Journal of Advanced Nursing, 1979, 4, 205-214
The British Nationai Heaith Service 1948-1978: shouid we start again?* June Clark B.A. M.Phil. S.R.N. H.V. Certificate Senior Research Officer, Department of Nursing and Community Health Studies, Polytechnic of the South Bank, London Accepted for publication 5 June
CLARK J. {igjgi) Journal of Advanced Nursing 4, 205-214
The British National Health Service 1948-1978: should we start again? The author concludes that since the British National Health Service is the product of a complex history, it is impossible to start again: however, the removal cf three factors and the development of one would greatly improve it. The factors to be removed are: (i) the witch hunt against management, which has become the scapegoat for other ills; (ii) the medical model of health care, which is no longer relevant or practical; (iii) the industrial model, which has forced the NHS into an inappropriate style of management, trade unionism and employment patterns. The factor to be developed is the clirucal skill of the nurse; such development requires improved educational opportunities and a clinical career structure.
A RHETORICAL QUESTION' The question asked in the title of this paper is certainly a rhetorical question. The short answer is 'no' and the re^j^n is simply 'we cannot'. As an old American proverb has it: 'you can't unscramble scrambled eggs'. Construction of a new building, as opposed to conversion or improvement of an old one, requires either virgin territory or demolition of what was there before, and the construction of a health service is no different. Except possibly in undeveloped countries which have no organized services, the territory is not virgin; in the United Kingdom the National Health Service (NHS) site is occupied by a hotchpotch of structures which have developed piecemeal and unplanned over a period of several hundred years. Moreover it is folly to think that even in 1948 it was possible to start from scratch. The NHS Act did not create health services. It simply took over, organized, fixed, formalized and some would say fossilized, what was already there. * Based on a paper read at the Ren professional conference at Harrogate, 5 June 1978. 0309-2402/79/0300-0205 S02.00
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And it did so in a manner which was determined not on the basis of society's needs, but on the basis of accommodating the vested interests of those involved in operating it: a compromise package deal made up mainly of medical protectionism • and political expediency. History has a habit of repeating itself. What happened in 1946 was a repetition of what happened in 1919 when the Ministry of Health was first established. It was repeated, to the point almost of monotony in 1974, when the NHS was reorganized. Discussions began in the late 1960s from the premise that the fragmentation of the service hindered patient care, and what was needed was integration: not a tripartite service, but a unified one. But as the covers of the government documents turned from green (discussion paper) to white (policy paper) to grey (final paper), the terminology also changed. There was less and less talk of integration and more and more of reorganization, and in order to get any change at all, the original premise was once again sacrificed on the altar of vested interest. The tripartite service was replaced with a bipartite service (because the general practitioner services are as separate from the rest as the hospital services were from the community services in the 1950s and 1960s). The same analysis can be used to explain many of the other disappointed expectations of the 1974 reorganization: the failure to shift the emphasis (in practical financial terms as opposed to pious declarations of intent) from acute hospital services to community based supportive services for the elderly, the handicapped and the chronic sick; the failure to translate into practice the knowledge that prevention is better (and probably cheaper) than cure; the wilfid neglect of the real needs of vast numbers of ordinary people, as described by Claire Rayner (1979), in favour of what is medically interesting and exciting. What I have done is to pick out just one or two things in the NHS that I would scrap immediately, yesterday if possible, and one or two things that I would preserve and develop in order to make them better.
SOME C H A N G E S NEEDED First, the things that I would scrap in the NHS. No, the first of them is not one tier of the management structure. Like most people I believe that our present management structure is unwieldy and inefficient, and the necessary streamlining must involve some amalgamation of the present three tiers. But my concern is that the management structure, and indeed management in general, is being used as a scapegoat for all the ills of the service and that by concentrating our attention on the scapegoat we are allowing ourselves to ignore real problems, many of which are susceptible to change and which ought to be dealt with. The first thing I would scrap in fact is the anti-management witch-hunt. I say that as a nurse who is not a manager and has no aspirations in that direction. I have always worked as a field-level practitioner, as a staff nurse
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in the hospital service and a health visitor in the community services. Perhaps that makes my argument all the more cogent.
The realities of the NHS First let us consider the realities. The NHS is an enterprise with a budget of some ^6ooom and a workforce of some 800000: the tenth largest employer in the world. The cost of its administration is in fact about 6% of its revenue expenditure, a figure which is low enough to be envied by many industrial enterprises. Secondly, let us be clear what we are talking about when we use the term administrative costs. Most of it is people. Most of the cost is for the army ofjunior clerks/typists and fmance clerks. Why have their numbers increased so dramatically since 1974, as they have? Well, take just one exam^ple: consider the number of fmance clerks required to pay basic wages or a simple incremental salary scale to however many staff there are on an Area Health Authority (AHA) payroll. Now consider the number required when, as has happened in the last 4 years, they have to cope with incentive bonus schemes, special duty payments, overtime, imits of medical time (UMTs) and two pay policy supplements, and as soon as they have got the system worked out, the whole thing is changed again. The same kind of explosion has also occurred in other areas, for example to document and service the whole panoply of NHS consultation procedures, grievance procedures and industrial disputes. Thirdly, it is worth remembering what management is for. The function of management in the NHS is to enable practice, that is patient care, to happen. It does this by providing the system and the support services. When there is no enabling, practice must suffer. And as a result of the witch-hunt and the consequent drastic cuts in management services, that is exactly what has happened. Let me give you just one example. A psychiatric hospital is making strenuous attempts to improve and individualize the care it gives its long term patients by encouraging each patient to have his or her own personal clothing. Someone h.as to see to the choosing, buying, issuing and laundering. But that is an administrative task, and the appointment of a clothing manager is an administrative cost. Within present constraints on NHS administrative costs a clothing manager cannot be appointed. So either patients continue to wear institutional clothing or the nurses take on the job. And when nurses take on such non-nursing functions the time available for their proper nursing function is inevitably reduced. Finally, since the witch-hunt is led, cats screaming and broomsticks at the ready, by the medical profession, perhaps it is appropriate to look at medical and nursing administration side by side. In the Department of Health and Social Security (DHSS), trapped in those corridors of power, are 53 nurses who, it is argued, would be better employed at the bedside. There are at the latest count 53 nurses; there are also 398 doctors. And to compare it with what is going on at the bedside, remember there are about
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50000 doctors in the NHS compared with more than 350000 nursing staff. Perhaps it still needs to be repeated that between 1963 and 1975, the number of nurses within the NHS employed in administrative grades above the level of ward sister dropped by almost half, from 5% to 3% of the total. Nursing, in my view, may sometimes be mismanaged, but it is not, in numerical terms at least, overmanaged. On every district management team (DMT) there is one nurse, one finance officer, one administrator; but three doctors. Three times the servicing and documentation, three times the professional time, as well as three times the vote: all for medical administration. In every AHA area there are professional advisory committees, one for each professional group: except of course medicine. Because doctors cannot agree with one another, a single committee is not enough. In the area administered by the Berkshire AHA, for example, a relatively small two-district area, the doctors have abandoned the medical advisory committee and instead have two committees, one for hospital doctors and one for GPs, in each district: four committees, four times the administrative servicing, four times the consultation procedures, four times the professional time. Until the medical profession can streamline its own administration and reduce its own management costs, it ill becomes it to rant and rave about others. However, the purpose of this polemic is not to replace the witch-hunt against managers by a witch-hunt against doctors, nor to allow any feelings of complacency among nurse managers. It is a plea to remember that all who work in the health service have, or should have, a common cause: to provide the best possible patient care. And if we are to achieve this common goal we must accept that we are all inter-dependent. Without management, practice cannot happen; without practice, management has no raison d'etre.
Putting medicme in its proper perspective The second thing I would scrap is the overwhelming dominance of medicine and the medical model of illness in health services. As Illich (1975) reminds us, 'We must not mistake medical treatment for health care'. Unfortunately the fact is that we have mistaken medical treatment for health care. We have made the mistake of thinking that the concern of health services should be with disease, and that disease is a physiological aberration which is susceptible to medical diagnosis and will be conquered, or at least controlled, by medical intervention. A system of health care based on knowledge of disease cannot produce health. It can only discover more disease and create the very needs which it is supposed to meet. A century ago such a definition of the problem might have been appropriate. Then mortality from infectious disease was so overwhelming that all other causes of disease paled into insignificance, and few people survived long enough to suffer the problems of old age. The way in which a problem is defined determines the way in which it is
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tackled and the services which are created in response. And coincidentally perhaps, but with what significant consequences, this was the crucial formative period of the present British health and medical services. This period (i.e. a century ago) saw the foundation of the pattern of British hospital services, the organization of the medical profession and the establishment of a system of medical education focused on the acute general hospital, which selected its admissions not on the criterion of patient need, but on the criterion of medical 'interest'. History's mark is difficult to erase. The NHS is still dominated by the concept of the acute general hospital as the fulcrum. It takes the lion's share of the available resources. Doctors and nurses are trained there, where they develop not only knowledge and skills but also their values about health and illness. This is the model which medicine uses in its own work, and this is the model to which the medical profession wants nursing also to conform. I believe this model of health care must be scrapped. Firstly, because it is ill suited to the problems which now confront us. To the degenerative disorders of an aging population, to the behavioural diseases such as obesity and alcoholism, to the care of the frail elderly and the physically and mentally disabled, medicine has little to offer by way of 'cure'. When what is curable has been cured and what is preventable has been prevented, there is still a good deal left. And what it needs is care. Secondly, because medical technology is costly and has outstripped the resources available to put it all into practice, even if it were desirable to do so. Medicine is not the only field where this has happened, and in medicine, as in other fields, priorities have to be determined. In most fields where choice is hmited by cost, one important criterion is effectiveness. Medicine however, as Thomas McKeown (1965) has pointed out, 'is the only enterprise, private or public, in which it has not been considered essential to equate effectiveness and cost'. Indeed there is increasing evidence that expensive high-technology methods: coronary care units, heroic surgery, are not necessarily more effective than conservative treatment and simple care, and that they may have costs other than financial: 100 000 people each year admitted to hospital suffering from problems which are directly attributable to previous medical treatment. And thirdly, because health is too important a matter to be left to doctors, who know very little about it. The authority of doctors, proper to their own field, the investigation and treatment of disease, is inappropriately applied to other fields. In the determination of social policy their authority is no greater than that of other kinds of specialists. Their contribution is important, but it is only one among many to be considered. Yet decision making within the NHS is, and always has been, dominated by medicine. One has only to consider the medical representation on health authorities, DMTs and in the DHSS, to see that this is so. And one has only to look at the shape of the NHS to see that in decisions made by doctors, the doctors' interests always come first. And so I would scrap the medical model of health and health services, and
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replace it by one based on prevention and care, in which care is a partnership between family, community and a multi-professional team.
ABOLISH THE I N D U S T R I A L M O D E L The third thing I would scrap, and though it comes third in order I would put it first in importance, is the industrial model. Like the medical model, the industrial model is entirely appropriate when applied to its proper, limited, field, in this case to industry. When it is applied to a field for which it is inappropriate however, the result is disaster. The NHS is not an industrial enterprise, and the effect of forcing it to conform to an industrial model as has happened in recent years has damaged it, in my view, more than all the financial constraints and structural deficiencies put together. First of all, the goal of an industrial enterprise is economic profit, and its whole structure and mode of operation is designed to achieve that goal. In achieving it, two factors are crucial: the efficient use of resources and maximum productivity from its workforce. Efficiency is important in any enterprise where resources are limited, and that certainly includes the NHS. In an industrial enterprise efficiency is achieved by centralization, mechanization and strict managerial control, and these are the techniques that have been applied in the search for efficiency in the NHS. But in this field, these techniques are inappropriate. Centralized decision making cannot meet the needs of widely differing local communities. Economy of scale is incompatible with individualized care. Industrial type management control is inappropriate to a professional service where the function of management is not to control practice, but to enable it to happen. And the most important resource of the NHS is not its hardware, but the people who work in it, and in particular their commitment to the service they give. And that resource, their commitment and goodwill, far from being conserved, is being dissipated and destroyed. What of productivity? In an industrial enterprise effort is measured in terms of productivity and rewarded accordingly. And because the system is effective in industry the government has seen fit to apply it to all, to make it the lynch-pin of its current pay policy. The NHS is not a productive industry and patient throughput is not necessarily the best criterion either of effort or of quality of care.
Trade unionism I want to consider the industrial model of trade unionism. The growth of trade unionism in the NHS is no accident. It was the inevitable response to the introduction of the industrial techniques which I have described. When control is vested in management it can only be counter-balanced by organized labour; when pay
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depends on incentive bonus schemes and productivity deals, with vi^hom does management negotiate? Trade unionism grew up in industry to meet the needs of industrial workers, as the means of establishing the rights of the worker in relation to those of the employer. What I object to is the transfer of that model to a different situation in which the rights of both employer and employee have to take account of the rights of a third group of people, the patients. The NHS does not exist for the benefit of the government, nor for the benefit of the staff who work in it. Its raison d'etre is patients. But the industrial trade union, by definition, exists solely for the benefit of its members. This model of trade unionism may be entirely proper in industry, but in my view it should have no place in the NHS. In particular it has no place in nursing because it is the complete antithesis of the cardinal professional principle of service before self. That is not to say that nurses do not have rights, in particular the right to proper remuneration and proper conditions of service, nor that they do not need an organization to fight for those rights. They do. "What is needed is a different kind of organization in which those rights can be achieved just as effectively, but not at the expense of those of patients. The Royal College of Nursing of the United Kingdom is such an organization. My concern is that not only has this model of labour organization been transferred to a field for which it is inappropriate, but its position has been institutionalized and confirmed by legislation which excludes the possibility of any other modus operandi. Let us look further at some of the implications of the industrial model of trade unionism within the NHS: first the use of sanctions. In profit-making industry the sanction of withdrawing labour is appropriate and effective because it hits the employer's pocket, and since the employer's goal is profit he loses out unless he accedes to the employee's demands. In the NHS the withdrawal of labour has no effect on the employer's pocket: indeed it might even save him money, as the junior doctors' strike did not so long ago, but it hurts the defenceless, the sick. There is no 'hierarchy' in patient care. Patients are harmed by the withdrawal of laundry services. In 1978 action by a British hospital porter closed an operating theatre and added 178 sufferers to the waiting list. And what of the position of the nurse when the services of other staff are withdrawn? Does she do the cleaning and the washing up? If she does not, she knows that patients will suffer. If she does, not only is she 'strike-breaking', a heinous crime in trade union eyes, but she does so at the expense of the time available for her proper nursing function. In patient care we are all inter-dependent. Consultation machinery Another implication of the industrial model of trade unionism is the machinery required to make it work. On the factory floor the withdrawal of one man
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from the production line to attend to his trade union duties does not greatly impair productivity. Indeed it may be in an employer's interest, as an acceptable price to pay for shop-floor 'cooperation', to continue to employ and pay a worker, the bulk of whose time will be spent not at his bench but on trade union activities. For, make no mistake, the time required is considerable: for joint consultation, representation of members, health and safety inspections, and so on. But what if the shop steward is a nurse, perhaps the sister in charge of a busy surgical ward; and the Joint Consultative Committee (JCC) meeting coincides with the operating theatre list; and the ward staffing is on the knife-edge of safe cover? Does she leave the ward to go to the meeting? She has the right to do so, enshrined in trade unionist legislation. If she goes, the patients will suffer, and so will her colleagues whose burden, already intolerable, is increased. If she does not go, the voice of professional nursing in what may be a crucial policy decision will either be lost completely or will be represented by a non-nurse who is there in her stead simply because his work-role happens to be one which is more easily 'spared'. Industrial relations Thirdly, let us look at industrial relations legislation, in particular the Employment Protection Act. Protection is certainly needed, inside as well as outside the NHS. But in the NHS it is not only the employee who needs protection. Patients need protection too. But within the industrial model the only interested parties are the employee and the employer. The model does not allow for the interests of patients. And so in disciplinary or dismissal procedures, particularly when they go to appeal, the key question is not 'Is this person safe to be caring for patients?' but 'Has this person had all his rights as an employee?' And as in most matters of law, procedure is everything. Appeals against dismissal have to be upheld purely because of breaches of procedure, and thereby a person may be sent back to direct patient care who is by any other criterion quite lansuitable. For nurse managers, correctness of disciplinary procedures has become more important than staff counselling and professional support. Educational needs are sacrificed to the risk of suits for constructive dismissal. Time and money which could be spent on other things is devoted to endless enquiries and appeals. While appeals are pending, and it can last for months, there is tension and suspicion and an atmosphere which is hardly conducive to good patient care. These are just three aspects of the industrial model: its goals, its trade union machinery and its legislation, which may work perfectly well in industry but do not work when applied to the NHS. So much for what I would scrap. What, then, would I preserve, foster, and develop?
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T H E N U R S E ' S C O N T R I B U T I O N T O P A T I E N T CARE Time limits m.e to picking just one, which, I beheve, is a precious resource that is at present under-developed and under-valued: the nurse's contribution to patient care. Nurses have an important contribution to make to health services as planners, managers and policy makers. But I want to concentrate particularly on the nurse's clinical role. I believe that the nursing model has a great deal to offer. My model of nursing is embodied in that definition by Virginia Henderson (1966): 'The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. The nursing model is based on the following two important principles. Firstly that nursing has a perspective on patient care which is different from and complementary to that of medicine, and valuable for its own sake. It must develop along its own lines, applying its own body of knowledge and its own skills, not merely taking on tasks relinquished by others. Secondly, that every professional nurse, whatever her field of work, whatever her specialty, must strive constantly for what Juanita Rule (1978) has called (translated from the Socratic 'arete') 'excellence in the craft'. These are the things, much more important than management structures and even more important than numbers of pairs of hands, which determine standards of care. I would like to pinpoint just two problems of this 'pursuit of excellence' in nursing: opportunities and incentives. I think nursing must be the only occupation in which, after a longish period of preparation leading to a statutory qualification, which is also (in order to protect the public) a licence to practice, the newly qualified practitioner is assumed to be competent in every specialty within the field and to have in her possession all the knowledge required for practice for the next 40 years. There is an urgent need for proper funding specifically allocated for nursing education, and particularly for post-basic education, just as happens for medical education in the UK. The need for study leave must be recognized in nurses' conditions of service just as it is for doctors, and taken account of in manpower planning and resource allocation. Without the proper educational opportunities nurses cannot develop the excellence in their craft which is essential for good standards of patient care. Nursing is also the only occupation I know where at the end of a long period of training and the award of the appropriate qualification, the qualified practitioner has to stop doing what she has been trained to do, in order to progress. Clinical nursing offers no career structure, no financial reward. The ambitious practitioner has reached her final grade (ward sister) within a year or two of her basic qualification, and her financial ceiling before she is 30.
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Clinical career development It seems to me quite reasonable to give increased financial reward for increased responsibility, provided that account is also taken of the relevant criteria such as experience and expertise. But managerial responsibility is not greater than clinical responsibility nor less than it; it is qualitatively different. Why should, say, a nursing officer, administratively responsible for a unit, feel threatened by the existence in that unit of a clinical practitioner, who is paid more by virtue of her different role, experience and expertise? Why cannot a senior nursing officer (clinical) work alongside and in equal partnership with a senior nursing officer (administration) and a senior nursing tutor. We do not need a proliferation of gradings or even a precise definition of the much misunderstood phrase 'clinical nurse consultant'. It can be done, and in some places it already has been done, for example, the Royal Marsden Hospital, where there is a commitment to the concept (Tiffany 1979). For years we have been saying that clinical practice was the essence of nursing. I would like to be shown how. The challenge is exciting, the potential rewards immense. We cannot unscramble those scrambled eggs. But with top quality ingredients, their individual flavours enhanced by the appropriate herbs and seasonings, skilfully blended and attractively served, scrambled eggs can be a dish fit for a king.
References HENDERSON V. (1966) The Nature of Nursing: a definition and its implications for practice, research and education. CoUier-Macmillan, New York. ILLICH I. (1975) Medical Nemesis: the expropriation of health. Calder & Boyars, Nev*r York. MCKEOWN T . (1965) Medicine in modem society. Allen & Unwin, London. RAYNER C . (1979) Reality and expectation of the British National Health Service consumer. _/oHr«fl/ of Advanced Nursing 4, i, 69-77. RULE J. (1978) The professional ethic in nursing Journal of Advanced Nursing 3, i, 3-8. TIFFANY R . (1979) Mobilizing nursing skills. JoHma/ of Advanced Nursing 4, i.
The British Nationai Heaith Service 1948-1978: shouid we start again?* June Clark B.A. M.Phil. S.R.N. H.V. Certificate Senior Research Officer, Department of Nursing and Community Health Studies, Polytechnic of the South Bank, London Accepted for publication 5 June
CLARK J. {igjgi) Journal of Advanced Nursing 4, 205-214
The British National Health Service 1948-1978: should we start again? The author concludes that since the British National Health Service is the product of a complex history, it is impossible to start again: however, the removal cf three factors and the development of one would greatly improve it. The factors to be removed are: (i) the witch hunt against management, which has become the scapegoat for other ills; (ii) the medical model of health care, which is no longer relevant or practical; (iii) the industrial model, which has forced the NHS into an inappropriate style of management, trade unionism and employment patterns. The factor to be developed is the clirucal skill of the nurse; such development requires improved educational opportunities and a clinical career structure.
A RHETORICAL QUESTION' The question asked in the title of this paper is certainly a rhetorical question. The short answer is 'no' and the re^j^n is simply 'we cannot'. As an old American proverb has it: 'you can't unscramble scrambled eggs'. Construction of a new building, as opposed to conversion or improvement of an old one, requires either virgin territory or demolition of what was there before, and the construction of a health service is no different. Except possibly in undeveloped countries which have no organized services, the territory is not virgin; in the United Kingdom the National Health Service (NHS) site is occupied by a hotchpotch of structures which have developed piecemeal and unplanned over a period of several hundred years. Moreover it is folly to think that even in 1948 it was possible to start from scratch. The NHS Act did not create health services. It simply took over, organized, fixed, formalized and some would say fossilized, what was already there. * Based on a paper read at the Ren professional conference at Harrogate, 5 June 1978. 0309-2402/79/0300-0205 S02.00
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And it did so in a manner which was determined not on the basis of society's needs, but on the basis of accommodating the vested interests of those involved in operating it: a compromise package deal made up mainly of medical protectionism • and political expediency. History has a habit of repeating itself. What happened in 1946 was a repetition of what happened in 1919 when the Ministry of Health was first established. It was repeated, to the point almost of monotony in 1974, when the NHS was reorganized. Discussions began in the late 1960s from the premise that the fragmentation of the service hindered patient care, and what was needed was integration: not a tripartite service, but a unified one. But as the covers of the government documents turned from green (discussion paper) to white (policy paper) to grey (final paper), the terminology also changed. There was less and less talk of integration and more and more of reorganization, and in order to get any change at all, the original premise was once again sacrificed on the altar of vested interest. The tripartite service was replaced with a bipartite service (because the general practitioner services are as separate from the rest as the hospital services were from the community services in the 1950s and 1960s). The same analysis can be used to explain many of the other disappointed expectations of the 1974 reorganization: the failure to shift the emphasis (in practical financial terms as opposed to pious declarations of intent) from acute hospital services to community based supportive services for the elderly, the handicapped and the chronic sick; the failure to translate into practice the knowledge that prevention is better (and probably cheaper) than cure; the wilfid neglect of the real needs of vast numbers of ordinary people, as described by Claire Rayner (1979), in favour of what is medically interesting and exciting. What I have done is to pick out just one or two things in the NHS that I would scrap immediately, yesterday if possible, and one or two things that I would preserve and develop in order to make them better.
SOME C H A N G E S NEEDED First, the things that I would scrap in the NHS. No, the first of them is not one tier of the management structure. Like most people I believe that our present management structure is unwieldy and inefficient, and the necessary streamlining must involve some amalgamation of the present three tiers. But my concern is that the management structure, and indeed management in general, is being used as a scapegoat for all the ills of the service and that by concentrating our attention on the scapegoat we are allowing ourselves to ignore real problems, many of which are susceptible to change and which ought to be dealt with. The first thing I would scrap in fact is the anti-management witch-hunt. I say that as a nurse who is not a manager and has no aspirations in that direction. I have always worked as a field-level practitioner, as a staff nurse
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in the hospital service and a health visitor in the community services. Perhaps that makes my argument all the more cogent.
The realities of the NHS First let us consider the realities. The NHS is an enterprise with a budget of some ^6ooom and a workforce of some 800000: the tenth largest employer in the world. The cost of its administration is in fact about 6% of its revenue expenditure, a figure which is low enough to be envied by many industrial enterprises. Secondly, let us be clear what we are talking about when we use the term administrative costs. Most of it is people. Most of the cost is for the army ofjunior clerks/typists and fmance clerks. Why have their numbers increased so dramatically since 1974, as they have? Well, take just one exam^ple: consider the number of fmance clerks required to pay basic wages or a simple incremental salary scale to however many staff there are on an Area Health Authority (AHA) payroll. Now consider the number required when, as has happened in the last 4 years, they have to cope with incentive bonus schemes, special duty payments, overtime, imits of medical time (UMTs) and two pay policy supplements, and as soon as they have got the system worked out, the whole thing is changed again. The same kind of explosion has also occurred in other areas, for example to document and service the whole panoply of NHS consultation procedures, grievance procedures and industrial disputes. Thirdly, it is worth remembering what management is for. The function of management in the NHS is to enable practice, that is patient care, to happen. It does this by providing the system and the support services. When there is no enabling, practice must suffer. And as a result of the witch-hunt and the consequent drastic cuts in management services, that is exactly what has happened. Let me give you just one example. A psychiatric hospital is making strenuous attempts to improve and individualize the care it gives its long term patients by encouraging each patient to have his or her own personal clothing. Someone h.as to see to the choosing, buying, issuing and laundering. But that is an administrative task, and the appointment of a clothing manager is an administrative cost. Within present constraints on NHS administrative costs a clothing manager cannot be appointed. So either patients continue to wear institutional clothing or the nurses take on the job. And when nurses take on such non-nursing functions the time available for their proper nursing function is inevitably reduced. Finally, since the witch-hunt is led, cats screaming and broomsticks at the ready, by the medical profession, perhaps it is appropriate to look at medical and nursing administration side by side. In the Department of Health and Social Security (DHSS), trapped in those corridors of power, are 53 nurses who, it is argued, would be better employed at the bedside. There are at the latest count 53 nurses; there are also 398 doctors. And to compare it with what is going on at the bedside, remember there are about
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50000 doctors in the NHS compared with more than 350000 nursing staff. Perhaps it still needs to be repeated that between 1963 and 1975, the number of nurses within the NHS employed in administrative grades above the level of ward sister dropped by almost half, from 5% to 3% of the total. Nursing, in my view, may sometimes be mismanaged, but it is not, in numerical terms at least, overmanaged. On every district management team (DMT) there is one nurse, one finance officer, one administrator; but three doctors. Three times the servicing and documentation, three times the professional time, as well as three times the vote: all for medical administration. In every AHA area there are professional advisory committees, one for each professional group: except of course medicine. Because doctors cannot agree with one another, a single committee is not enough. In the area administered by the Berkshire AHA, for example, a relatively small two-district area, the doctors have abandoned the medical advisory committee and instead have two committees, one for hospital doctors and one for GPs, in each district: four committees, four times the administrative servicing, four times the consultation procedures, four times the professional time. Until the medical profession can streamline its own administration and reduce its own management costs, it ill becomes it to rant and rave about others. However, the purpose of this polemic is not to replace the witch-hunt against managers by a witch-hunt against doctors, nor to allow any feelings of complacency among nurse managers. It is a plea to remember that all who work in the health service have, or should have, a common cause: to provide the best possible patient care. And if we are to achieve this common goal we must accept that we are all inter-dependent. Without management, practice cannot happen; without practice, management has no raison d'etre.
Putting medicme in its proper perspective The second thing I would scrap is the overwhelming dominance of medicine and the medical model of illness in health services. As Illich (1975) reminds us, 'We must not mistake medical treatment for health care'. Unfortunately the fact is that we have mistaken medical treatment for health care. We have made the mistake of thinking that the concern of health services should be with disease, and that disease is a physiological aberration which is susceptible to medical diagnosis and will be conquered, or at least controlled, by medical intervention. A system of health care based on knowledge of disease cannot produce health. It can only discover more disease and create the very needs which it is supposed to meet. A century ago such a definition of the problem might have been appropriate. Then mortality from infectious disease was so overwhelming that all other causes of disease paled into insignificance, and few people survived long enough to suffer the problems of old age. The way in which a problem is defined determines the way in which it is
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tackled and the services which are created in response. And coincidentally perhaps, but with what significant consequences, this was the crucial formative period of the present British health and medical services. This period (i.e. a century ago) saw the foundation of the pattern of British hospital services, the organization of the medical profession and the establishment of a system of medical education focused on the acute general hospital, which selected its admissions not on the criterion of patient need, but on the criterion of medical 'interest'. History's mark is difficult to erase. The NHS is still dominated by the concept of the acute general hospital as the fulcrum. It takes the lion's share of the available resources. Doctors and nurses are trained there, where they develop not only knowledge and skills but also their values about health and illness. This is the model which medicine uses in its own work, and this is the model to which the medical profession wants nursing also to conform. I believe this model of health care must be scrapped. Firstly, because it is ill suited to the problems which now confront us. To the degenerative disorders of an aging population, to the behavioural diseases such as obesity and alcoholism, to the care of the frail elderly and the physically and mentally disabled, medicine has little to offer by way of 'cure'. When what is curable has been cured and what is preventable has been prevented, there is still a good deal left. And what it needs is care. Secondly, because medical technology is costly and has outstripped the resources available to put it all into practice, even if it were desirable to do so. Medicine is not the only field where this has happened, and in medicine, as in other fields, priorities have to be determined. In most fields where choice is hmited by cost, one important criterion is effectiveness. Medicine however, as Thomas McKeown (1965) has pointed out, 'is the only enterprise, private or public, in which it has not been considered essential to equate effectiveness and cost'. Indeed there is increasing evidence that expensive high-technology methods: coronary care units, heroic surgery, are not necessarily more effective than conservative treatment and simple care, and that they may have costs other than financial: 100 000 people each year admitted to hospital suffering from problems which are directly attributable to previous medical treatment. And thirdly, because health is too important a matter to be left to doctors, who know very little about it. The authority of doctors, proper to their own field, the investigation and treatment of disease, is inappropriately applied to other fields. In the determination of social policy their authority is no greater than that of other kinds of specialists. Their contribution is important, but it is only one among many to be considered. Yet decision making within the NHS is, and always has been, dominated by medicine. One has only to consider the medical representation on health authorities, DMTs and in the DHSS, to see that this is so. And one has only to look at the shape of the NHS to see that in decisions made by doctors, the doctors' interests always come first. And so I would scrap the medical model of health and health services, and
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replace it by one based on prevention and care, in which care is a partnership between family, community and a multi-professional team.
ABOLISH THE I N D U S T R I A L M O D E L The third thing I would scrap, and though it comes third in order I would put it first in importance, is the industrial model. Like the medical model, the industrial model is entirely appropriate when applied to its proper, limited, field, in this case to industry. When it is applied to a field for which it is inappropriate however, the result is disaster. The NHS is not an industrial enterprise, and the effect of forcing it to conform to an industrial model as has happened in recent years has damaged it, in my view, more than all the financial constraints and structural deficiencies put together. First of all, the goal of an industrial enterprise is economic profit, and its whole structure and mode of operation is designed to achieve that goal. In achieving it, two factors are crucial: the efficient use of resources and maximum productivity from its workforce. Efficiency is important in any enterprise where resources are limited, and that certainly includes the NHS. In an industrial enterprise efficiency is achieved by centralization, mechanization and strict managerial control, and these are the techniques that have been applied in the search for efficiency in the NHS. But in this field, these techniques are inappropriate. Centralized decision making cannot meet the needs of widely differing local communities. Economy of scale is incompatible with individualized care. Industrial type management control is inappropriate to a professional service where the function of management is not to control practice, but to enable it to happen. And the most important resource of the NHS is not its hardware, but the people who work in it, and in particular their commitment to the service they give. And that resource, their commitment and goodwill, far from being conserved, is being dissipated and destroyed. What of productivity? In an industrial enterprise effort is measured in terms of productivity and rewarded accordingly. And because the system is effective in industry the government has seen fit to apply it to all, to make it the lynch-pin of its current pay policy. The NHS is not a productive industry and patient throughput is not necessarily the best criterion either of effort or of quality of care.
Trade unionism I want to consider the industrial model of trade unionism. The growth of trade unionism in the NHS is no accident. It was the inevitable response to the introduction of the industrial techniques which I have described. When control is vested in management it can only be counter-balanced by organized labour; when pay
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depends on incentive bonus schemes and productivity deals, with vi^hom does management negotiate? Trade unionism grew up in industry to meet the needs of industrial workers, as the means of establishing the rights of the worker in relation to those of the employer. What I object to is the transfer of that model to a different situation in which the rights of both employer and employee have to take account of the rights of a third group of people, the patients. The NHS does not exist for the benefit of the government, nor for the benefit of the staff who work in it. Its raison d'etre is patients. But the industrial trade union, by definition, exists solely for the benefit of its members. This model of trade unionism may be entirely proper in industry, but in my view it should have no place in the NHS. In particular it has no place in nursing because it is the complete antithesis of the cardinal professional principle of service before self. That is not to say that nurses do not have rights, in particular the right to proper remuneration and proper conditions of service, nor that they do not need an organization to fight for those rights. They do. "What is needed is a different kind of organization in which those rights can be achieved just as effectively, but not at the expense of those of patients. The Royal College of Nursing of the United Kingdom is such an organization. My concern is that not only has this model of labour organization been transferred to a field for which it is inappropriate, but its position has been institutionalized and confirmed by legislation which excludes the possibility of any other modus operandi. Let us look further at some of the implications of the industrial model of trade unionism within the NHS: first the use of sanctions. In profit-making industry the sanction of withdrawing labour is appropriate and effective because it hits the employer's pocket, and since the employer's goal is profit he loses out unless he accedes to the employee's demands. In the NHS the withdrawal of labour has no effect on the employer's pocket: indeed it might even save him money, as the junior doctors' strike did not so long ago, but it hurts the defenceless, the sick. There is no 'hierarchy' in patient care. Patients are harmed by the withdrawal of laundry services. In 1978 action by a British hospital porter closed an operating theatre and added 178 sufferers to the waiting list. And what of the position of the nurse when the services of other staff are withdrawn? Does she do the cleaning and the washing up? If she does not, she knows that patients will suffer. If she does, not only is she 'strike-breaking', a heinous crime in trade union eyes, but she does so at the expense of the time available for her proper nursing function. In patient care we are all inter-dependent. Consultation machinery Another implication of the industrial model of trade unionism is the machinery required to make it work. On the factory floor the withdrawal of one man
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from the production line to attend to his trade union duties does not greatly impair productivity. Indeed it may be in an employer's interest, as an acceptable price to pay for shop-floor 'cooperation', to continue to employ and pay a worker, the bulk of whose time will be spent not at his bench but on trade union activities. For, make no mistake, the time required is considerable: for joint consultation, representation of members, health and safety inspections, and so on. But what if the shop steward is a nurse, perhaps the sister in charge of a busy surgical ward; and the Joint Consultative Committee (JCC) meeting coincides with the operating theatre list; and the ward staffing is on the knife-edge of safe cover? Does she leave the ward to go to the meeting? She has the right to do so, enshrined in trade unionist legislation. If she goes, the patients will suffer, and so will her colleagues whose burden, already intolerable, is increased. If she does not go, the voice of professional nursing in what may be a crucial policy decision will either be lost completely or will be represented by a non-nurse who is there in her stead simply because his work-role happens to be one which is more easily 'spared'. Industrial relations Thirdly, let us look at industrial relations legislation, in particular the Employment Protection Act. Protection is certainly needed, inside as well as outside the NHS. But in the NHS it is not only the employee who needs protection. Patients need protection too. But within the industrial model the only interested parties are the employee and the employer. The model does not allow for the interests of patients. And so in disciplinary or dismissal procedures, particularly when they go to appeal, the key question is not 'Is this person safe to be caring for patients?' but 'Has this person had all his rights as an employee?' And as in most matters of law, procedure is everything. Appeals against dismissal have to be upheld purely because of breaches of procedure, and thereby a person may be sent back to direct patient care who is by any other criterion quite lansuitable. For nurse managers, correctness of disciplinary procedures has become more important than staff counselling and professional support. Educational needs are sacrificed to the risk of suits for constructive dismissal. Time and money which could be spent on other things is devoted to endless enquiries and appeals. While appeals are pending, and it can last for months, there is tension and suspicion and an atmosphere which is hardly conducive to good patient care. These are just three aspects of the industrial model: its goals, its trade union machinery and its legislation, which may work perfectly well in industry but do not work when applied to the NHS. So much for what I would scrap. What, then, would I preserve, foster, and develop?
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T H E N U R S E ' S C O N T R I B U T I O N T O P A T I E N T CARE Time limits m.e to picking just one, which, I beheve, is a precious resource that is at present under-developed and under-valued: the nurse's contribution to patient care. Nurses have an important contribution to make to health services as planners, managers and policy makers. But I want to concentrate particularly on the nurse's clinical role. I believe that the nursing model has a great deal to offer. My model of nursing is embodied in that definition by Virginia Henderson (1966): 'The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. The nursing model is based on the following two important principles. Firstly that nursing has a perspective on patient care which is different from and complementary to that of medicine, and valuable for its own sake. It must develop along its own lines, applying its own body of knowledge and its own skills, not merely taking on tasks relinquished by others. Secondly, that every professional nurse, whatever her field of work, whatever her specialty, must strive constantly for what Juanita Rule (1978) has called (translated from the Socratic 'arete') 'excellence in the craft'. These are the things, much more important than management structures and even more important than numbers of pairs of hands, which determine standards of care. I would like to pinpoint just two problems of this 'pursuit of excellence' in nursing: opportunities and incentives. I think nursing must be the only occupation in which, after a longish period of preparation leading to a statutory qualification, which is also (in order to protect the public) a licence to practice, the newly qualified practitioner is assumed to be competent in every specialty within the field and to have in her possession all the knowledge required for practice for the next 40 years. There is an urgent need for proper funding specifically allocated for nursing education, and particularly for post-basic education, just as happens for medical education in the UK. The need for study leave must be recognized in nurses' conditions of service just as it is for doctors, and taken account of in manpower planning and resource allocation. Without the proper educational opportunities nurses cannot develop the excellence in their craft which is essential for good standards of patient care. Nursing is also the only occupation I know where at the end of a long period of training and the award of the appropriate qualification, the qualified practitioner has to stop doing what she has been trained to do, in order to progress. Clinical nursing offers no career structure, no financial reward. The ambitious practitioner has reached her final grade (ward sister) within a year or two of her basic qualification, and her financial ceiling before she is 30.
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Clinical career development It seems to me quite reasonable to give increased financial reward for increased responsibility, provided that account is also taken of the relevant criteria such as experience and expertise. But managerial responsibility is not greater than clinical responsibility nor less than it; it is qualitatively different. Why should, say, a nursing officer, administratively responsible for a unit, feel threatened by the existence in that unit of a clinical practitioner, who is paid more by virtue of her different role, experience and expertise? Why cannot a senior nursing officer (clinical) work alongside and in equal partnership with a senior nursing officer (administration) and a senior nursing tutor. We do not need a proliferation of gradings or even a precise definition of the much misunderstood phrase 'clinical nurse consultant'. It can be done, and in some places it already has been done, for example, the Royal Marsden Hospital, where there is a commitment to the concept (Tiffany 1979). For years we have been saying that clinical practice was the essence of nursing. I would like to be shown how. The challenge is exciting, the potential rewards immense. We cannot unscramble those scrambled eggs. But with top quality ingredients, their individual flavours enhanced by the appropriate herbs and seasonings, skilfully blended and attractively served, scrambled eggs can be a dish fit for a king.
References HENDERSON V. (1966) The Nature of Nursing: a definition and its implications for practice, research and education. CoUier-Macmillan, New York. ILLICH I. (1975) Medical Nemesis: the expropriation of health. Calder & Boyars, Nev*r York. MCKEOWN T . (1965) Medicine in modem society. Allen & Unwin, London. RAYNER C . (1979) Reality and expectation of the British National Health Service consumer. _/oHr«fl/ of Advanced Nursing 4, i, 69-77. RULE J. (1978) The professional ethic in nursing Journal of Advanced Nursing 3, i, 3-8. TIFFANY R . (1979) Mobilizing nursing skills. JoHma/ of Advanced Nursing 4, i.
