Public Health The Journal of The Society of Community Medicine (Formerly the Society of Medical Officers of Health)

Volume 89

Number 3

March 1975

Is Anyone Satisfied? If so Why? Before 1974 the challenge of the reorganization of the National Health Service appealed to community physicians more than to general practitioners and hospital doctors. Perhaps this was because both preventive ideals and a medical administrator's outlook gave a wider vision of a promised land of integration, an oasis of constructive concord for the N.H.S. within the national scene of nomadic rivalry where sand buries the losers. It seems that Dr G. W. Knight's H.M. Reorganized Health Services (Public Health, July, 1974) is really a ship of the desert. It is clear, as it should have been from the start, that a year is too short a time to reach the oasis of integration; indeed it is scarcely long enough to read the guidance for travellers which is so copiously distributed. It is, however, possible to comment on the scene as it now appears. The view is necessarily largely subjective when regarded from any particular tier of the new structure and by individuals who may have been fortunate or less fortunate so far. From an area standpoint the first question may be, " H o w many tiers are there ?" Some appear to think that there are three below the Department of Health, but this is certainly mistaken for districts are part of the area structure, in spite of the somewhat complicated relationships on paper between individual members of the area team of officers and the district management team, because the latter are collectively and individually directly responsible to the area health authority. A close relationship of the districts, where operational health services are organized, with the area is one of the most important needs for integration. Otherwise there is a likelihood of the partial persistence of the old system of regional hospital board and hospital groups, with the area and its relationship with local government left isolated and ineffective. Already it is being whispered that either the regions or the areas must vanish from the National Health Service structure, leaving but one kind of health authority sub elephante. This immediately takes us back to the three-and-sixpenny Green Paper of 1968 which proposed this kind of structure. It was widely rumoured at the time that the First Green Paper was not merely a discussion document but a diversion to draw fire away from the Government's real intentions. At any rate the document was shattered with almost universal execration, to be followed in 1970 by the ~ve-shilling Green Paper. 89

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C. D. L. Lycett

Speaking as perhaps the only First Green Paper man, it is encouraging to descry the present trend of thought. Others would say that neither regions nor areas can remain alone in their present form because their numbers are too small, in the one case, and too large in the other, to act as a single tier (the 1968 Green Paper proposed about 40 area boards, each of which would have been expected to develop operational district arrangements). Obviously the immediate objective must be to retain, and if possible to improve upon, the best practices of both the hospital and the local government services and to discard the worst. This aim is easy to state but difficult to achieve, firstly because of the fixed thought patterns inherited from the former services, secondly because the Department of Health, although internally reorganized, does not seem to have altered in essence or to provide enough stimulus to change the old procedures, and thirdly because the shortage of resources, which ought to encourage new and ingenious methods of thinking, tends to do the opposite by enveloping the reorganization in a pall of discouragement. The doctrine of "the global sum" which some prefer to allude to as "the cake" arbitrarily divided at each tier between the hungry supplicants, as the method of financial allocation, is a direct disincentive to rational planning based upon thorough ascertainment of the pattern of health and disease in each district and area. It inhibits the frank epidemiological exposition which is so seriously needed as the basis for health service planning and the outspoken reporting which was one of the best features of old-style local government public health departments. The fact that such reports from medical officers of health were quite often ignored or only partially implemented because other interests in local government competed successfully with health requirements in no way diminishes the value of the method, which clarifies the actual needs and places major responsibility upon the members, to whom it belongs. A possible move away from stereotyped global sum money rationing is foreshadowed by. the advocacy of zero budgeting which is now faintly heard in conference rooms and which might encourage the necessary epidemiological approach to planning. It would have to be accompanied by really effective delegation downwards of the initial planning function. Surely, also, it is time that five-year budgeting was substituted for annual estimates, or is it another victim of inflation ? How splendid it would be if areas were to encourage health-care planning within the districts directed towards the right balance of care between the hospital and the patients' homes. This ought to be a present aim and could be achieved to a useful extent without awaiting the full development of information systems and epidemiological assessment of the community's state of health and disease. However, it requires the imaginative release of resources at the outset in the expectation of economy and more efficient patient care in the longer term. Will these resources be forthcoming, to allow, for instance, the improvement of out-patient and diagnostic services and time for domiciliary visits by consultants, so that general practitioners can treat more patients entirely at home and minimize the length of stay in hospital for others ? This concept, like others, involves the relationship with local government, which is particularly the responsibility of area health authorities because of the supporting services which should be provided by the new counties and metropolitan districts. Joint consultative committees seem to have made a cordial start but the hard work is still to come. Even social services departments are now severely restricted in development and need further considerate treatment by the Government if rational health care planning is to make progress. The Seebohm honeymoon is over, the gifts have been used, but where are the services for the elderly and the mentally ill or handicapped ?

Is anyone satisfied?

91

Within health authorities themselves the almost incredible feat of putting together the three parts of the National Health Service with less money in real terms than was previously spent appears to the public to have been achieved without serious impairment of the services but in fact there are strains and weaknesses which must cause damage unless they are remedied soon. Examples are to be found in the management structure and failure to provide attached administrative staff of adequate numbers and calibre to support community medicine members of management teams and other scarce specialists is wholly unacceptable. Although the age structure within the specialty of community medicine may not differ from that in the clinical specialties as much as was first thought, the clinical consultants have junior staff waiting to replace them. There is a risk of community medicine being unable to fully demonstrate its usefulness because there are too few specialists and at the same time failing to attract recruits because its interest and potency are not sufficiently apparent. Too much of the work being done is concerned with the immediate needs of reorganization or with day-to-day operation, with insufficient time and support for the full exercise of specialist knowledge in policy and planning. Hasty extemporization rather than forethought, extends also to whole management teams. The air so far appears to be filled with the sweet sounds of consensus as the members of each team adjust to one another in this atmosphere of quandary, but whether continual consensus is necessarily right is another matter and the community physician member may sometimes be able to make his best contribution by ensuring that his views are directly represented to the authority without compromise. It would help if more of our colleagues understood the definition of community medicine. This can be the subject of lengthy philosophical argument, but for practical purposes that of the Faculty of Community Medicine or of the Royal Commission on Medical Education (1968) is sufficient. The word "community" itself causes difficulty because it is used to mean "outside hospital" instead of in the wider sense intended in the definition of community medicine. There are indeed many current problems in setting up the services too well known to need elaboration, including the extent to which it is practicable to make further appointments of specialists in community medicine at the present time, the future of the clinical doctors transferred from local health authorities and the difficulties in running services such as chiropody and speech therapy which are the direct responsibility of area medical officers when professional officers in immediate charge are not allowed to be appointed, even on an acting basis, because of national delay in deciding salary scales. But there are also major questions of principle facing the N.H.S. and the medical profession. At the end of the first year from the Appointed Day, is anyone satisfied and, if so, why ? This question must be summarily disposed of by answering " N o " to the first part. Nevertheless, though much has been delayed and much still hangs in the balance, nothing important has been lost for the National Health Service or for community medicine. The hopes with which reorganization started still remain. The proper question is "Should community medicine ever be satisfied ?"

C. D. L. Lycett

Is anyone satisfied? If so why?

Public Health The Journal of The Society of Community Medicine (Formerly the Society of Medical Officers of Health) Volume 89 Number 3 March 1975...
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