, of course, l have described is really a minute exercise in.co-ordination seen against the country as a whole; and 3,et it was clear, looking back, that integration is very largely a matter of people I think that if you can get people in the field to agree dn a c o m m o n policy, and t am speaking shall we say in terms of general practitioner or health visitor or nurse, and if they can al! mutiny against the hierarchy at the same tim~ and say,~"~'thSsis what we want?' then there is a fair chance of persuading those at higher echelons that this is desirable. Morale in general practice is high just now, at least compared with ten years ago. The cynics would claim that the reason for this is that general practitioners have never had it so good financially. This is true, but I .think there are.other reasons also. The 70 Yoreimbursement Of ancillary staff salaries has led to the employment of secretarial staff, and this in turn h a s led to improved practice organization and less non-medical work for general practitioners. On paper, about ttalf of all health visitors ~nd local authority n u r s e s a r e attached to general practices. By the end of December-19/0, 187 health centres had been built and were functionir!g, 99 were being built and" 69 had been approved. It might be argued that health centres accommodate only a small proportion of general practitioners~ actually about t0 or 12 ~ I t h i n k ~ b u t on the other hand, of the 187 completed health centres, 147, about 80 9~ were opened between the 1st Jammry 1968 a n d t h e 30th December 1970, so we have m o v e d quite fast within the last three or four years. More than half of all general practitioners ~now practice in groups. In 1970' there were 195 ~trainee general practitioners and there are. n o w a •substafitial. n u m b e r o f .vocational trai~fing schemes' for general practice an d n e w ones are app¢ar[ng in tile~journals almost weekly. All appears to be going well and the pragm'atists wotild put forward tlae vie~w that if 5~u provide the setting, t,ke cash, the facilities and the resoia.rces, then everythir/g will

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be all right in the end. Maybe the pragmatists wilt prove to be right, but I have certain reservations about what has been occurring during the past decade, mainly t think because certain fundamental problems have not yet been tackled. For example, 1 think that recruitment to general practice is something infinitely more complicated than merely provkting a good income and adequate premises and sufficient supporting staff. If a proportian of young, able doctors are turning away from a career in hospital, and looking Iowards the community, in doing so they are looking for something Par more sophisticated than a mere elaboration of what we knew, or know, as general practice. 1 am disappointed also that there has not been more research into alternative ]nelhods of providing primary medical car¢~. J am sure that whatever form of gei~eraI practice, or whatever organization is used to provide general medical sei'vices in'ihe community, direct access will always be the common ' denominator, but 1 think that there are variations Of this and.that research into this has bern disapp0ihtingly sparse. am also very conscious that forlthe fii:.~t time we are begirtnin~ to meet fairly w~desprlmlltt consumer dissatisfac(ion, not, oddly enough, on the~romids o'f qt~a.lit'y of care, but becmise of inaccessibility an'el appointmet~t systerfis, ofrotas and generally the rathel[ iltlpers9nal atmosphere one sometimes senses in large' practices. I would not wi~h.you t0inFer from this that i think that large organizations are necessarib impe1:sonat. All of I.!S .have known enormous expensive hotels whi.ch gave superb personal service, and yet cm the other hand we have all stayed in rather cosy, chtlmmy small h:otels in countrS' villages where the personal service has been appall i n ~ However, size zgfunits is obviously.s.omething that we l~ave to look'tit very carefully. There i s a feeling am6rtgst the public; n o t ~;;'ithout foui'idatlon:, that appointment-s~stems, rot-as, and so on were..-..not--i-n.nove~tions-dek4gned:-ft~'the~benefit of the public, but f o r the benetit~of ' file doctors concerne.d. I thi~k that also initiative medicine, and theallocation-of more time to preventive and supervisory medici'ne b~) the general pract!lioner is really not.feasible in depth unless we come to.terms witl) and establ.ish clear p01icyabout p'~ir~t-medical help and until we liave developed wont
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tt~e p;l~t few years, and 1 ~¥as rather disturbed by a paragraph which appeared in the B.M.A. News lbr t:ebruary 1972. It would appear thai in its last ammal report, the G.M.S.C. included some comments on the ownership of practice premises, in which it was stated that the committee believed that the majority of family doctors wot~td prefer to work in their own premises rather than move into statutory health centres. This belief has apparently been confirmed by the results of a survey, on which I have no detailed information, carried out last ~summer by th.e healtl~ departments. It would seem that only about three out of ten principals not at present in, or committed to, health centre practice, expressed axl interest in heMth centre accommodation, i f w e add to this 30 o~ who are interested in health centres, and perhaps 10 ;~,,;who are already workii~g in health centres, or are likely to enter health ceutres shortly to be built, then we t~ave still got a substm~tial number of general practitioners, about ,u6 r~"//o,who will be practising from private premise% Furthermore it has been estimated that approximately t000 health centres will be required to accommodate general practitioners likely to practice from health centres within five years, so we really must move even faster than we have done in the last two or three years. In view of this then I would like to put to you a number of points which l hope we may have an opportunity of discussing. If we assume that all general practitioners are not hopelessly coi~servative and neurotic about their independence, what are the real reasons for their lack of enthusiasm lk)r healih centres ? And come 1974 can we devise a simpler, more streamlined procedure, whereby agreement can be reached, and a health centre be built and functioning with a minimum of delay ? A word now about attachments. Recently in company with a medical otficer of health and his chief nursing officer, I visited some general practitioners. We ]lad been asked as part of an overall review of the medical service in this area to look at the local authority amlchment scheme in ~nedical practice. It was clear, that there was nothing very much wrong with the attachment scheme, except that there just wasn't enough of it. The general practitioners were in fault too; they were too rigid and not prepared to experiment. But basically the main trouble was that there ji~st were not enough health visitors and nurses to go round to meet the needs of the practices. 1 hope you will not infer from this, any criticism of the M.o.H. who in actual fact is one of the most progressive of medical officers of health, it was just that he had insufficient resources to meet the needs. If nothing else happens in 1974 I hope that we shall see a much larger proportion of the available cash diverted to the community services. There are certain areas in clinical practice, notably in midwifery, child health, geriatric medicine and psychiatry, where obviously co-operation between the various professional people concerned, not just doctors, nurses and health visitors, but many others, would be of beneiit to the patient. I think this is particularly important in child health, where one has only to think of a condition like epilepsy to realize that it is only by a co-ordinated etlbrt by a wide, variety of people, teachers, social workers, general practitioners, nurses, t~.ealth visitors, community physicians, paediatricians, employers, that people with epilepsy can hope to get a l~ir deal. In the area in which I work, recently an informal Working Party has b e e n set up to look at the de.vetopment of the Child Health Service, now and in 1974. This Working Party consists of hospital paediatricians, general practitioners, nursing and health visitor representatives, and local authority doctors. I think that this is valuable, and that the idea might be extended. I believe it is in actual fact in my area being extended to geriatric medicine also, This is sometkirlg rather different from the maternity liaison committees, different in the sense that it is a Working Party that has been. set up locally just with one objective, to discuss 1974.

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Finally a word about information systems. It seems to me that one of the most imporlant functions of the community physician in 1974, will be to se! up comprehensive information systems ifhe is going to be the co-ordinator of ~he various services. Wiflmut this ] would have thought that it would be extremely difficult to do his job effectively. I wo~ld like to put i't to you that this area of district information system, if it is going to collate intbrmation about all the medical services, irtcluding general practice, within the district, then certain basic informalion about 951,I~; of the population exists in Executive Council and general practice files. My point is not that general practice records are of a high standard, but that they include certain information about most people in a definable population. This was the basis of the pilot study with which I was associated in the Qxford Record Linkage Study, which has since blossomed into th.e Community Health project there. We have been experimenting along lhe same lines in Southampton and we now have basic identil},illg informatiort on punch cards, ready to be computer held, for 25,000 Southampton. patients, about 12 ~'.,',{of the population. This has been achieved at reasonable cost in about five mon.ths. Furlher information will be added to these iiles cumulatively and this project, th.ough. admittedly it is designed for research and teaching purposes, suggests a principle and methods which might possibly prove useful to the community physicians in 1974. The subject of integration is an enormous one and 1 have only picked out really three or four points which seem to me to be of particular .interest. I have not for example, discussed the place of the G.P. in hospital, which I think is, despite wh.al has been said today, one of the most enormously complicated things and something that one cannot generalize about because of the enormous variations from area to area in the attitude of G.P.'s I would, however, remind you that the Brotherston Report, comes down very heavily and very emphatically on the need lbr general practitioners to be integrated into hospitals. And certainly it' some of the plans tor tire-day community hospitals and so on, designed for short term su~Tgeryand psychiatric and geriatric cases, are implemented; it seems to me that the general practitioner is going to be involved in the mere presence of a community hospital. All that it stands for is going to affect his work in the community, and it seems to me that it will be ahnost impossible to staff a ,:ommunity hospital unless we are going to involve general practitioners.

General Discussion Chairman We have had three very differing contributions this afternoon which 1 think have also complemented what we had in the form of "theory" this morning. Certainly in discussion. I hope you will take this any way yott want. Tomorrow we shall have ample opportunity of talking about the rule of the community physician himself, and perhaps less chance to take up some of the points that have arisen such as the relative rules of the district and area, how G.P's are going to come into the Cogwheel structure--particularly when as Dr Hampson was saying, this has got to be at district level, whereas the family practitioner committee will be at area level.

Dr E. W. Wright Medical Officer of Health, London Borough of Waltham Forest Could I ask the speakers what role they do see for the local authority clinicians, the people who are now staffing the infant welfare clinics and school health service. How do they fit into tl~is whole structure ?

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Dr Forbes This is a very interesting point. I did mentton very briefly the need for general practitioners to have a greater imerest in initiative medicine and that they have to start looking for the needs in the population for which they are responsible. 1 would have thought, though 1 am not just quite sure how this might be organized, that the local authority clinicians could make a very valuable contribution here. How t~ey are going to be incorporated, or whether they would wish to be incorporated, into health centres, I am not sure, but one thinks of course of paediatrics, particularly developmental paediatrics, and the contribution of people who have been in the school health service and in infant welfare clinics. If their attiludes and their approach to the problems could be introduced to general practice I think this would be extremely valuable, and I would hope that general practitioners would fi~tlow the lead, but I do not think that this will really be very successful unless the local authority clinician starts moving a little bit towards general practice also. This hard division between preventive medicine and curative medicine is quile false. There is an enormous area in between, and to me it has always seemed rather an anomaly that one doctor is concerned only with preventive medicine and another te~ds to be a contingency medicine man. I know what the ilrmlediate arguments against tlfis are. People Say that if you mix up preventive and curative medicine then it eventually all becomes curative medicine and prevention takes a back seat. I think there is some truth in this but I do not think it would necessarily be true. If I could summarize I would have thought that if local a.'~thority clinicians feel this way, that they could be incorporated into the general practice set up, into health centres, where they would practice particularly specialties like paediatrics, and they may welt do curative paediatrics, ordinary contingency paediatrics also.

Dr Hampson There are only two points really that I would like to add. One is that 1 think the question must be looked at in relation to th.is growing developing concept of patient groups ..... paediatrics, geriatrics or whatever---in regard to the total care of those groups, and theretbre 1 would not go all the way with Dr Forbes on the emphasis he has put on a future for these people in general practice. We have got to get away from this kind of spli~ting; certainly many of them will be doing that work, and of course nobody has told us yet what the future of the School Health Service is going to be. The other relevant concept surely must be the idea of comprehensive paediatric units. We are hoping to build one in our own hospital soon and clearly I should think there must be a role for some of our clinicians in local authority work at present, in units of that kind.

Dr M. P. Menzies City of Glasgow M u c h of this depends from the point of view from where you are standing. Most of the people in clinical work in the local authority field have graduated from practice to specialize in this field, and I do not see them, having emancipated themselves, wanting to come back into general practice. I would say this, that we have in my district tried for long to train our general practitioners towards some learning of our skills, and 1 am told on all counts that their practices are not geared to permit them coming into nay service to get the kind of training, the learning that I would like to see them have. I do feel that they have a big part to play and I would like to see them coming out of their centres to some of the School Health Service work perhaps, and taking their part in this, but they always assure me, when I oiler this to any one of them, that they are not geared in their practice to come out and take

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part in a learning scheme to tit themselves for this job. t wotlld lake issue with Dr Forbcs. 1 hear so often ~llat the only thing thal you can lhink about when you think of' these clinical services is child development and developmental thinking. This is all very "~et!, but in my service we go right up the scale of age with pre-vocational work and with the number of furtl~er educatiou colleges we have in m y district, I in fact am looking after master mariners and their mates, and I could not begin to call them paediat~ic or developmental cases.

Dr Forbes I agree with a lot o f what has been said by the last speaker. What I a m trying to say is that I think we have both got a contribution to make. Whether you call tl~is general practice, or c o m m u n i t y medicine, providing medical services in the comraunity, 1 do not think really matters. 1 am quite sure that the skills of the local authority clinician would be very valuable in the setting o f general practice, and conversely I think that if the local authority cliniciau .... this is what 1 lhh~k is the most provocative point, but which I feel is most important, speaking as a general praetilioner.--4hat the local authority clinician must move a little bit away from pure prevenlive and supervisory medicine, and must move into the tield of clilfical medicine. Whenever I say clinical medicine, this spells responsibility, and getting involved with children in their homes.

Dr A. ~1.'-Gregor Medical Officer of Heahh, Cio' 0/" Southamptol7 There are two points here. There is what I think of as the immediate practical short term, that we have in front o f us, and in this short term its inconceivable either that general practitioners will take over the school medical work ltaat we have been doing for so m a n y years, or alternatively, that we could d u m p this work and convert all our school doctors into general practitioners. It is just not practical, but looking very much further ahead, we have two possibilities. We have talked I think constantly for m a n y years of lhe need to involve general practitioners in the school medical service, and as Dr Forbes knows, in Southampton of course we are doing this as in m a n y other areas. M a n y of our general practitioners do in fact do school medical inspections for us. They have in fact gone through departmental training for lhis purpose. 1 would suggest to you that this is nevertheleas not enough. What Dr Forbes is suggesting is in a sense more revolmionary. We are thinking in terms o f interesting general practitioners in our work, that is in breaking down a barrier but without making a concession from our side. It seems to me that if you look at it over all, we suggest that general practitioners should go into hospital, and act as specialists in the specialty of their interest, in effect I think D r H a m p s o n suggested that they might even become consultants this way. At the same time it seems to me that we ought to thi~tk seriously of breaking down the barrier between traditional public health and general practice. Dr Forbes is saying in effect that we ought to think of our doctors doing ordinary G.P. as well as public health w o r k simultaneously. If we reject this out o f hand, without thinking it through, we are maintaining a barrier indefinitely. We are seeing this barrier dissolved between general practice and specialist services on the one hand, we are seeing it dissolved in a sense between general practice and ourselves by G.P.'s learning our work; surely we should also look at the possibility o f dissolving it the other way by our traditional p u n i c health doctors somehow crossing this barrier which has built up over the years between them a n d G.P.

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Dr B. G. Gretto~-Watson CounO' Medical ()ricer, Cheshire I find myself very nluch in agreement with Dr Forbes. I think the key to all this is for groups of general practitioners to take on a specialty, not to take them out of the general practice, but to add to it. [ tltink that we should be encouraged by the relatively small number of areas where this does work~ rather than discouraged by the number of areas where i! doesn't. I feel his ideas are not impossible but they will take a very long time. My authority has been running courses in developmental paediatrics for the new look of" the child health service for about four years, and on these courses we have roughty a third of general practitioners, a third of married women doctors unattached, and a third of local authority doctors. This tnovement is growing and withi~ practices of six or so, one of the practitioners very often will take on this toad. Where mine of the practitioners are prepared to, simply because of their present comm{tlnents, we are trying to attach a local authority doctor to the group to work with the group in that capacity, and i l\?r one feel certain that these are targets we should aim at; they are attainable, but I think they will take timE. Dr A. W. Macara UniversiO, o[" Bristol I want to take Dr Hampson up if 1 may, on a point on which I think he challenged us. namely whether we could provide a sufficient number of community physicians to staff the likely posts to be made available in the reorganized health service. May we remind him that there are upwards of 600 medical officers of health, whose duties are exclusively or predominantly adlninistrative in character, who have "jumped through successive hoops" in the past in acquiring a wide range of hospitai and in many cases general practice experience, who have the equipment and the experience and who are prepared at ]east tO try to fill the sort of posts which are likely to become available. Our anxiety is not so muctl whether we can fill the posts, but rather whether there will be enough posts for the people to fill. We certainly find ourselves in a situation of great uncertain as to what the shape of lhe future is going to be and it is very difficult not to be a little envious of the consultant and the general practitioner who might expect not to have to change anything very much. They should bear with us and try to understand that we are working in a situation in which we are groping forward, hoping to get a little light shed upon the situation, as we go, but confident that we can make the contribution which is required. Dr Hampson Very often in this kind of field M~at counts is appearances, and there is now, and has been for a very long time, a difference between recognized higher qualifications and diplomas relating a whole range of specialties. I welcome your Faculty which I think is going to demonstrate to one and all that the qualification in administrative and community medicine, is in every respect the equal of other higher qualifications. What you have just said has convinced me of a certain justification for concern, because you were at pains to explain about the administrative skills, the administrative knowledge, and the administrative wisdom o f the people who will be available for these posts. I concluded my paper by saying that unless integration took place at districts, it was not going to take place at all, and I had been, I thought, careful earlier on to explain that what we are going to demand from the community physician at the district was a great deal

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more than admhfistrative ability. The ltunter Committee has tried to set out some of lhe thin_gs which we thought community physicians at district level would require to have. Whea 1 asked my question it was a genuine question, and if you feel that there are enough people with the skiils in these backgrounds, ready to take over in 1974. Iben mrl delighted.

Dr tL E. Muir Medical OD~'eer q[' Ilea/th, Borough of Gillingham In my town of 100,000, the Cogwheel structtlre has a c o m m u n k y division of which l a.m chairmam In the meetings I attend, whether in the general hospital or tile subnot-mality hospitals, there are no invidious comparisons of status. The other disciplines seek our advice on ctmununity problems, particularly in paediatrics, geriatrics and raental health, .jUst as Mr Lee implied would happen with the future cmmnunity physician's department. We meet regutar}y in my department with tile general practitioners and different consuhants. }:or instance on the development of paediatric training in the community, thirty general practitioners, the paediatricians concerned, and all my staff met to form a suggested. pattern for future nursing and medical staff training in the community. We did the same in geriatrics, and we have a geriatric medical ol~icer in the comanunity staff. We also have in mental heah.h a new psychiatrist who tbr the tirst time is looking at the community, where never has it happened bel\~re. The psychiatrist had never referred anyone for commtmily support in our area matit this new Olin was appointed. He suggested for-ruing a day hospital, so every general practJlioner came to meet him, it is only by trying at th.is sort of level to get co-operation and co-ordination that we shall continue to fulfil the role that Dr Hampson thinks we should be fultilling. Dr H. W. S. Francis (West Riding) Those members who [mve looked at the list of people attending the Symposium will see that I am given as a member of the Department of Health and Social Security. Tile Department has kindly paid my lee for the Symposium during nay temporary secondment to Alexander Fleming House. If 1 may say so, my being at the Department represents a t e m p o r a w delinquency and not chronic recidivism. I m~lst confess that when I saw Jimmy Lee's diagrams of possible management structures for the National Health Service, I felt much as when I ~aw the first set of forms and programmes which the systems analysts produced for the West Riding vaccination and immunization computer scheme: vet)' surprised and a little shocked. But as 1 have learnt to value the work of :my computer colleagues, so I have come to see the virtues of Mr. Lee's concepts. It would, however, be wholly improper for me as a member of the N.H.S. Re-organization Management Team to advocate at this point in time the acceptance of the whole of the ideas as being appropriate. May I, however, draw your attention to four aspects of the "hypotheses" which I feel that we as doctors, and especially as medical administrators, should look at carefully: First, the proposals are based firmly on people; mid that is on patients and clients who need ,:,are and on persons who need preventive help and advice. Second, the idea of clinical freedom is taken quite seriously and the formulations make lull provision for it. Third, particular!y through the kind of concept behind "patient groups", provision is made for collaboration at the district level, right across the whole range of health and related services, in order that continuity of care for each patient, or client, or each person can be ensured.

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F o u r t h , the suggestions for unification are based on and in fact demand medical administration of the highest possible quality. I confide that as a group we can provide this.

Dr J. .McA. Taggart Medical @ricer of Health, Be(fast Mr Lee suggests that the district chainnun o f the medical committee and his deputy should be ful' members of the district team. These gentlemen will be full-time clinicians, either genlerai practitioners or consultants; how does he envisage that they v,ill be able to make any valid contribution to such an important team, which may be extremely unwieldy already. Obviously to m a k e any valid contribution they will need to be presem at meetings ofx, arious committees and it seems as if this team will be sitting at commiltees for m u c h of their working day. Will these people be seconded or be salaried or how does M r Lee envisage that they will be able to contribute Wry m u c h from their busy time ? Will the team have a chairman and will the chaiiman be appointed by the committee c}r by the Area Board? Will he be looked upon as the leader o f the team or just first among equals.

M.r Lee I' tried not to suggest that these were committees, but used the term teams. This may in fact be semantic juggling, but in fact there probably is a difference in that these are not necessaril~y: forgaal, routine, decision-making bodies, but groups o f otlicers who come together each with their own particular role to play, in order to m a k e joint decisions at times when decisions are in fact required to be m a d e jointly. So we are not in fact either in the district management ieam, or in the teams at the lower level, to create a mass of routine bodies. If we start with the idea o f th~ clinicians on the team, because it is not a fomml routine committee, and is m a d e up of members who all have their own distinct roles to play as individt,.als, 1 would expect that this group would not meet m u c h more than once a week, and perhaps not even that. There are examples of such nianagemen! teams in existence...... admittedly in the hospital service---where in fact chairmen o f medical conrail trees already do contribute m u c h to the working o f the team and perform a very useful role as a m e m b e r o f the team. Whether or not they should be paid for this work is Very much a Departn~ent of Health policy decision. Would the chairman be elected or appointed ? There is a basic choice between an appointed man or an elected man, or a hybrid o f one elected and one appointed. There are arguments on both sides~ Tlae elected ones clearly will throw up the sort of man who commands the respect of members of the team. The disadvantage of that, and the advantage of the appointed one, is that if you appoint a m a n then you can in some sense hold him responsible and accountable for carrying out a particular activity. An elected representative's loyalty is to the people who elected him rather:than to the people who appoint him. I suspect, in fact, beca~Jse o f that the split between a m a n appointed to co-ordinate and a m a n ejected to chair is probably a very atfractive.alternative. As [ see it, all the people in the team would in fact be equals. We m a y seem to have created a lot of participator 5, bodies. These replace a lot o f coordinating mechanisms,. Committees which exist just now which m a y be replaced or, hopefully, these teams will m a k e them redundant. Instead of making them as specific as 1 showed them (e.g. to maternity, to child health, to mentally handicapped) they could either Ice grouped, perhaps one dealing with maternity, child health and mental handicap

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together, l suppose you could look upon Professor Holland's division o f community medicine at St. Th.omas's, as a si~lgte group carrying out this function. ! personally would not like to see the single group, because l think these are very definite specific problems tier which you need to im,olve different people. If there is any possibility that people are going t-o be overloaded with participating in policy, and planning bodies, then the number of" bodies must be reduced.

Professor A. L. Cochrane Epidemiotogical Research Unit, Medical Research Couacil I would like to ask a question about testing the hypothesis. As Professor Warren has pointed out° we~are getting better and better at testing m o r e and m o r e complex hypothesus, using the randomized control trial to measure the optimum place of treatment and the optimum lenglh of stay, but I am more worried by using this phrase "testing hypotheses" in this respecl. Would it not be more correct to say that by means o f some rather coarse observation you are going to guess which o f tlae two schemes is going to be less workable?

Mr Lee I think that the idea of |estiag hypotheses has been somewhat set back by the Pearce Commission. and one might not be fitr wrong in suggesting that our testing process has got some shortcomings. We have no scientific, disciplined a p p r o a c h I o t h e thing {,It all, because I do not think this is possible. I genuinely dd'nbt think there are ways of collecting dala that, would answer some of these issues that i have raised just now, but what we would hope w come back with at the ~nd o f the test period is some fonl~ of ag/~eed solution which was acceptabie to a reasm?abl~ representative group o f people in a specific situation. It" that proved to be acceptable, and we agreed tkat it was reasonably consistent wilh whal came out of other areas, it was worth while.

Dr ,L L. Gilloran Medical O~cer oj Health, Cio' of Edinburgh Does Mr Lee see the local health councils fitting into his structure? Does he see them having representation on the planning teams which he proposes, or does he see perhaps the c o m m u n i t y physician as representing consumer interests.

Mr Lee [ think.the straight answer to this is that at the m o m e n t we have not considered putting representatives of the colnmunity health copncil on either the planning teams or on the district managenient team in a formal sense. We would see the district m a n a g e m e n t team as being the counterpart of the c o m m t m i t y health councils so that in each case where there was a community, as distinct fi'om a district under a district management, ~.eam there would also be a c o m m u n i t y health council to w h o m it related. Whether or not any one individual such as the c o m m u n i t y physician Would be the person exclusively dealing with the c o m m u n i t y heallh cotmcfl I a m not sure, I suspect for example that the administrator would also have dealings with him, and. it would be very m u c h a team affair. Chairman Migl~t [,ask M r Lee whether the ministerial hypothesis o f the cormnunity health council has been practically tested, or is going to be tested ?

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,~& Lee No is the answer. If one takes seriously what ] was saying about trying to make plans responsive to local needs, the sort of epidemiolog~cal analysis that a comnmnity physician does, or would do, is only one measure of what the community needs. The community health council could be a very significant source of information for these planning groups. Dr C. D. L. Lycett CotmO' Medical QTficer, Wiltshire How does Mr Lee or the Management Study Group, see medical advisors from community medicine being included in the medical advisory machinery with their colleagues. His diagram appears to show a general practice body,'a hospital specialist body, coming so to speak at the top level of the district, as a medical advisory body in the shape of the DMC. It is extremely important that we should get community physicians into this structure. It is done now. Medical officers of health, although they are largely'-medica!!y administratively oriented, sit on local medical committees, and on hospital medical advisory committees with very good effect. I think this has a mutually civilizing influence on the medical administrator and the clinician. How is this to be achieved in the set up which is proposed by the Management Study Group? t was a little appalled at the use of the word "community" in some of Mr Lee's diagrams. I have had the advantage of seeing these papers before. "Cormnunity" is a very confusing word and there is a box in that diagram which says "'con~lunity nursing organization". This ,~f course means something quite different from cormnunity ph.ysicians or community medicine, and ] suggest that it is really an inappropriate use of the word "conmmnity", because we should not think of the community as being outside hospital. Professor Warren said that me,dical and non-medical adaniaistrators must work together and fllere is plenty for both to do. Of course this is perfectly true and we all accept it, but what is the relationship between them?. This did not emerge very clearly from Mr Lee's diagrams, nor perhaps from the two hypotheses which he says are now to be looked at closely, ls there for instance a variant being tested which includes the dual team of doctor/ administrator and lay manager ? M r Lee I have to be very careful here because I think I have already, overstepped the mark a bit on saying what I thought the community physician could do within the District Managemeut Team. 1 should have said, I am sorry for omitting it, that we of course await the recommendations of the Hunter Working Party in order realty to set us straight on whether or not what 1 was t~,,~$gesting as one of the roles of the communityphysician fits in with flaeir general recommendations, or whether or not we have created something new. My own personal view is that they certainly should be and that diagramatically the community physician is shown in a slightly different relationship in the sketch of the District Management Team because of his other functions in relation" to planning and to these planning groups, but he would also, as [ see it, be a member of the district medical conm~ittee. When the Consultative Document talked about the strong medical advisory machinery it referred more to the medical advisory machinery to the Boards and of course we would see the district management committee not so much as medical advisory machinery as such, but as an integral part of the district organization. There would be, above the level of the district medical committee, some way in which advice could be brought to the Area

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Health Authority itself, which I did not discuss, which is really a separate question. 1 am sorry about 1he diagrtma showing the box with community nursing organization on it, because 1 take the point very tbrcibly. I was one of the people who was always trying to suggest that the district was the c o m m u n i t y of which the hospital was a part, but too m a n y people do refer ~o the hospital and the community, as opposed to the c o m m u n i t y containing the hospital. In our Steering Committee the proposals for a two-headed administration, or a twoheaded team was proposed and was rejected quite summarily. There is a very strong emergence of the nursing profession in its own right, and any such consideration certainly produces a triarchy as far as our Steering Committee is concerned.

Pro~,ssor Warrelt 1 am glad Dr Lyccll raised lhis p/obtem of the division and the community physician. I think we have really got to think m u c h more about the Cogwheel Structure. What I was trying to suggest in my paper was really to open up this and not let us make assumptions lhat Cogwheel has actually solved anything very much. It is the sort o f pattern which is beginning, and we are gelling some experience but there are all sorts of problems and one of these, as Dr Lycelt mentioned, is should there be a c o m m u n i t y medicine division, or is the community physician a m e m b e r o f all the divisions ex officio. In the area where I am, our Cogwheel has a public health and general practice division and this really a d s as an excellent liaison between the services outside the hospital and the services inside. The hospital is extremely sensilive to lhe opinions expressed by this particular division, but it is not a sort of division reflecting the needs and the development o f general practice in the area of north-east Kent. Maybe that is a function o f a Cogwheel type division at district level that we should be thinking about. The other difficulty is taking decisions in Cogwl:,.el with no resources. We have no resources in our division at all. We have to discuss and that is all; it can be extremely frustrating if one comes to a decision and has no resources. M/" Lc~?

a m afraid any systematic approach to this can only put off the awful point at which o,~e makes the eventual value judgement. I suppose there is some merit in suggesting that the c o m m u n i t y physician could help structure the argument a little better and demonstrate some facts, but unless one has some agreed weighting system it would still be a choice o f judgements even then.

Dr A. W. Mrclntosh Deputy CounO, Medical OJficer, North Riding of Yorkshh'e We have been told by our speakers this morning that the whole reorganization o f the service is based on the assessment of need and meeting those needs. It seems to me, having listened to what has been said this morning, that the community physician alone cannot m a k e an assessment of need without specialist support~epidemiological support, the support of statisticians and m a n a g e m e n t services and o f operational research. Is it expected that these services will be available to him at district level, or are they going to be only available at area level. If so, are their findings going to be imposed on the district community physician from above ?

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Pr~E~sor Warren I do not know lhe answer to this at all. I ~hould have thought that a lot of the backing would be at Area level if"not Regional level. We have not heard very much about the region recently, but a lot of this data collection and dissemination of information can be done economically from the region and then be fed back Io district level, and much of this information has more value if it can be compared with other districts. Mr/Lee I agree entirely, tn fact I did not cover the regional level simply because of time, and also because in the theme of integration I wanted to show that probably where integration was going to take a bite was at the local level. I think epidemiological research and analysis could be centred, and should be centred, on the R.H.A.. but because an analytical service is provided from a particular level does not necessarily mean that that then dictates the conclusion you draw fi-om it, or how you use it. I think one would want to use it as a service provided to the District Community Physician rather than anything being imposed upon him.

Dr 7". McL. Galloway Medical Officer of Health, 1Vest.Sussex I think we have got to remember in all this that we are in the middle of what is fundamentally a political retreat from the two main theses of reorganization. One was that there should be unitary local government, and the other was that there should be an integrated system of administration of the health service. I listened with fascination but growing alarm to both our speakers this morning, and M r Lee's diagrams seem to me more to be a description of a recipe for democratic political popularity than a draft for the provision of an organized health service. We are in effect introducing a false train of gears into our grinding gearbox and with every additional interface that is introduced we not only throw up far more opportunities for wasted effort, but we reveal to the public at large out woeful lack of resources of almost every, kind, inch~ding the proper kind of motivation. It seems to me that a good many of the recent lessons have been fbrgotten in this predominantly academic exercise, and one hopes that the products of the Working Parties m a y - - i f I s o u n d a little abrasive you will forgive m e - - b e a bit more realistic. There are a lot of medical officers of health, and quite a number of key people in the hospital and other branches of the medical service, who have emerged as significa~:t influences in their areas who have already carved a niche for themselves as community physicians over large tracts of the country. It seems to me that if you are going to put them in the situation of being equated with other people who are just there because they are drafted, or are interested in a part-time kind of way, you are running the risk of devatuing quite seriously an asset which has emerged over the last 25 years, which may very well disappear because there are other attractions for those able people.

Mr Lee I can only say I am somewhat surprised by that, because I and I think most of the people on the management study are firm proponents of the idea of the conmmnity physician, and the conmlunity physician's role in the districts, and far from wasting an asset I think that the idea o f the district community physician is building on one, I am afraid I was not quite sure whether or not Dr Galloway's idea was because it had been demonstrated that the cmrmmnity physician role could be carried out over a wider

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area than the district suggested, one was going to in some way devalue the larger asset tha~. had been built up by dismembering it into smaller communities, I would go back, at the risk o f repeating myself, to say that I think there are some very strong arguments indeed for some form of integrated unit within these la.rger area health authorities ! talked about l:,c[bre, and it is unfi)rtunate 1 k n o w that what appears to have come out of the thing is a gearbox that is going to need a g o o d deal of oil from time to thne. ] think that the best oil that could be used is to make absolutely clear why each level is there, and what it is thal it has to do in relation to the others. This is what we are trying to do aItd what the Management Study was alI about. I do not see tile district creating a fourth tier as such, but I would rather look upon the Area Health Authority as an area composed of its executh'e districts ",~hich are formed in a federation if you like, in order to provide the necessary cross over with the local authority, the social services department, the education department, and the environmental aspects. You started by saying, o f course, that one set out to get unity with local government, and 1 suspect ihat ~he separate director of social services, in tile Seebohm Report. is one of the reasons why the Area Iteatth Authoriiy has become such an important level, but it is there and we have got to take account of it.

Prqfi'ssor tt ~rren I am worried about the three levels, and wonder whether if it was not for the political considerations one would not be thinking in terms of district and region. It seems to me we are ~rying ~o create an area job. This certainly worried me. Dr It. IV. S. F)'ancis When t t~rst saw Mr Lee's diagrams, very early on. several months ago, I was fl'ightened, but having worked with them and talked a b o u t them 1 have come to see their virtues. It would be qufie wrong if I advocated them strongly, but m a y t point out four possible virtues that exist in the hypotheses. First that lhe hypothesis is strongly patient-, or perso~based. The second is. it does allow for clinical a u t o n o m y and responsibility and ! think this is important. Thirdly it does encourage co-operation straight across the b o a r d at district level, and fourfllly, and this is most important for us, it does depend heavily on medical administration, and medical adminstration o f a very high quality. I hope, sir, that we can provide il. Chairman

O u r speakers have given us much to think about. Obviously we are worried about some o f the things we have heard, apprehensive for our services, our conmlunities, and possibly even for ourseh'es, but at least we can be assured that a tremendous a m o u n t of constructive thought is being given to the administration o f our new services.