Conflicts in the National Health Service

Keith Barnard, Kenneth Lee

• Publisher: Routledge
• Year: 2022
• eBook ISBN: 9781000573312
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Originally published in 1977, this book explored some of the major problems besetting the Health Service during the second half of the twentieth century. Now, as then, they offer both historical perspective on contemporary difficulties and invite debate about the future development of health services. The main themes are the medical care system and its organisational structures; the managers and the providers of the system, their tasks and responses; the resources available whether financial, human or material; and finally the consumers and their influence upon the overall direction of the system.

1 PROMISES, PATIENTS AND POLITICS: THE CONFLICTS OF THE NHS

Keith A. Barnard

I

This book is about problems. It is about problems which have surfaced, are surfacing, or are expected to surface. These problems have many causes, and indeed allow of several alternative explanations. But it is not unreasonable to see the roots of these problems in promises, patients and politics. Back in 1948, the public was led to believe that through the inauguration of a national health service, we could conquer at least one of Beveridge’s Five Giants—that of Disease. That promise remains a mirage, yet expectations rise with every promise of a new breakthrough in medical science to relieve distress and defer death. And then again in 1974, the Service was subjected to a massive organisational upheaval and its whole administration put into the melting pot with the promise that while reorganisation was not about patient care, it would indirectly ensure better quality care. Time has passed and the promise is perceived as unfulfilled—certainly by staff and indeed by the public, at least through their proxies, the Community Health Councils. Thus, the problems of the Service can be seen to be, in an important measure, the problems of unfulfilled promises.

To the staff, the problems are not just promises, or receding promises, of adequate resources to do a good job for the public they serve. Patients too are a cause of anxiety, concern or even anger. The world of grateful patients, angelic nurses and learned doctors has long been confined between the covers of romantic fiction. Indeed the no-longer grateful patients are often likely to want to be equal partners in the determination of services. In contrast, other patients may now expect general practitioners to make decisions and take responsibility where an earlier generation would have used common sense, self-help, and had an intelligently circumscribed idea of what the doctor could be asked to do. Families may now even expect hospitals to relieve them of their responsibilities for their dependent members, the old and the mentally disordered. To add to these pressures from some sections of the public, patients are increasingly acting collectively to bring further influence to bear through pressure groups at both national and local level—a pressure, moreover, which can no longer be discounted.

To the observer the problems of the NHS are often seen as the problems of politics. In the cosy world of a decade or more ago, it was possible to sound plausible in pleading to keep politics out of health or health out of politics. But politics have rudely broken in. As in other sectors of public life, improvement in everything cannot be achieved by tomorrow. With the possible and the desirable always running ahead of both the resources available and the intellectual and emotional time and energy needed to harness those resources to provide a service, so enter problems of choice, of objectives and priorities, and of strategies to attain the desired ends. In short, so enters politics. These are matters for society acting through government and other political institutions, not least the health authorities. But government is dependent on those who provide the services even though the constitutional formal responsibility is government’s.

So, equally, the politics of the organisation are as vital to those within the Service: how are they to order priorities within the organisation; how do they interpret government policies and exhortations; how do they respond to the pressures from the local community; how do they start to collaborate with other agencies providing caring services; and how do they respond to the ambitions and aspirations of their colleagues in seeking increased status and recognition as much as higher incomes? In summary: how are conflicts of interest and values acknowledged and handled on the local stage? Certainly, these political problems are emerging with greater intensity and the time seems past when these problems of the NHS could be claimed as soluble by the techniques of medical or economic or management science. Expert solutions always evade or conceal the underlying problem of politics—in a situation of choice, whose will prevails?

II

But before exploring these kinds of issues in the remainder of the book, and because so much is expected of and claimed for the NHS by both protagonists and antagonists alike, it might be worthwhile to look at the NHS in the simplest terms: how it is structured; what has influenced its development, and, to some extent, how it relates to the rest of society. More detailed discussion on particular matters will follow from later contributors.

In the first place, the NHS is essentially a system of medical care, with access to the system almost invariably initiated by self-referral to a general medical practitioner. Ideally, there is a continuing relationship between the individual and the general practitioner who thereby acquires a comprehensive understanding of the individual, his health status and needs. The practitioner is the decision-maker as to what further resources available under the NHS should be made available to the individual, e.g. by prescribing drugs or by referring him to hospital for a specialist consultation. In this latter case, the hospital consultant acquires responsibility for the individual’s medical care, but surrenders this back to the GP at the end of the particular episode of care and treatment.

This system of care functions in the context of an organisational structure. The structure of the NHS when it was set up in 1948 was essentially the culmination of an historical evolution of hospital provision, medical professional practice, and public administration, together with a number of compromises necessary to acquire the maximum political consensus that would enable the Service to be launched. The effect of the decisions made on structure was to create three administrative sectors providing, respectively, general practitioner services, hospital and specialist services, and, thirdly, a range of community and personal support services as diverse as home nursing and ambulances.

This tripartite structure was soon seen to have problems. Although the service was financed by public expenditure, mainly from general taxation, the administrative fragmentation made co-ordination of services and ‘rational’ planning very difficult. Pressure grew by the 1960s for some form of administrative unification to facilitate co-ordination and comprehensive planning better in order to ensure better quality patient care. Various proposals were subjected to public debate and eventually in 1973 Parliament passed the legislation authorising the re-organisation of the NHS.

As under the original NHS Act, 1946, the Secretary of State for Social Services was ultimately responsible for the NHS; through the Department of Health and Social Security (DHSS) he would issue policy guidelines to the Service and would make financial allocations to the 14 Regional Health Authorities (RHAs) who, in turn, would act similarly towards the 90 Area Health Authorities (AHAs), within their territory. For management purposes large Areas were divided into comprehensive Health Districts, resulting in the creation of about 200 such Districts in England and Wales. The boundaries of the Area Health Authorities were fixed to be coterminous with the new local authorities—principally the county councils (in the conurbations, with the metropolitan district councils and, in London, with groupings of boroughs). Although the AHAs were constitutionally quite separate from local government, they had an obligation to collaborate with their matching councils over matters of joint concern and, in particular, were expected to plan together those services, such as the care of the elderly, where their contributions were complementary. Two other features of the new structure were the provision of professional advisory committees at Regional and Area levels to enable the views of the medical and other health professions to be made known to the Authority before decisions were made, and at District level, a District Medical Committee, representing all medical practitioners, would be an important influence on the District management team.

At the same time, it was recognised that the consumer voice was also needed as an influence on the Area Authority and on District management. A Community Health Council was established in each District to act as a public watchdog, patients’ friend, and constructively critical commentator on the Service’s plans and performance. For the first time there was an attempt to create a consumer voice identifiably separate from management to match the voice of the professional providers of services which had always been heard.

The momentum for reorganisation of the NHS which built up from the mid-1960s coincided with certain trends that were to become influential in the NHS. First, there was a world-wide growth of interest in health planning and organisation reflected in the professional literature on medical care and in the expert publications of the World Health Organisation. In essence, the planning argument was that socioeconomic development could not be left to chance and that the health sector was an important element which needed to be integrated into overall social planning. A number of particular factors were identified, including the pressure on human and financial resources, the growing technological possibilities thrown up by medical science and by engineering, increased consumer expectations, and the general political pressure to provide health services that accorded with the perceived needs of the population. Against that background, a participative form of planning involving all the interested parties—consumers, professional providers, administrators and politicians—was seen as a way of generating realistic proposals for the future commanding widespread commitment to their successful implementation. In this sense, planning was seen as much as a broad-based political and social process as a set of technical and administrative procedures that could be remitted to a designated set of professional experts.

A second trend was the growing commitment of large organisations (initially in the private sector and later spreading to the public sector) to some form of corporate strategy and management. Studies have shown that many large organisations were influenced by a recurring set of factors: the complexity of the organisation in both its internal and external relationships; the very size of the enterprise; the sensitivity of the organisation and its business to technological change; and the importance of capital developments to the enterprise. By any of the conventional criteria, e.g. the size of its operating budget, its number of employees, its number of operational locations, or its number of agents, the NHS is a very large organisation and demonstrates in some significant measure the same kinds of influences that have led other large enterprises to adopt the corporate approach.

With all modern technologically-based organisations too much is at stake to be left to chance. There must be some attempt to minimise uncertainty, ‘to control the future’. The size factor makes it increasingly difficult to control the enterprise from the centre, from head office. A way must be found of identifying the key decisions whereby the centre can control the general direction and development of the whole organisation while delegating as much operational decisionmaking as possible to the subsidiary units who can act both in the light of centrally-determined general policy and in their awareness of local conditions and circumstances. A formal corporate planning and management system is seen as an effective means of achieving this. Each subsidiary agrees plans with headquarters, who then authorise the subsidiary’s expenditure and monitor the performance and issue the instructions for corrective action should this become necessary. Thus, broad policy and financial control remains with the centre who are also relieved of a good deal of detailed decision-making that for various reasons they are not fitted to discharge.

Given the apparent appropriateness of this model for the NHS, it is not surprising that once the structure of statutory authorities for the reorganised NHS was fixed, and the objective of integrating the services to provide better patient care was reaffirmed, attention was directed towards evolving a corporate planning system; designed to achieve that objective, and to enable the operational relationships between the various tiers in the structure (government, region, area, district) to be developed as free of friction as possible.

There are, however, a number of problems in applying the model to the NHS which need to be identified and which will no doubt influence the way the corporate approach in the NHS finally evolves. There is no simple product, or indeed range of products, the manufacture of which could be rationalised in the interests of efficiency. Nor do consumers of health services appear to behave with the same kind of rationality that they are assumed to display when making decisions about, say, household durables. Thirdly, the machinery for consultation and collaboration at the Area level with the consumers, the professional providers and the local authority may generate pressures on the AHA and their officers contrary to the guidance and, possibly, directives reaching the Area from government and the regional authority. Lastly, in emphasising planning, there is an assumption that one’s present decisionmaking is decisively influenced by a wish to see a desirable state of affairs being reached at a point in the future: the culture of the Health Service and the medical profession emphasises relieving present problems of pain and distress rather than working towards some future benefit: moreover, the motivation of the politicians who temporarily occupy the highest posts as Ministers heading up the government department (DHSS) responsible for the Service, lies in the need to demonstrate their impact quickly if they are to further their political careers. In fact, there is a direct conflict between long-term planning and the pressures of the political arena. These are potentially powerful factors militating against the sustained application of the corporate planning approach as outlined here to the development of the NHS.

However, a system has now been introduced (from April 1976) and is being applied throughout the Service. The particular mechanisms used to achieve the balance between essential central control and delegated decision-making are complicated and need not be spelt out here for the essential principle is a simple one. The Secretary of State, through his Department, DHSS, issues policy guidelines and makes financial allocations. These are filtered through regional and area authorities to the managers and the staff providing the services. In return, the providers make proposals for developing and (particularly important in times of financial restraint) rationalising the services in the light of guidelines and the funds made available to them, and in the light of their awareness of the local situation, and their consultations with all local interests. In short, the system is an attempt to reconcile conflicting pressures which are indeed common to all public sector organisations—the need to introduce efficient management to husband limited resources; and at the same time to recognise that the organisation is operating in a political context and that means must be found to give open expression to conflicts of interests and values in order that they can be reconciled or accommodated in policy and decision-making.

For a long time the medical care field has been spared these pressures. Medical activity with its connotation of life-saving interventions was universally held to be self-evidently desirable and deserving of increasing resources. As its technological possibilities expanded, so did public expectations and also the size of its financial and human resource budget. But gradually this view has come under pressure. A number of informed commentators have questioned the efficacy of medical interventions and have established that the dramatic improvements in health as measured by life expectancy and infant mortality (the classic indicators) occurred before the explosion in high-cost, high-technology, hospital-based medicine and that the dramatic growth of the medical care budget (measured in constant prices to take account of inflation) over the past twenty years has coincided with minimum improvements in life expectancy. Thus, there are growing doubts being expressed about the net benefit accruing from further investment in high-technology medicine; and growing advocacy that future investment should be directed to non-medical activities such as better housing, better social support and income maintenance for the socially disadvantaged, and generally improving public amenities and the physical environment. Parallel with this admittedly still fledgling assault on the medical establishment is another attack on the way the NHS has evolved: not only has high-technology medicine been favoured with resources at the expense of the ‘caring’ specialties of geriatrics and psychiatry, but gross geographical inequalities (measured on a population basis) have been perpetuated and any mitigating efforts so far have proved ineffective. Thus, the corporate planners and managers have to effect a reorientation both in geography and in the emphasis on service development. This exercise will be conducted in a climate of winners and losers where the losers can be expected to be very vociferous and not without political resources harnessed in an effort to minimise the impact of the planned changes.

So far the picture has been painted of the NHS emerging as another form of large-scale organisation or public corporation with its pressures and contradictions, its search for efficiency and its attempts to accommodate its internal and external political environment. Above all, conflicts and tensions will have emerged as increasing possibilities and expectations compete with limited financial and human resources; and as decisions to cut back on the increasing emphasis on high technology in order to favour the caring services are perceived as attacks on all hospital services, even those whose efficacy has been conclusively demonstrated.

III

Against that background sketch the course to be charted through the rest of the book can now be plotted. Because the NHS is a system of medical care, attention is first directed towards the medical profession, who have necessarily dominated the Service as their skills are crucial to its purpose. But the dominance of the medical profession and their high status in society at large may now be ebbing. For various reasons, their authority is being questioned and their own ranks, always in some senses divided, are now showing conflicts in a way that had not been expected until recently.

A consideration of the problems of the profession leads into the one essay which looks at a service provided to patients where the problems arise of what is rational and efficient, of how to reconcile apparently conflicting objectives, of what behaviour professionals have a right to expect of patients; and of what the implications are of taking patients’ wishes and behaviour into account. The service examined is the Accident and Emergency Department, but the problems of patient access and efficient service reflect the problems facing much of the NHS generally.

Taking account of patient behaviour in their utilisation of A and E Departments in turn calls for a broadly based review of the patient—practitioner relationship...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• Preface
• 1. Promises, Patients and Politics: The Conflicts of the NHS Keith A. Barnard
• 2. Medical Autonomy: Challenge and Response Mary Ann Elston
• 3. Access and Efficiency in Medical Care: A Consideration of Accident and Emergency Services Arthur Gunawardena and Kenneth Lee
• 4. Patients: Receivers or Participants? Malcolm L. Johnson
• 5. Power, Patients and Pluralism Chris J. Ham
• 6. Participation or Control? The Workers’ Involvement in Management Stuart J. Dimmock
• 7. Health Administration and the Jaundice of Reorganisation J. Crossley Sunderland
• 8. Making Reorganisation Work: Challenges and Dilemmas in the Development of Community Medicine David Towell
• 9. Planning, Uncertainty and Judgement: The Case of Population Andrew F. Long
• 10. Public Expenditure, Planning and Local Democracy Kenneth Lee
• Bibliography
• Index