D O C U M E N T IS T H E P R O P E R T Y O F H E R B R I T A N N I C M A J E S T Y ' S
CP(72)79
GOVERNMENT
COPY NO
65
12 July 1972
CABINET
NATIONAL H E A L T H SERVICE REORGANISATION
M e m o r a n d u m b y t h e S e c r e t a r y of S t a t e f o r Social Services 1.
In M a y 1971 I i s s u e d a C o n s u l t a t i v e D o c u m e n t on N a t i o n a l H e a l t h
S e r v i c e (NHS) R e o r g a n i s a t i o n i n E n g l a n d .
This followed d i s c u s s i o n in
the S o c i a l S e r v i c e s Cornrnittee and the C a b i n e t (CM(71) 19th and 24th
Conclusions).
2.
I n t h e l i g h t of c o m m e n t s o n a n d d i s c u s s i o n s a b o u t t h e
Consultative Document, I a m now ready for ­
a.
p u b l i c a t i o n of a W h i t e P a p e r a n n o u n c i n g t h e G o v e r n m e n t ' s
d e c i s i o n s on NHS R e o r g a n i s a t i o n ; and
b.
t h e p r e p a r a t i o n of t h e n e c e s s a r y l e g i s l a t i o n .
WHITE P A P E R
3.
A draft i s attached for approval.
In g e n e r a l , i t r e a f f i r m s t h e
a d m i n i s t r a t i v e pattern d e s c r i b e d in the Consultative Document.
A few
points on the draft White P a p e r w h i c h the Cabinet w i l l w i s h to h a v e d r a w n
t o i t s attention a r e s e t out in the A n n e x t o t h i s m e m o r a n d u m .
LEGISLATION
4.
T h e r e o r g a n i s a t i o n of t h e N H S m u s t t a k e e f f e c t a t t h e s a m e t i m e a s
t h a t of l o c a l g o v e r n m e n t , i . e 1 A p r i l 1 9 7 4 .
To give time for preparatory
w o r k that cannot be s t a r t e d until the A c t i s on the statute book, i t m u s t be
our a i m to s e c u r e R o y a l A s s e n t by E a s t e r 1973.
This i n turn m e a n s that
t h e B i l l s h o u l d b e i n t r o d u c e d a t t h e s t a r t of t h e 1 9 7 2 - 7 3 S e s s i o n .
The
intention i s to introduce it in the L o r d s .
The main Instructions are with
Parliamentary Counsel.
1
FINANCIAL AND MANPOWER IMPLICATIONS
5.
O n e of t h e c h i e f a i m s of t h e a d m i n i s t r a t i v e r e o r g a n i s a t i o n i s t o
s e c u r e b e t t e r value for m o n e y .
In t h e l o n g t e r m , t h e r e f o r e , i t w i l l n o t ,
of i t s e l f , g i v e r i s e t o a d d i t i o n a l c o s t .
In the s h o r t t e r m , e x t r a
administrative c o s t s (attributable to retraining p r o g r a m m e s and other
t e m p o r a r y f a c t o r s ) totalling about £ 1 3 m i l l i o n w i l l be i n c u r r e d o v e r the
four y e a r s 1972-73 to 1 9 7 5 - 7 6 .
This expenditure has already been
p r o v i d e d for in the White P a p e r "Public E x p e n d i t u r e to 1 9 7 5 - 7 6 "
(Cmnd 4829).
6.
T h e r e o r g a n i s a t i o n w i l l s i m i l a r l y h e l p t o s e c u r e a b e t t e r u s e of
m a n p o w e r , a n d i s n o t e x p e c t e d , of i t s e l f , t o i n c r e a s e s t a f f n u m b e r s ,
e x c e p t to the v e r y s m a l l extent n e e d e d to cope with the e x t r a
a d m i n i s t r a t i v e w o r k that h a s to b e done d u r i n g the t r a n s i t i o n a l p e r i o d .
HOME AND SOCIAL AFFAIRS COMMITTEE
7.
The draft White P a p e r h a s b e e n c o n s i d e r e d by the H o m e and
S o c i a l Affairs C o m m i t t e e , who a g r e e d that it should be published.
The
t e x t now c i r c u l a t e d i s that a p p r o v e d by the C o m m i t t e e , e x c e p t that s o m e
d r a f t i n g a m e n d m e n t s h a v e b e e n m a d e t o S e c t i o n XIII ( " M e d i c a l a n d D e n t a l
Teaching") to m e e t suggestions m a d e b y the Lord Chancellor.
These
a m e n d m e n t s a r e d e s i g n e d t o i m p r o v e t h e p r e s e n t a t i o n of t h e p r o p o s a l s
r e l a t i n g to teaching h o s p i t a l s but d o not affect t h e i r s u b s t a n c e .
D A T E O F P U B LICA TI O N
8.
T h e C o m m i t t e e a s k e d m e to c o n s u l t the L o r d P r e s i d e n t of the
C o u n c i l a n d t h e S e c r e t a r i e s of S t a t e f o r S c o t l a n d a n d f o r W a l e s a b o u t the
t i m i n g of p u b l i c a t i o n .
I n t h e l i g h t of t h e s e c o n s u l t a t i o n s I p r o p o s e t h a t
w e should a i m for p u b l i c a t i o n on T u e s d a y 1 A u g u s t , s u b j e c t t o final
c o n f i r m a t i o n w i t h t h e L o r d P r e s i d e n t of t h e C o u n c i l n e a r e r t h e t i m e .
CONCLUSION
1
9.
I n o w s e e k t h e C a b i n e t s a g r e e m e n t t o p u b l i c a t i o n of t h e W h i t e
Paper.
K J
D e p a r t m e n t of H e a l t h a n d S o c i a l S e c u r i t y
12 July 1972
2
Annex Management Structure (Section XIV and Appendix III) 1.
The management
structure at regional, area, and district levels and in the individual institutions, cannot be settled until a detailed study, which is being undertaken with the help of management consultants, has been completed and there have been consultations with interested organisations on its outcome.
The study should be completed at the end of this month and the consultations will take place in the autumn. An outline of some ideas developed in the study is included in Appendix III. Local Authority Representation on Area Health Authorities
(paragraph 9 8 )
2.
An Area Health Authority will normally have a membership of about 15.
The Consultative Document proposed that "some" of its members should be appointed by the corresponding local authority (ie the non-metropolitan county council, or, in the conurbations, the metropolitan district or London Borough Council).
The primary purpose of such membership is not that the area health authorities may be aware of the views of the public - this will be achieved through the representatives of the district councils and voluntary organisations who will sit on the community health councils ­
but that the area health authority should include some members active in and knowledgeable about the management of closely related local government services. 3.
The draft White Paper proposes that the number of local authority members on each AHA should be four.
This will provide room for members with knowledge of the personal social services, education and other relevant services and of the local authority^ general policies.
may say that four is not enough.
Local government interests
But an increase in this number would overweight the local authority s influence on the 1
3
area health authority'3 financial and other decisions;
it
would destroy a proper balance in the area health authority's composition (unless the total number of members were increased to an undesirable extent);
and it would also be strongly resisted by many working in, and associated with, the NHS who are hostile to local authority party politics exercising too great an influence over its operation and development. (paragraph 91) Payment of Chairmen
h.
It is proposed to take power to remunerate the chairmen of the regional and area health authorities - and only the chairmen,
not the other members.
Payment - on a part-time basis - is thought to be justified for the chairmen (and for them alone), because their responsibilities will be heavy and they may have to forego other work;
they will all be chosen and appointed by the Secretary of State, whereas this will not be so in the case of members of the area health authorities other than the chairmen. Teaching Hospitals
5.
(Section XIII) Special arrangements are proposed for the incorporation of the teaching hospitals in the integrated regional and area management structure.
These vary in detail from those set out in the Consultative Document and are the result of long negotiations, which are continuing, with the Teaching Hospitals Association. School health
6.
(paragraphs 3t 20-21) The Consultative Document left open the future arrangements for the school health service.
These have been considered by a sub-committee of the Working Party on Collaboration between the National Health Service and Local Government.
The Secretary of State for Education and Science and I are agreed, in the light of this committee's work, that the future development of health services for schoolchildren and their co-ordination with other i branches of the NHS can best be achieved by responsibility for the school medical and dental service being with the NHS but with the education service retaining its responsibilities for the special education of handicapped children. Attached
Draft
of W h i t e
Paper
CONFIDENTIAL
DRAFT WHITE PAPER NATIONAL HEALTH SERVICE REORGANISATION; ENGLAND CONTENTS Foreword by the Secretary of State for Social Services Paragraphs Section The reorganised Service; the main features I
Unification
II
The consultative document 12-16 III
Services within and outside the NHS 17-26 IV
NHS authorities and their functions 27-40 V
Area health authorities - functions 41-52 VI
Area health authorities - collaboration with local government 53-65 VTI
Area health authorities - family practitioner 1-11 66-73 services VIII
Regional health authorities 74-85 IX
Central Department 86-89 X
Membership of authorities 90-99 XI
Professional advisory machinery 100-104 XII
Community health councils 105-112 XIII
Medical and dental teaching 113-126 XIV
A sound management structure 127-144 XV
The staff of the Service 145-155 XVI
Financial administration 156-161 The reorganised Service; other issues XVII
Voluntary services 162-165 XVIII
The private sector 166-169 XIX
Endowments
XX
Handling complaints XXI
Special hospitals XXII
Arrangements for London 182-187 XXIII
Running the Service until 1974 188-191 XXIV
Preparing for 1974 192-201 XXV
Conclusion
170-174 175-180 181 v
202-208 APPENDICES I
List and map of regions and areas II
Secretary of State for Social Services' Parliamentary announcement on Health Service Commissioner III
Management Study CONFIDENTIAL
foreword by the Secretary of State for Social Services For two years I have been responsible for the National Health Service ­
and for the personal social services. Throughout this time my respect for the achievements of the National Health Service has steadily grown. Whatever its defects we would be utterly wron?r to take for granted the massive performance of this remarkable network of services and the ease of mind that it has brought to all the people of this country.
I am sure that they feel a deep sense of gratitude to all those involved: to the members of the governing authorities; to the men and women who make their career in the Service whether in direct contact with patients or in supporting services; and to the voluntary workers. But at the same time I have come to recognise, as many others have, that while this good work will continue, nothing like its full potential can be realised without changes in the administrative organisation of the Service. It is about administration, not about treatment Hence this White Paper.
and care. I make no apology for that. Administration is not of course an
end in itself. But both the patients and those who provide treatment and care will gain if the administration embodies a clear duty to improve the Service and the facilities for doing so. I
Let me illustrate this. Everyone is aware of gaps in our health services. Even for acute illness, where we provide at lea^t as good a service for our whole population as any country in the world, there are some respects in which we achieve less than we could.
On the non-acute side the services for the elderly, for the disabled, and for the mentally ill and the mentally handicapped have failed to attract the attention and indeed the resources which thoy need - and all the more credit to the staff who have toiled so tirelessly for their patients despite the difficulties. It is well unaerstood now, moreover, that the domiciliary and community services are under-developed - that there is a need for far more home helps, home nurses, hostels and day centres and other services that support people outside hospital. Often what there is could achieve more if it was better co-ordinated with other services in and out of hospital. It is well understood too that there must be more emphasis on prevention - or at the least on early detection and treatment. For the imbalances and the gaps Governments must take their share of the responsibility.
Resources were and still are stretched . The acute services had a legitimate priority. But the shortcomings were not rational. They did not result from a calculation as to the best way to deploy scarce resources. They just happened. Why did they just happen? Because it has never been the responsibility - nor has it been within the power - of any single named authority to provide for the population of a given area of a comprehensible size the best the health service that/money and skills available can provide. There has been no identified authority whose task it has been, in co-operation with those responsible for complementary services, to balance needs and priorities rationally and to plan and provide the right combination of services. It is to enable just such an authority to operate in each area, with the best professional advice, that the Government proposes to reorganise the administration of the National Health Service as explained in this White Paper. The National health Service is one of the largest civilian organisations in the world.
Its staff is growing rapidly.
It contains an ever-growing multitude of stills that depend on and interact with each other. It serves an ever-growing range of health needs with ever more complex treatments and techniques. And though the Government has made substantial additions 2
to un expenditure programme which was already planned to grow at an above­
average rate, there is never enough money - and never likely to be - for everything that ideally requires to be done. Nor. despite the great increases since 1948, are there ever enough skilled men and women. Real needs must therefore be identified, and decisions must be taken and periodically reviewed, as. to the order of priorities among them. Plans must be worked out to meet these needs and management and drive must be continually applied to put the plans into action, assess their effectiveness and modify them as needs change or as ways are found to make the plans more effective. Effective for what?
These are not plans for individual care but for the support of the professions that provide the whole range of services to the public. They must therefore be effective in providing what patients need: primarily, treatment and care in hospital; support at home; diagnosis and treatment in surgery, health centre or out-patient clinic; or day care. The health services depend crucially on the humane planning and provision of the personal social services, and therefore on effective and under­
standing collaboration with local government. No doubt arguments will continue about the theoretical advantages of making both health ana social services the responsibility of a single agency. But the formidable practical difficulties, which have been fully argued elsewhere, rule this out as a realistic solution, and require us to concentrate instead on ensuring that the two parallel authorities - one local, one health - with their separate statutory responsibilities shall work together in partnership for the health and social care of the population. This White Paper demonstrates the Government's concern to see that arrangements are evolved under which a more coherent and smoothly interlocking range of services will develop for all the needs of the population. 3
The doctor and other professional workers will gain too. The organisational chun :et; will not affect the professional relationship between individual patients and individual professional workers on which the complex of health services is so largely built. The professional workers will retain their clinical freedom - governed as it is by the bounds of professional knowledge and ethics and by the resources that are available - to do as they think best for their patients. This freedom is cherished by the professions and accepted by the Government. It is a safeguard for patients today and an insurance for future improvements. But the organisational changes will also bring positive gains to the professional worker. He - or she - will have the opportunity of organising his or her own work better and of playing a much greater part than hitherto in the management decisions that are taken in each area. At the same time the more systematic and comprehensive analysis of needs and priorities that will lie behind the planning and operations of each area will help professional workers to ensure that their skills bring the greatest possible benefit to their patients. Vheue arc Lhe reasons for issuing a White Paper, and for promoting legislation, about the administration of the National Health Service. Administrative reorganisation within a unified health service that is closely linked with parallel local government services will provide a sure foundation for improving the service to the public. 4 The reorganised Service: the main features I
1.
UMFI&WPENTIAL The National Health Service should be a. single service.
Its separate parts are intended to complement one another, and not to
function as self-sufficient entities. In practice, however, the fragmented
administration we now have throws barriers in the way of efforts to
organise a proper balance of services - hospital and community - throughout
the country. The administrative unification of these services will make
a firmer reality of the concept of a single service.
2. Unification of NHS administration forms part of the Government*s wider programme of administrative reform.
In the autumn of 1970, the Central Government machine was reorganised.
The emphasis was on grouping of functions in departments with a wide span, so as to facilitate unified policies over inter-related areas. 3.
The Government also announced in the autumn of 1970 its decision to unify the NHS - already proposed by the previous Government. This unfication will draw together the administration of the family practitioner services, the community health services, and the hospitals. Unification will also bring the administration of the school health service within the NHS. 4.
Far-reaching changes are also proposed in local government, under the Local Government Bill now before Parliament. These will create new areas ishich, without losing their local character, will be large enough to enable authorities to plan and provide good quality services with the necessary numbers of trained and specialised staffs. 5.
The personal social services have already been brought together under the Local Authority Social Services Act 1970 - passed under the previous Government with full support from the then Opposition. Under this Act, the personal social services which were previously divided between the children's, welfare and health committees of the local authorities have been gathered together under a single committee. This arrangement will continue when the Local Government Bill comes into operation. 6
This local unification of the personal social services has been
matched centrally by concentrating responsibility, p r e v i o u s l y shared
with the Home Office, in the DHSS, which is a l s o r e s p o n s i b l e f o r
a d m i n i s t e r i n g c a s h benefits, i n c l u d i n g t h o s e p a i d t o t h e s i c k and
disabled.
7,
All this has not been done just to get a d m i n i s t r a t i v e tidiness.
Unification offers solid advantages to the individual and the family,
because their needs for health and social services are not divided into (
separate compartments. A single family, or an individual, may in a short
space of time, or even at one and the same time, need many types of health
and social care, and these needs should be met in a co-ordinated way.
Otherwise they will get an u n s a t i s f a c t o r y s e r v i c e o r e v e n no s e r v i c e
at a l l .
8.
There are very strong arguments for b r i n g i n g health and s o c i a l services
under a s i n g l e a d m i n i s t r a t i o n .
T h i s c o u l d be a c c o m p l i s h e d by p u t t i n g t h e NHS
within local government. But, for reasons accepted and fully explained
by both the previous and the present Government, t h a t is not attainable,
at least in the foreseeable future. What therefore needs to be done is
to make sure that the two parallel structures - the health service and
the local authorities - work together as a joint enterprise in both the
planning and the operation of services of common concern. More is said
about this later.
9.
Narrowing our view now to the NHS, the Government 's plans for u n i f i c a ­
t i o n of i t s administration offer the prospect o f r e a l b e n e f i t s , not only t o
the i n d i v i d u a l and t h e f a m i l y , b u t t o t h e p u b l i c i n g e n e r a l .
They p r o v i d e
for a single administering body locally, which will draw its funds from
one source, and will take a wide, u n b i a s e d and c o n s t r u c t i v e v i e w o f t h e
p r i o r i t i e s a c r o s s t h e whole range o f n e e d s s e r v e d by t h e g e n e r a l
p r a c t i t i o n e r and o t h e r community h e a l t h s e r v i c e s and
by t h e h o s p i t a l s .
NHS u n i f i c a t i o n .
T h i s i s t h e hub o f t h e GSovernment^s p r o p o s a l s f o r
"Unbiased" i s i m p o r t a n t .
There w i l l be no q u e s t i o n
o f t h e community h e a l t h s e r v i c e s s w a l l o w i n g up t h e h o s p i t a l s , o r , a
more common s u s p i c i o n , v i c e v e r s a
"Constructive" i s a l s o important
because t h e aim w i l l be t o k e e p t h e n e e d s o f t h e l o c a l p e o p l e
constantly
under r e v i e w , and t o improve and a d j u s t s e r v i c e s i n o r d e r t o p r o v i d e
the best p r a c t i c a b l e h e a l t h f a c i l i t i e s f o r a l l .
10.
The NHS a d m i n i s t e r i n g a u t h o r i t i e s w i l l be e n t i r e l y new b o d i e s
c o v e r i n g t h e whole f i e l d o f h e a l t h c a r e , d o m i c i l i a r y and i n s t i t u t i o n a l .
T h e i r membership and a d m i n i s t r a t i v e s t r u c t u r e w i l l be such t h a t t h e y a r e
h o t dominated by p e o p l e whose main i n t e r e s t s l i e i n one or o t h e r s e r v i c e .
They w i l l have capable members, and w i l l a p p o i n t s k i l l e d and a p p r o p r i a t e l y
trained s t a f f .
They w i l l be armed w i t h t h e most e x p e r t a d v i c e .
They w i l l
have e f f e c t i v e c h a n n e l s f o r t h e e x p r e s s i o n o f l o c a l p u b l i c o p i n i o n .
These p o i n t s a r e d e v e l o p e d i n l a t e r S e c t i o n s o f t h i s White P a p e r .
11*
These f e a t u r e s w i l l e n a b l e t h e a u t h o r i t i e s , w i t h i n t h e g e n e r a l
framework o f n a t i o n a l p o l i c y , t o p r o v i d e a s e n s i t i v e ,
c o n s t a n t l y improving
s e r v i c e i n t h e i r a r e a s , g i v i n g proper a t t e n t i o n t o care as w e l l as cure,
and a much n e e d e d impetus t o be g i v e n t o t h e p r e v e n t i o n o f i l l n e s s and
t h e promotion o f h e a l t h .
8
II
12.
THE CONSULTATIVE DOCUMENT
The p r e v i o u s Government had g i v e n much t h o u g h t t o
unification,
and had i s s u e d two Green Papers f o r p u b l i c
discussion.
The p r e s e n t Government was n o t however s a t i s f i e d t h a t t h e p r o p o s a l s
i n t h e , G r e e n P a p e r s would c r e a t e t h e a d m i n i s t r a t i v e
needed f o r a f u l l y e f f e c t i v e NHS i n England.
structure
A c o n s u l t a t i v e document
was t h e r e f o r e i s s u e d i n May 1 9 7 1 .
13.
T h i s p r o v i d e d f o r a c l e a r d e f i n i t i o n and a l l o c a t i o n o f
r e s p o n s i b i l i t i e s , w i t h maximum d e l e g a t i o n downwards, matched by
a c c o u n t a b i l i t y upwards.
There would be r e g i o n a l a u t h o r i t i e s between
t h e C e n t r a l Department and t h e a r e a a u t h o r i t i e s .
set
The aim would be t o
o b j e c t i v e s and s t a n d a r d s and t o measure performance a g a i n s t them.
A sound management s t r u c t u r e would be c r e a t e d a t a l l l e v e l s .
would be k e p t s m a l l and a b i l i t y ,
Authorities
d r i v e and judgment would be t h e main
c r i t e r i a f o r t h e s e l e c t i o n o f members.
The v i e w s o f t h e p u b l i c would
be v o i c e d , n o t by way of membership o f t h e h e a l t h a u t h o r i t i e s but more
directly,
through r e p r e s e n t a t i v e community h e a l t h c o u n c i l s i n e a c h
locality,
to a d v i s e t h e a r e a a u t h o r i t y and keep i t i n ^ l o s e touch w i t h
local
14.
opinion.
The c o n s u l t a t i v e document a l s o promised t h e e a r l y s e t t i n g up
o f two s p e c i a l s t u d i e s .
The f i r s t was an e x p e r t s t u d y o f t h e
management a r r a n g e m e n t s , a t b o t h member and o f f i c e r l e v e l ,
detailed
in the regions,
a t t h e a r e a h e a d q u a r t e r s , i n t h e d i s t r i c t s w i t h i n t h e a r e a s and i n t h e
i n d i v i d u a l h o s p i t a l s and o t h e r i n s t i t u t i o n s .
The s e c o n d s t u d y was o f t h e
a r r a n g e m e n t s n e e d e d t o s e c u r e c l o s e c o l l a b o r a t i o n between t h e a r e a h e a l t h
a u t h o r i t i e s and the l o c a l a u t h o r i t i e s ; a working p a r t y , r e p r e s e n t a t i v e
t h e i n t e r e s t s c o n c e r n e d , was t o undertake t h i s s t u d y .
were s t a r t e d i n t h e summer of 1 9 7 1 .
CONFIDENTIAL
Q
Both s t u d i e s
of
r 15.
There were a l s o t o be c o n s u l t a t i o n s w i t h t h e o r g a n i s a t i o n s
concerned about t h e s h a p i n g o f the g e n e r a l arrangements t o meet t h e
s p e c i a l c o n d i t i o n s i n G r e a t e r London.
These c o n s u l t a t i o n s , t o o , began
i n t h e summer o f 1971*
16.
Comments on t h e c o n s u l t a t i v e document were r e c e i v e d from
n e a r l y 600
o r g a n i s a t i o n s and i n d i v i d u a l s , and d i s c u s s i o n s were
h e l d w i t h a number o f t h e p r i n c i p a l b o d i e s c o n c e r n e d .
I n the l i g h t
o f t h e s e , t h e Government has reached f i r m d e c i s i o n s on t h e f u t u r e
a d m i n i s t r a t i o n o f t h e NHS.
Sections of t h i s Paper.
These d e c i s i o n s are s e t out i n l a t e r
L e g i s l a t i o n i s b e i n g prepared and w i l l be
i n t r o d u c e d i n t i m e f o r t h e r e o r g a n i s e d NHS t o come i n t o o p e r a t i o n on
t h e same d a t e a s t h e r e o r g a n i s a t i o n o f l o c a l government i e 1 A p r i l 1 9 7 4 .
III
SERVICES WITHIN AND OUTSIDE THE NHS
National Health Service
17*
The s e r v i c e s t h a t w i l l be brought t o g e t h e r under u n i f i e d NHS
administration are t h e s e :
t h e h o s p i t a l and s p e c i a l i s t s e r v i c e s now a d m i n i s t e r e d by
t h e R e g i o n a l H o s p i t a l B o a r d s , H o s p i t a l Management Committees
and Boards o f Governors;
t h e f a m i l y p r a c t i t i o n e r s e r v i c e s now a d m i n i s t e r e d by t h e Executive Councils; t h e p e r s o n a l h e a l t h s e r v i c e s now a d m i n i s t e r e d by t h e l o c a l
a u t h o r i t i e s through t h e i r h e a l t h c o m m i t t e e s ; ( s e e t h e n e x t paragraph)
and t h e s c h o o l h e a l t h
18.
service.
The p e r s o n a l h e a l t h s e r v i c e s a r e t h o s e which now s t a n d
r e f e r r e d t o t h e l o c a l a u t h o r i t y ' s h e a l t h committee under t h e NHS A c t s and
t h e Local A u t h o r i t y S o c i a l S e r v i c e s A c t , 1 9 7 0 .
They i n c l u d e
ambulance s e r v i c e s ; e p i d e m i o l o g i c a l work, i n c l u d i n g g e n e r a l s u r v e i l l a n c e
of t h e h e a l t h o f t h e community; family planning; health centres; health v i s i t i n g ; home n u r s i n g and m i d w i f e r y ; m a t e r n i t y and c h i l d h e a l t h c a r e ; m e d i c a l , n u r s i n g and s u p p l e m e n t a r y arrangements f o r t h e p r e v e n t i o n o f i l l n e s s , c a r e and a f t e r c a r e ;
v a c c i n a t i o n and i m m u n i s a t i o n . and
19.
The registration of nursing hoses will also become the responsibility
of the NHS.
School Health
20.
Those providing health services for schoolchildren will need to work
closely with the hospital service and personal health services for families
and children and with the education service.
Local education authorities' present responsibilities for school medical and
dental services will be transferred to the NHS. Local education authorities
will remain responsible for the ascertainment and education of children who
through handicap or disability need special education. The NHS will make
available to local education authorities the advice and the medical, dental,
nursing and allied resources which they need to discharge these functions,
and will give them similar help in such fields as health education and
school hygiene.
There will be arrangements for joint planning and
co-ordination of the two services.
21 *
With the fusion of the organisation and management of all the
present dental services within the new health authorities, hospital dentists,
general dental practitioners and dentists providing services for schoolchildren,
children below school age, and expectant and nursing mothers will be able to
work together more closely.
Child guidance 2 2 .
The child guidance service is made up of three distinct elements.
They are child psychiatry (which may in future increasingly be based in
general hospitals); social work (which will have its main'base in local
/
authority social servicesdepartments); and educational psychology, which
falls to local education authorities. The present pattern of organisation,
with work centred in many areas in a clinic in local education authority
premises, is likely
on present trends to give way gradually to looser and more
flexible arrangements. What is essential is that the three services should
continue to work in close partnership to meet the needs of children with
e m o t i o n a l , l e a r n i n g or b e h a v i o u r a l p r o b l e m s .
P a r t n e r s h i p i s needed i n e n s u r i n g
c o - o r d i n a t i o n o f t h e o b s e r v a t i o n , a s s e s s m e n t and t r e a t m e n t a c t i v i t i e s o f t h e
h e a l t h a u t h o r i t i e s , t h e e d u c a t i o n s e r v i c e and t h e l o c a l a u t h o r i t y
social
services for ohildren in care.
Health education
23*
As p a r t o f t h e i r r e s p o n s i b i l i t y f o r t h e p r e v e n t i o n o f i l l n e s s ,
the
h e a l t h a u t h o r i t i e s w i l l have comprehensive h e a l t h e d u c a t i o n p o w e r s . But
b e c a u s e t h e y a r e r e s p o n s i b l e f o r e n v i r o n m e n t a l h e a l t h s e r v i c e s such a s
food s a f e t y and h y g i e n e , l o c a l a u t h o r i t i e s w i l l have complementary powers;
l o c a l education a u t h o r i t i e s w i l l retain t h e i r r e s p o n s i b i l i t y for health
education within the school curriculum.
The H e a l t h E d u o a t i o n
Counoil w i l l c o n t i n u e t o work w i t h t h e v a r i o u s b o d i e s c o n c e r n e d w i t h h e a l t h
e d u c a t i o n , and t o p r o v i d e a n a t i o n a l f o c u s and c e n t r e o f a c t i v i t y .
Personal s o c i a l s e r v i c e s
24.
The p e r s o n a l s o c i a l s e r v i c e s w i l l c o n t i n u e t o be p r o v i d e d by t h e
l o c a l a u t h o r i t i e s - t h e c o u n t i e s ( o t h e r than the m e t r o p o l i t a n c o u n t i e s ) ,
t h e m e t r o p o l i t a n d i s t r i c t s and t h e London Boroughs - through t h e i r
s e r v i c e s committees.
social
The f u t u r e o f h o s p i t a l s o c i a l work i s under
review.
Environmental h e a l t h
25*
Environmental h e a l t h
o f l o c a l government.
w i l l a l s o c o n t i n u e t o be a f u n c t i o n
T h i s term i n c l u d e s measures f o r p r e v e n t i n g t h e s p r e a d
of communicable d i s e a s e ( o t h e r than r o u t i n e i m m u n i s a t i o n , some e p i d e m i o l o g i c a l
i n v e s t i g a t i o n and t r e a t m e n t ) ;
powers r e l a t i n g t o food s a f e t y and h y g i e n e ,
p o r t h e a l t h , and t h e d i s e a s e s o f a n i m a l s i n s o f a r a s t h e y a f f e c t human
h e a l t h ; t h e p u b l i c h e a l t h a s p e c t s of e n v i r o n m e n t a l s e r v i c e s ; and t h e
of r e q u i r e m e n t s about e n v i r o n m e n t a l c o n d i t i o n s a t work p l a c e s .
These
e n v i r o n m e n t a l h y g i e n e r e s p o n s i b i l i t i e s w i l l be v e s t e d i n "the d i s t r i c t
authorities.
enforcement
local
The l o c a l a u t h o r i t i e s w i l l be encouraged t o s e e k t h e a d v i c e , and
i n d e e d t h e s e r v i c e s , o f m e d i c a l s t a f f employed by t h e h e a l t h a u t h o r i t i e s ,
though s t a t u t o r y r e s p o n s i b i l i t y w i l l r e s t on t h e l o c a l a u t h o r i t i e s , n o t t h e
health authorities.
Occupational h e a l t h
26.
The h e a l t h a u t h o r i t i e s w i l l be concerned w i t h p r e v e n t i v e
h e a l t h measures of many k i n d s and w i l l p r o v i d e t r e a t m e n t and c a r e f o r
people who s u f f e r i n j u r y o r i l l h e a l t h however c a u s e d .
However,
r e s p o n s i b i l i t y f o r t h e h e a l t h o f p e r s o n s i n r e l a t i o n t o t h e i r employment
l i e s w i t h t h e Department o f Employment.
In matters a f f e c t i n g the h e a l t h
and s a f e t y of employed p e r s o n s t h e r e must always be c l o s e working
between t h o s e r e s p o n s i b l e f o r h e a l t h and t h e environment both i n s i d e
and o u t s i d e t h e w o r k p l a c e .
I t i s i n t e n d e d t h a t t h e r e s h o u l d be v e r y
c l o s e c o - o p e r a t i o n between t h e NHS and t h e Employment M e d i c a l A d v i s o r y
S e r v i c e i n r e l a t i o n t o b o t h p o l i c y f o r m u l a t i o n and day t o day o p e r a t i o n s .
In a d d i t i o n arrangements a r e b e i n g made f o r EMAS t o u s e NHS l a b o r a t o r i e s
and o t h e r i n v e s t i g a t o r y
facilities.
IV NHS AUTHORITIES AND THEIR FUNCTIONS 27.
A national service calls for a national strategy, with national objectives, standards and priorities. It is, however, equally important to encourage variety and flexibility in working out the strategy over the country, tfithin the national framework, therefore, administration will be delegated to local bodies, who will set out their own objectives and be responsible for achieving them. Regional and area levels of management 28.
The Government has decided that effective organisation of the health services in England requires two levels - regional and area - in addition to the central department. At each of these levels there will be a unified administra­
tion covering the whole span of the NHS. The old administrative divisions between community and hospital services will completely disappear. Since each area health authority will serve the same population within the same boundaries as its matching local authority, the purpose will be that formal divisions between the health, the education and the personal social services will be bridged by the arrangements for collaboration. There will in effect be parellel organisations with links between them. 29*
There is a difference between the local authority and its matching health authority. Where statutory responsibility for the administration of a local service is placed on independent local authorities, the Ministers responsibilities being correspondingly limited, it is right that the local authorities should deal directly with the central Department. The personal social services, where the Department of Health and Social S e c u r i t y has c e n t r a l
30.
responsibility,
are an example of t h i s .
But the M S i s i n a d i f f e r e n t p o s i t i o n .
P a r l i a m e n t has p l a c e d
f u l l s t a t u t o r y r e s p o n s i b i l i t y f o r t h e s e r v i c e on t h e S e c r e t a r y of S t a t e
and h o l d s him a c c o u n t a b l e f o r t h e money spent on i t - n e a r l y a l l
which comes from c e n t r a l s o u r c e s .
of
Moreover, a g r e a t d e a l o f p l a n n i n g
and a l l o c a t i o n o f r e s o u r c e s must t a k e p l a c e on a w i d e r - t h a n - a r e a b a s i s :
f o r example, t h e s e r v i c e s l i n k e d w i t h U n i v e r s i t y m e d i c a l s c h o o l s and
t h o s e b a s e d on r e g i o n a l c e n t r e s .
31.
T h i s means t h a t the S e c r e t a r y o f S t a t e must s a t i s f y
t h a t t h e s e r v i c e i n England i s b e i n g e f f i c i e n t l y r u n .
himself
I n S c o t l a n d and i n W a l e s ,
w i t h t h e i r r e l a t i v e l y s m a l l p o p u l a t i o n s , i t w i l l be p r a c t i c a b l e t o do
t h i s by means o f a r e a h e a l t h a u t h o r i t i e s i n d i r e c t r e l a t i o n s h i p w i t h
t h e o e n t r a l Departments i n Edinburgh and C a r d i f f .
Health services i n
t h o s e two c o u n t r i e s c o u l d t h e r e f o r e be o p e r a t e d w i t h o u t i n t e r p o s i n g a r e g i o n a l
o r g a n i s a t i o n between t h e c e n t r a l H e a l t h Departments and t h e a r e a s .
Bvt i n England, a c e n t r a l Department o p e r a t i n g from London c o u l d n o t
hope t o e x e r c i s e e f f e c t i v e and prompt g e n e r a l s u p e r v i s i o n over area a u t h o r i t i e s
whose numbers w i l l be s i x t i m e s t h o s e o f t h e i r c o u n t e r p a r t s i n S c o t l a n d
and e l e v e n t i m e s t h o s e i n W a l e s .
Regional administrative
32.
tier
I n t h e o r y , t h e r e g i o n a l o r g a n i s a t i o n n e c e s s a r y i n England c o u l d t a k e the
form o f r e g i o n a l o f f i c e s o f t h e c e n t r a l Department.
In p r a c t i c e ,
they
would be much l e s s e f f e c t i v e t h a n s e p a r a t e r e g i o n a l a u t h o r i t i e s .
33.
To p l a c e t h e whole j o b on t h e c e n t r a l Department and i t s
regional
o f f i c e s would r e s u l t i n o v e r - c e n t r a l i s a t i o n and d e l a y ; i t would draw t h e
Department i n t o many m a t t e r s t h a t s h o u l d be r e s o l v e d l o c a l l y o r r e g i o n a l l y ;
and i t would d i s t r a c t t h e Department's a t t e n t i o n from t h e p o l i c y t a s k s
which must be done c e n t r a l l y and which, are i t s proper c o n c e r n .
34.
There i s a l s o a p o s i t i v e c a s e f o r s e p a r a t e r e g i o n a l
r a t h e r t h a n r e g i o n a l o f f i c e s of t h e c e n t r a l Department.
authorities
Each r e g i o n a l
a u t h o r i t y w i l l be a body o f l o c a l p e o p l e k n o w l e d g e a b l e about t h e i r r e g i o n ' s
needs.
They w i l l have c l o s e r e l a t i o n s h i p s w i t h t h e u n i v e r s i t y , which lias a k e y
p a r t t o p l a y i n t h e r e g i o n ' s work t h r o u g h i t s t e a c h i n g and r e s e a r c h a c t i v i t i e s ,
and w i l l be able to develop a continuing and constructive dialogue with
their Areas .
35*
These a r e t h e main r e a s o n s why t h e Government h a s d e c i d e d i n
f a v o u r o f a r e g i o n a l a d m i n i s t r a t i v e t i e r f o r t h e NHS.
The job to be done: n a t i o n a l l y , r e g i o n a l l y ,
36*
locally
Under these a r r a n g e m e n t s , t h e r e w i l l be c e n t r a l
strategic
p l a n n i n g and m o n i t o r i n g by DHSSj r e g i o n a l p l a n n i n g and g e n e r a l s u p e r v i s i o n o f
o p e r a t i o n s ( a s w e l l a s some d i r e c t e x e c u t i v e f u n c t i o n s ) by r e g i o n a l
a u t h o r i t i e s ; and a r e a p l a n n i n g and o p e r a t i o n a l c o n t r o l by a r e a a u t h o r i t i e s
c o - o r d i n a t e d w i t h l o c a l a u t h o r i t i e s s h a r i n g common b o u n d a r i e s .
37*
This means t h a t the p l a n n i n g f u n c t i o n i n t h e NHS w i l l be e x e r c i s e d
a t t h r e e l e v e l s , a r e a , r e g i o n and c e n t r a l department.
distinctive role.
Each h a s i t s own
The c e n t r a l department w i l l s e t t l e n a t i o n a l h e a l t h
p o l i c i e s , o b j e c t i v e s and p r i o r i t i e s .
The RHA w i l l have a r e g i o n a l p l a n n i n g
r e s p o n s i b i l i t y w h i c h w i l l i n c l u d e s e t t l i n g p r i o r i t i e s when t h e r e a r e c o m p e t i n g
c l a i m s between a r e a s .
w i l l be t h e a r e a .
But t h e fundamental u n i t i n t h e p l a n n i n g p r o c e s s
Area h e a l t h a u t h o r i t y p l a n s f o r t h e communities
w i t h i n the area - t h e " d i s t r i c t s " - w i l l s t r o n g l y i n f l u e n c e t h e way i n
which l o c a l , r e g i o n a l and n a t i o n a l p r i o r i t i e s a r e c a r r i e d i n t o e f f e c t
t h e a r e a , and how t h e y a r e harmonised w i t h l o c a l a u t h o r i t y p l a n s .
in
Management s t u d y
38.
As mentioned i n paragraph 1 4 , t h e c o n s u l t a t i v e document s a i d
t h a t t h e S e c r e t a r y of S t a t e would have a s t u d y made o f t h e
detailed
arrangements f o r management a t r e g i o n a l , a r e a and d i s t r i c t l e v e l and i n
t h e i n d i v i d u a l h o s p i t a l s and o t h e r i n s t i t u t i o n s .
The s t u d y i s
being
s u p e r v i s e d by a S t e e r i n g Committee which i n c l u d e s members from t h e
t h r e e b r a n c h e s o f t h e p r e s e n t NHS and from t h e Department, whose
Permanent S e c r e t a r y i s i t s chairman.
D e t a i l e d work and d i s c u s s i o n s
w i t h e x i s t i n g h e a l t h s e r v i c e a u t h o r i t i e s are b e i n g undertaken by a s t u d y
group a c t i n g on t h e S t e e r i n g Committee's b e h a l f .
Committee's terms o f
These a r e t h e S t e e r i n g
referencet
"On t h e b a s i s o f t h e G o v e r n m e n t s c o n s u l t a t i v e dooument on NHS
r e o r g a n i s a t i o n , and t a k i n g a c c o u n t o f o t h e r r e l e v a n t s t u d i e s
commissioned
by t h e S e c r e t a r y o f S t a t e , t o make recommendations on management s y s t e m s
f o r t h e s e r v i c e s f o r w h i c h r e g i o n a l and a r e a h e a l t h a u t h o r i t i e s w i l l be
r e s p o n s i b l e and on t h e i n t e r n a l o r g a n i s a t i o n o f t h o s e a u t h o r i t i e s .
39
1
M
The method f o l l o w e d i n t h e s t u d y h a s b e e n t o produce a range
o f h y p o t h e t i c a l models o f o r g a n i s a t i o n a t t h e v a r i o u s l e v e l s and t o
t e s t them i n d i s c u s s i o n w i t h a c r o s s - s e c t i o n o f h e a l t h a u t h o r i t i e s
throughout E n g l a n d .
40.
A f t e r t h e S e c r e t a r y o f S t a t e has r e c e i v e d recommendations from
t h e management s t u d y , he w i l l c o n s u l t the i n t e r e s t s c o n c e r n e d .
Decisions
w i l l n o t be t a k e n on t h e recommendations u n t i l t h e v i e w s o f t h o s e
have b e e n c o n s i d e r e d .
interests
Some o f t h e i d e a s b e i n g d e v e l o p e d i n t h e management
s t u d y a r e however d e s c r i b e d i n t h e document a t Appendix I I I t o t h i s White
Paper.
T h e s e i d e a s a r e p r o v i s i o n a l and s u b j e c t t o change i n t h e l i g h t
of f u r t h e r work i n t h e management s t u d y .
V
41*
AREA HEALTH AUTHORITIES - FUNCTIONS The last Section sketched the basic functions of the three
levels of authority in the reorganised NHS: the areas, the regions
and the central Department. In this and in the next four Sections,
the work of the authorities and the relationships between them will
be looked at in more detail.
Area planning 42.
The area health authority will be responsible for achieving
national health care objectives through the provision of comprehensive
health services designed to meet the needs of the communities within
its districts. It will be responsible for planning and developing
services in consultation with its matching local authority and with
the regional health authority. It will regularly and systematically
appraise the quality of existing services in the districts and assess
unmet needs, comparing the situation with national standards of care
and identifying opportunities for improvement. This approach will
encourage comparisons between alternative methods of care, in the
home and in the hospital.
, It will also make it possible for the area authority, with guidance from the region, to gear its plans in such a way that, in time, its services match national standards of care. 43*
The planning process will mean that the area must work very
closely with the local authorities so that improvement programmes
requiring action by both sets of authorities can be approved and
implemented effectively. More is said about this in the next Section.
The process will also of course involve continuing discussion with the
regional health authority which will use approved area plans as its
basis for assessing the a r e a a u t h o r i t y ' s
performance,,
Area operation of services
44*
The area health authority will be an operator o f services as well as
a planner.
As such, it will be the employer of the staff who work at area
headquarters and in the districts.
For a period, however, medical and dental
consultants and senior registrars, except those working in "teaching areas"/,
will continue to be appointed and employed at regional level, in order to
consolidate recent improvements in the machinery for manpower planning and
distribution. These arrangements will be reviewed after five years. The
authority will also be responsible for the quality of the "hotel" services
- catering, domestic work and so on - and other supporting services which back up the health professions and in so doing, influence patient care. The " d i s t r i o t s "
45.
The day t o day r u n n i n g o f s e r v i c e s w i l l be b a s e d on l o c a l i t i e s
( " d i s t r i c t s " ) w i t h i n which i t i s p o s s i b l e t o s a t i s f y t h e g r e a t e r part o f
the p u b l i c ' s h e a l t h care n e e d s .
As s u c h , t h e d i s t r i c t w i l l form t h e
n a t u r a l community f o r t h e p l a n n i n g and d e l i v e r y o f comprehensive h e a l t h
care.
I t w i l l be s m a l l enough f o r p r o f e s s i o n a l r e p r e s e n t a t i v e machinery t o
be e f f e c t i v e w i t h i n i t , i t w i l l c o n t a i n a d i s t r i c t g e n e r a l h o s p i t a l - o r
s e v e r a l h o s p i t a l s t o g e t h e r c a r r y i n g o u t t h e f u n c t i o n s o f such a h o s p i t a l
and w i l l u s u a l l y have a p o p u l a t i o n o f between 2 0 0 , 0 0 0 and 5 0 0 , 0 0 0 .
­
Because
t h e b o u n d a r i e s o f t h e h e a l t h d i s t r i c t w i l l be r e l a t e d t o h e a l t h care n e e d s ,
they w i l l not n e c e s s a r i l y correspond w i t h t h e boundaries of a l o c a l govern­
ment d i s t r i c t , f o r which d i f f e r e n t c r i t e r i a a r e a p p r o p r i a t e .
Many AHAs
w i l l be r e s p o n s i b l e f o r only one o r two d i s t r i c t s j a few w i l l have up to
five.*
46.
The d i s t r i c t s w i l l n o t i n any s e n s e form a s e p a r a t e formal
o f a u t h o r i t y below t h e a r e a s .
W i t h i n them, however, i t w i l l be possible
f o r t h e s e r v i c e s o f d o c t o r s , n u r s e s and o t h e r s t o be o r g a n i s e d s o
a s to answer community n e e d s most e f f e c t i v e l y ,
and t o f u l f i l t h e a r e a
a u t h o r i t y ' s o b l i g a t i o n t o ensure u n i f i c a t i o n of h e a l t h s e r v i c e s .
The
o r g a n i s a t i o n i n a d i s t r i c t w i l l be d e s i g n e d t o a c h i e v e i n t e g r a t i o n o f
/ S e e paragraph 114
* S e e footnote t o paragraph 5 3
tier
2
Q
CONFIDENTIAL
all health servioes available within it, ao that the representatives of Llw modioal profoooion and the profeseional heads of services in the district can jointly make the important district decisions and in that way be responsible, not merely for running district services but for helping to shape them. 47*
The document at Appendix III outlines the management study s 1
provisional views on arrangements for district management. Boundaries and patients 48.
"Regions", "areas" and "districts" should not and will not be barriers to the use of health services. The user will be able, as now, to cross boundaries without hindrance or formality, to get the services best suited to his needs, his convenience and, as far as practicable, his choice. 49*
Where the natural community for health care substantially overlaps the new area boundaries, special administrative arrangements will be required. These are being worked out as part of the management study. General guidance will be issued and in areas of particular difficulty there will be local discussions. Collaboration between areas 50.
There will be many instances in which one AHA will provide services
for another and ABAs generally will collaborate with each other in matters
of common interest. There will for example be a need for collaboration
between adjacent ambulance services in such matters as emergency cover
(including cover for serious accidents), the best'use of ambulance stations
situated near area boundaries, and training.
There may well also be
scope for joint action between neighbouring authorities in the ordering,
storage and distribution of supplies. In addition, some area health
authorities may need to arrange for certain
services to be provided from neighbouring areas. In some instances, the area authorities concerned will be situated in different regions, which will mean collaboration across regional boundaries. Joint health authorities 51.
Some functions may best be performed by a joint health authority (JHA)
covering more than a single area. Such a body would, in its own sphere,
have the powers (eg to employ staff and enter into contracts) held by AHAs
in their wider spheres. The new authority that will price prescriptions
for the whole of England will be a JHA responsible directly to the Secretary
of State.
Medical and dental teaching 52.
The administrative arrangements in areas in which facilities in
support of medical and dental teaching are provided, are discussed in
Section XIII.
CONFIDENTIAL VI
AREA 1IRALTH AUTHORITIES -
COLLABORATION WITH LOCAL GOVERNMENT Common boundaries for NHS and local government 53.
The AHA will be the operational NHS authority, responsible for
assessing needs in its area and for planning, organising and administering
area health services to meet them.
successfully on its own.
But it cannot hope to do these things
It is crucially important for the citizen requiring
help of both the health and social services that collaboration between the
two should be firmly established.
This points to the need for identity
between the health area and the area of the local authority responsible for
the personal social services. In almost all cases this identity will be
complete. The only exceptions will be in London where the 53 Boroughs
(including the City) will be grouped to form a smaller number of health areas.
This means that, subject to the outcome of the Local Government Bill, there
will be 72 AHAs autside London (38 corresponding with non-metropolitan
counties, and 34 with metropolitan districts). A list and map are given
in Appendix I, /
Need for other links
54*
Identity of area for health and personal social services will be
valuable, but close links are also needed between the health authority
and the local authorities responsible for education,
/
It will be for the area health authorities to examine in detail the number of districts needed in each area. Preliminary study suggests however that, outside London, 27 areas might contain one district only; and that there might, be 21 areas of 2 districts, 11 areas of 3 districts, 8 areas of 4 districts and 4 areas of 5 districts, making an approximate total of 154 districts. 23
dT% Kl El
KITIA I
environmental health, housing and other services where interests overlap. The position here is complicated by the fact that theBe local government services will not all be administered by the same authorities: personal social services by the non-metropolitan counties, the metropolitan districts and the London boroughs; education by these authorities except in central London where the ILEA is responsible; environmental health and housing by the non-metropolitan districts, the metropolitan districts and the London boroughs. 5 5 .
In any case, collaboration cannot be left to depend merely
on common
boundaries. Services of mutual concern have to be identified,
and arrangements made between the authorities to plan, develop and operate
them so that they satisfy mutual needs.
In the circumstances of a
radical reorganisation in both the NHS and local government, this must
mean a full study in advance of the scope for collaboration and of the
ways in which links between them can be devised.
Working Party on Collaboration between NHS and local government 56.
The links are already being studied by the working party
proposed in the consultative document, to which reference has been
made in paragraph 1 4 .
This working party has been set up jointly by
the main local authority associations and the appropriate central
departments, and is broadly representative of local government, the
NHS and central government.
57
A wide range of matters, both general and detailed, are being
studied by the working party, which will continue in being during and
after the passage of the NHS Bill to advise on the guidance about
collaboration to be given to the health and local authorities in readiness
for the reorganisation of the NHS and local government on the 1 s t April 1 9 7 4 .
But a number of important recommendations have already been made by the
working party and, subject to the outcome of consultations
24
with interested organisations, it is likely that the arrangements will cover the matters set out in the following paragraphs. Working Party's recommendations 58.
Collaboration must include planning and investment on the
one hand and day to day operations on the other.
59*
On planning and investment, the requirements of an area need
to be jointly identified and, in the light of the resources available,
the best ways of fulfilling them agreed between the health and local
authorities concerned.
60.
On day to day operations, the arrangements for collaboration must
cover the general sharing of goods and facilities, such as the use of
premises; the bulk purchase of supplies; building and associated maintenance
services; "hotel" services like catering, domestic work and laundries;
and management services such as computers, 0 and M and work study, and
information services. The arrangements must also extend to the provision
by one authority to the other, of the advice and services of professional
staff. For example, social services staff will need to be made available
by the local authority to the health authority.
Equally, local
authorities must continue to have professional advice - from doctors,
dentists and nurses - in order to carry out their statutory functions
in the personal social services, education, environmental health and
housing. They should look to the health authorities for such help.
61.
There must be means of making s u r e t h a t t h e arrangements
for
working t o g e t h e r a r e f i r m l y e s t a b l i s h e d and comprehensive and t h a t
t h e y i n v o l v e members and s e n i o r s t a f f o f t h e a u t h o r i t i e s
concerned.
There w i l l t h e r e f o r e be l o c a l j o i n t c o n s u l t a t i v e c o m m i t t e e s of
members of t h e a u t h o r i t i e s t o examine j o i n t l y t h e p l a n s of t h e
a u t h o r i t i e s and t o a d v i s e on t h e p l a n n i n g and o p e r a t i o n of
services
i n s p h e r e s of common c o n c e r n .
committee
One s u c h j o i n t c o n s u l t a t i v e
might be e s t a b l i s h e d i n a m e t r o p o l i t a n d i s t r i c t t o c o v e r a l l
the
s e r v i c e s o f common c o n c e r n ; but i n a n o n - m e t r o p o l i t a n c o u n t y two
committees would be needed - one c o v e r i n g p e r s o n a l s o c i a l
services
and s c h o o l h e a l t h , and r e p r e s e n t i n g on t h e l o c a l a u t h o r i t y s i d e t h e
county c o u n c i l ; and a n o t h e r f o r e n v i r o n m e n t a l h e a l t h and h o u s i n g ,
which would i n c l u d e r e p r e s e n t a t i v e s o f a l l t h e l o c a l
district councils.
a r e a s , e g London.
authority
S p e c i a l arrangements would be n e e d e d i n some
Each j o i n t c o n s u l t a t i v e committee would be
supported by a group o f s e n i o r o f f i c e r s from t h e
authorities
concerned.
62.
The j o i n t c o n s u l t a t i v e committee would make i t s v i e w s known
t o t h e c o n s t i t u e n t h e a l t h and l o c a l a u t h o r i t i e s arid t h e s e v i e w s
might be p u b l i s h e d .
I t i s e x p e c t e d t h a t d i s c u s s i o n s on t h e
j o i n t committees would g e n e r a l l y l e a d t o agreement b e i n g r e a c h e d
between t h e a u t h o r i t i e s but t h e r e w i l l be arrangements u n d e r which
an a u t h o r i t y can s e e k t h e h e l p o f t h e c e n t r a l Gfovernment on any
m a t t e r where i t h a s n o t been p o s s i b l e t o r e a c h a g r e e m e n t .
63.
I n a d d i t i o n t o t h e j o i n t c o n s u l t a t i v e c o m m i t t e e s , e a c h AHA
w i l l i n c l u d e i n i t s membership members o f t h e c o r r e s p o n d i n g l o c a l
a u t h o r i t y ( s e e S e c t i o n X) j and l o c a l a u t h o r i t i e s w i l l be
26
strongly recommended to co-opt to their relevant committees members or officers of the AHA. These arrangements for membership of the authorities or committees will be supplemented by close working relationships between the chief officers of the authorities and by the arrangements for sharing the services of professional staff. Statutory provisions for collaboration In the last resort, the quality of collaboration will depend on the readiness of those concerned at all levels to communicate and collaborate with each other. But it is desirable to provide an administrative setting for this, as described above. And it is desirable also to provide a sound statutory basis. It is therefore proposed that the NHS Reorganisation Bill should contain a general obligation on the authorities concerned to collaborate 5 should give them the fullest possible powers to provide each other with goods and services; and should make it obligatory to set up joint consultative committees. Finance
65.
A p p r o p r i a t e f i n a n c i a l arrangements between h e a l t h and l o c a l
a u t h o r i t i e s t o c o v e r t h e s e d i f f e r e n t forms o f c o l l a b o r a t i o n w i l l be
recommended i n t h e l i g h t o f a d v i c e from t h e Working P a r t y on
Collaboration.
j 27 VII AREA HEALTH AUTHORITIES - FAMILY PRACTITIONER SERVICES 66.
Unification of the health services will not change the status of
the general medical and dental practitioners, ophthalmic medical
practitioners, opticians and pharmacists. They now provide services as
independent contractors, and they will continue to do so.
67.
Unification will however open up new opportunities for family
practitioners to develop their services as integral parts of comprehensive,
integrated health care.
Family practitioner committee 68.
To administer the contracts, the AHA will be required by statute
to set up a Family Practitioner Committee. Its work will consist of
entering into contracts with the individual practitioners, and administering
their terms of service, including remuneration schemes,(which will be settled
nationally), and the statutory disciplinary arrangements (which will^be
unchanged). On all of these matters, the Committee will deal direct with
the Central Department.
69*
The Committee will be made up in
the same way as are
Executive Councils at present outside the London area. There will be 30 members, half of them appointed by...the-professions themselves. The 15 professional members - 8 doctors, 3 dentists, 2 pharmacists, one ophthalmic optician and dispensing optician - will be appointed by the local, professional committees for the area, which.will perform broadly the same functions as they now. do in relation to the family practitioner services.
Of the remaining 15 members, 11 will be appointed by the AHA (at least one being an area authority 28 CONFIDENTIAL member) and 4 by the local authority (or authorities) entitled to appoint members to the AHA.
(See Section X for details of AHA membership). The chairman will be appointed by the Committee from among its own members. AHA responsibilities 7 0 .
If there is to be proper integration of health care in the reorganised
service, the AHA must itself take responsibility for those issues where the
provision of family practitioner services involves other parts of the unified
M S or the personal social services. These include the planning and
development of health centres; the approval where necessary of practitioners'
own proposals for providing premises; plans for contractor services in new
towns and redevelopment areas; and general arrangements for nursing and other
skilled staff employed by the AHA or by the local authority to work with
family doctors in their own practices, whether in health centres or elsewhere.
The AHA will of course want to be sure that plans for developments which
affect contractor services are generally acceptable to its family
practitioners. It will therefore consult the FPC and the local professional
committees, and will take full account of their views before it makes decisions
on these matters.
Staff for the family practitioner committee 71*
The^ staff serving the p p c will, like other staff working
within the area, be employed by the AHA, but the Committee will be
consulted before senior appointments are made. Some staff may choose to
make their career in the service of the Committee, but those who want a
wider career will be given opportunities to transfer between the work of
the Committee and other parts of the area administration,
72,
These arrangements willgive the Committee a better prospect of
getting the services of the best quality staff than would be the case if
staff were to be appointed by them because in that event, career prospects would inevitably be limited. Medical Practices Committee, Dental Estimates Board, Joint Pricing Committee 73.
The work of the Medical Practices Committee and the Dental Estimates Board
will remain unchanged in the new structure. The Joint Pricing Committee
will be replaced by a joint health authority with the same functions.
CONFIDENTIAL
VTII
74*
REGIONAL HEALTH AUTHORITIES The re^ion l task will be in part strategic planning,
a
in part co-ordination and supervision, in part executive. Planning
75*
The regional health authority will develop strategic plans and
priorities based on a review of the needs identified by AHAs and on its judgment
of the right balance between the individual areas' claims on resources.
It will plan the ways and the pace at which area needs may be met, guided
where appropriate by agreed national and regional policies and standards.
76.
The RHA will be responsible for identifying, in consultation with
AHAs, services that need a regional rather than an area approach, and
arranging for their provision, either direct or through specified AHAs.
with professional advice, The authority will need to develop,/an overall regional plan for specialist services and to pay particular attention to the provision and location of rarer specialties such as neurology, neurosurgery, radiotherapy and some forms of laboratory investigation.
The deployment within the region of senior hospital medical, dental and scientific staff will be determined by this plan. 77*
The RHA will have a special responsibility for ensuring - with
the Universities and AHAs concerned - that satisfactory service facilities
are provided to support medical and dental teaching, undergraduate and
postgraduate, and research. It will therefore have a close relationship
with a University providing medical and dental undergraduate education,
and there will be many links between the health services and the specialised
woric and research that are associated with the medical and dental schools. Co-ordination and supervision 78*
The RHA will review the plans of each of its areas to satisfy
itself that they contain programmes to achieve necessary improvements in
services, that they are attainable within available regional resources, that
they are consistent with national and regional polcies, and that they have been
co-ordinated with the planning and operational activities of local authorities. They will also need to see that area plans collectively fit together to meet the needs of communities: sometimes this may call for the provision of services to people of one area from hospitals outside their area. (The same situation may also arise as between regions). 19.
Having agreed area plans with the area health authorities, it will allocate resources between them, and will monitor their performance against a set of agreed objectives and programmes for which the resources have been allotted. Executive functions 80.
The most important of these will be the design and construction of new building and works. The RHA will itself undertake the more important projects, subject to any necessary approval by the central Department and to guidance on such matters as design and cost standards and building techniques and methods. The design and execution of other new building work will be delegated to AHAs, subject to any necessary approval and guidance by the RHA.
The latter will however be the main executive building agency and will employ architects, engineers and quantity surveyors not only for its own work but also to help AHAs on building projects delegated to them. Responsibility for operation and maintenance of engineering plant and services and for the maintenance of existing premises will be delegated to the areas, subject to regional supervision. 81.
A great deal of work has been done on the functional planning of hospitals: this work is being carried forward in the standardisation of departmental designs. The use of these designs will encourage a high quality of architecture and a high priority will be given in the reorganised service to the architectural and environmental standards of new hospital buildin Ambulance service 82.
The RHA will need to see that there is effective co-ordination and collaboration between adjacent AHA services in such matters as emergency CONFIDENTIAL cover, the siting and use of ambulance stations, and training. And in the group of health areas corresponding to a metropolitan county, there will be advantage in providing a single ambulance service; this could be operated by the RHA as a service to its AHAs. Other services 83.
These will include the provision of a blood transfusion service;
and the sponsorship of some research projects, including regional
epidemiological studies. Some parts of the overall plan for supplies in the
region - for example, the purchase of certain items of equipment - may be
discharged most economically or effectively on a regional basis (just as
others will best be handled at area or national level). Again, some
management services may be provided most effectively by the RHA: for example,
the provision of computer facilities, the compilation and processing of
statistics, and certain aspects of the personnel function including the
provision of selected training facilities for use by the staff of AHAs as
well as by those of the RHAs.
RIL^s:
84.
numbers and boundaries
The location and size of health regions are determined by several
factors. The location should be such that each Region has a University
medical school within its boundaries. The size must be sufficient for
satisfactory planning but not too large for the co-ordination and
supervision of the AHAs; and it must be suitable for the exercise of
regional executive functions. It is also obviously desirable to avoid
disturbing the forward planning of the hospital service, unless other
factors make this unavoidable. In the light of these considerations, the
Government has decided that the new health regions will be based on the
14 planning regions now in use for the hospital service.
85.
Each region will consist of a number of complete health areas - no
area being split between regions - and this means that a number of
adjustments are needed in the present hospital regional boundaries to
secure conformity with the new area boundaries. Details outside London are
set out in the list and map of areas and regions in Appendix I.
IX
06.
CENTRAL DEPARTMENT
The RHAs w i l l be a c c o u n t a b l e t o t h e S e c r e t a r y o f S t a t e f o r t h e i r
own a c t i v i t i e s and f o r t h o s e o f t h e AHAs.
The S e c r e t a r y o f S t a t e w i l l
c o n t i n u e t o have r e s p o n s i b i l i t y t o Parliament f o r t h e N a t i o n a l H e a l t h
S e r v i c e a s a whole and w i l l determine n a t i o n a l p o l i c y .
The Department
must a s s i s t him i n t h e s e ways:
( 1 )
S e t t l i n g , w i t h i n t h e framework l a i d down by t h e A c t , t h e
k i n d , s c a l e and b a l a n c e o f s e r v i c e s t o be p r o v i d e d i n t h e
r e g i o n s and a r e a s .
For t h i s purpose i t must d e v e l o p , i n
c o n s u l t a t i o n w i t h t h e f i e l d a u t h o r i t i e s and t h e p r o f e s s i o n s ,
a p p r o p r i a t e l o n g term o b j e c t i v e s , p r i o r i t i e s and s t a n d a r d s
o f c a r e a s g u i d e l i n e s f o r e f f e c t i v e a r e a and r e g i o n a l
planning.
( 2 )
Guiding, s u p p o r t i n g and ( t o t h e e x t e n t t h a t t h i s i s
c o n t r o l l i n g t h e RHAs.
desirable)
I t must h e l p t h e f i e l d a u t h o r i t i e s
to
understand t h e g u i d e l i n e s and t h e r e a s o n i n g b e h i n d them.
And i t must a l l o c a t e t o RHAs t h e r e s o u r c e s f o r p u t t i n g them
into
( 3 )
effect.
O b t a i n i n g o r d e v e l o p i n g r e s o u r c e s which s t r o n g l y i n f l u e n c e
adequa c y , e f f i c i e n c y and economy o f t h e s e r v i c e s .
This requires
s p e c i a l i s t work on p a r t i c u l a r r e s o u r c e s - p e r s o n n e l ;
p r o p e r t y and b u i l d i n g ; s u p p l y .
the
financej
The c e n t r a l Department w i l l
have a s p e c i a l r e s p o n s i b i l i t y i n r e l a t i o n /to s t a f f i n g .
The
r e c r u i t m e n t and t r a i n i n g of t h e s k i l l e d manpower r e q u i r e d i n
t h e NHS c a l l f o r v a r i o u s measures a t n a t i o n a l l e v e l e g t o
f o r e c a s t s t a f f r e q u i r e m e n t s , t o p l a n numbers o f
training
p l a c e s , where a p p r o p r i a t e t o m o n i t o r t h e q u a l i t y o f
training,
and t o arrange p u b l i c i t y t o a t t r a c t e n t r a n t s . . The r e q u i r e d
qualifications,
remuneration and c o n d i t i o n s o f s e r v i c e
will
c o n t i n u e t o be s e t t l e d a t t h e c e n t r e .
A l s o , a l l l a n d and
property w i l l v e s t i n the Secretary of S t a t e .
And t h e
Department w i l l c o n t i n u e t o be r e s p o n s i b l e f o r o v e r a l l
central
budgeting
and a c c o u n t i n g o f h e a l t h e x p e n d i t u r e .
( 4 )
Carrying out o t h e r f u n c t i o n s t h a t a r e b e s t o r g a n i s e d
centrally.
J u s t a s some t h i n g s n e e d t o be done by t h e RBA r a t h e r t h a n t h e
AHA, s o t h e r e are t h i n g s b e s t done c e n t r a l l y .
Examples a r e some
t y p e s o f r e s e a r c h and t h e s t a n d a r d i s a t i o n and p r e p a r a t i o n o f
national s t a t i s t i c s .
Purchase o f equipment o r s u p p l i e s
centrally
may be j u s t i f i a b l e i n economic terras o r by r e a s o n o f c o n t r o l o f
quality or distribution.
The NHS s u p e r a n n u a t i o n scheme w i l l
c o n t i n u e t o be c e n t r a l l y a d m i n i s t e r e d .
A microbiological
also
service
r e l a t e d t o communicable d i s e a s e w i l l c o n t i n u e t o be a d m i n i s t e r e d
c e n t r a l l y by t h e P u b l i c H e a l t h L a b o r a t o r y S e r v i c e Board on b e h a l f
of t h e S e c r e t a r y o f S t a t e .
( 5 )
S u p p o r t i n g t h e S e c r e t a r y o f S t a t e i n h i s P a r l i a m e n t a r y and p u b l i c
duties.
87.
I n a d d i t i o n , t h e c e n t r a l Department h a s r e s p o n s i b i l i t i e s towards o t h e r
s e r v i c e s b e s i d e s t h e NHS, p a r t i c u l a r l y t h e p e r s o n a l s o c i a l s e r v i c e s and
social security.
And i t d i s c h a r g e s some c e n t r a l Government t a s k s s u c h a s
t h e l i c e n s i n g o f m e d i c i n e s ( i n a s s o c i a t i o n w i t h t h e M e d i c i n e s Commission),
t h e c o n t r o l of f o o d s a f e t y and h y g i e n e , and a c t s a s t h e p r o d u c t i o n a u t h o r i t y
f o r the medical supply i n d u s t r y .
These r e s p o n s i b i l i t i e s have t o be c o - o r d i n a t e d
w i t h t h e D e p a r t m e n t ' s r e s p o n s i b i l i t i e s t o w a r d s t h e NHS.
88.
As a l r e a d y announced, t h e o r g a n i s a t i o n and o p e r a t i o n o f t h e Department
h a s been r e v i e w e d , w i t h t h e h e l p o f management c o n s u l t a n t s .
P r o p o s a l s have been
f o r m u l a t e d which a r e d e s i g n e d t o e n a b l e t h e Department t o c a r r y out e f f e c t i v e l y t h e
f u n c t i o n s i t w i l l have a f t e r NHS r e o r g a n i s a t i o n .
The p r o p o s a l s a r e b a s e d
c l o s e l y upon t h e Department's r o l e a s d e f i n e d a b o v e .
( a )
In particular,
emphasis i s p l a c e d on t h e development o f a p r o c e s s of
p l a n n i n g , i n a s s o c i a t i o n w i t h the f i e l d a u t h o r i t i e s ,
help the Secretary of State to decide national
and p r i o r i t i e s .
to
objectives
One o f t h e main s e c t i o n s o f
t h e Department w i l l be o r g a n i s e d t o a s s i s t i n t h i s
1
process, with particular attention t o assessing people s
n e e d s f o r h e a l t h and s o c i a l care and p r o p o s i n g how t h o s e
n e e d s can b e s t be met from t h e f u l l range o f s e r v i c e s
t h a t can be made a v a i l a b l e i n t h e r e o r g a n i s e d NHS, t h e
p e r s o n a l s o c i a l s e r v i c e s , and o t h e r r e l e v a n t
( b )
services.
g r e a t importance i s a t t a c h e d t o a c l o s e and c o n t i n u i n g
r e l a t i o n s h i p w i t h RHAs.
Departmental group
For t h i s p u r p o s e , a n o t h e r main
w i l l be o r g a n i s e d a s t h e f o c a l p o i n t
f o r a c t i o n i n p a r t n e r s h i p w i t h t h e RHAs.
Its
Divisions
w i l l be r e s p o n s i b l e f o r a s s i s t i n g RHAs t o produce and
implement p l a n s which w i l l g i v e e f f e c t t o n a t i o n a l
and p r i o r i t i e s w h i l e t a k i n g f u l l a c c o m t o f l o c a l
p r i o r i t i e s and p o l i c i e s .
policies
circumstances,
They w i l l a l s o e n s u r e t h a t t h e BHAs
r e c e i v e any h e l p from t h e Department t h a t t h e y n e e d .
And
t h e y w i l l be r e s p o n s i b l e f o r s u r v e i l l a n c e o v e r t h e q u a l i t y
and e f f e c t i v e n e s s o f h e a l t h s e r v i c e management.
When
a p p r o p r i a t e , RHAs w i l l communicate d i r e c t w i t h o t h e r , more
s p e c i a l i s t p a r t s o f t h e Department, but t h e s e D i v i s i o n s w i l l
be c r e a t e d s p e c i f i c a l l y t o support and g u i d e them a c r o s s t h e
f u l l range o f t h e i r b u s i n e s s .
( c )
t h e D e p a r t m e n t ' s s t a f f concerned w i t h p e r s o n n e l p o l i c i e s
in
t h e NHS w i l l a l s o be i n c r e a s e d , and w i l l be o r g a n i s e d i n a
t h i r d main g r o u p .
89.
Thus t h e c e n t r a l Department w i l l be o r g a n i s e d on an
i n t e r - p r o f e s s i o n a l b a s i s t o c a r r y out t h r e e main groups o f t a s k s i n
c o n n e c t i o n w i t h t h e NHS: p l a n n i n g t h e k i n d , s c a l e and b a l a n c e o f
s e r v i c e s i n a s s o c i a t i o n w i t h t h e f i e l d a u t h o r i t i e s and t h e p r o f e s s i o n s ;
working i n p a r t n e r s h i p w i t h t h e RHAs and p r o v i d i n g them w i t h support
and g u i d a n c e ; and c a r r y i n g o u t c e n t r a l NHS p e r s o n n e l f u n c t i o n s .
Department i s a l s o p l a n n i n g t o i n c r e a s e t h e number o f NHS s t a f f
The
seconded
t o i t , and o f i t s own s t a f f who spend t r a i n i n g s p e l l s i n t h e r e o r g a n i s e d
service.
CONFIDENTIAL
X MEMBERSHIP OF AUTHORITIES
90.
The s t r e n g t h of t h e new a d m i n i s t r a t i v e s t r u c t u r e w i l l i n t h e
Government's v i e w l a r g e l y depend on t h r e e f a c t o r s ; s m a l l and c a p a b l e member­
s h i p o f a u t h o r i t i e s t o approve and m o n i t o r p o l i c i e s ; e f f e c t i v e machinery
f o r g e t t i n g e x p e r t a d v i c e t o t h e members from t h e m e d i c a l and o t h e r h e a l t h
p r o f e s s i o n s , and f o r g a t h e r i n g , a p p r a i s i n g and h a n d l i n g i n t e l l i g e n c e ; and
c h a n n e l s by w h i c h , i n e v e r y h e a l t h d i s t r i c t , t h e u s e r s of s e r v i c e s can
r e p r e s e n t t h e i r v i e w s v i g o r o u s l y t o management.
T h i s S e c t i o n examines t h e
f i r s t o f t h e s e f a c t o r s ; t h e f o l l o w i n g two S e c t i o n s d i s c u s s
professional
a d v i s o r y machinery and t h e community h e a l t h c o u n c i l s .
V o l u n t e e r members; remuneration f o r chairmen
91*
The Government b e l i e v e s t h a t , a s i n t h e p a s t , t h e NHS s h o u l d be
a d m i n i s t e r e d by t r a i n e d s t a f f , under t h e g e n e r a l d i r e c t i o n o f
authorities
oomposed o f p a r t - t i m e members who g i v e t h e i r s e r v i c e s v o l u n t a r i l y .
Members
o f t h e a r e a and r e g i o n a l h e a l t h a u t h o r i t i e s w i l l s e r v e i n an unpaid c a p a c i t y
though t h e y w i l l be e n t i t l e d t o t r a v e l l i n g and o t h e r a l l o w a n c e s .
The
chairman w i l l however have a s p e c i a l l y h e a v y and t i m e - c o n s u m i n g j o b and
i t i s d e s i r a b l e t h a t t h e r e s h o u l d be n o f i n a n c i a l b a r r i e r t o h i s g i v i n g a s much
o f h i s time t o t h e h e a l t h s e r v i c e a s t h e j o b demands.
The l e g i s l a t i o n
i n c l u d e a p r o v i s i o n t o make i t p o s s i b l e f o r t h e chairmen o f h e a l t h
t o be remunerated on a p a r t - t i m e
Scope o f t h e a u t h o r i t i e s
9 2 .
1
will
authorities
basis.
work
The new a u t h o r i t i e s w i l l have i m p o r t a n t work t o d o .
f o r example w i l l employ t h o u s a n d s of s t a f f ,
The a r e a a u t h o r i t i e s
responsible for
p r o f e s s i o n a l and o t h e r s , t h e y w i l l
t h e h e a l t h c a r e o f up t o a m i l l i o n p e o p l e o r e v e n more, t h e y w i l l a d m i n i s t e r
annual b u d g e t s running i n t o m i l l i o n s ( i n some c a s e s many m i l l i o n s ) o f pounds
and w i l l be r e s p o n s i b l e f o r b u i l d i n g s and p l a n t worth many m i l l i o n s .
93.
I n g e n e r a l t e r m s , members w i l l have two i n t e r a c t i n g s e t s o f r e s p o n s i ­
b i l i t i e s : t h e s u p e r v i s i o n o f t h e c r e a t i o n and development by t h e i r
chief
o f f i c e r s o f p o l i c i e s i n r e s p o n s e t o c h a n g i n g n e e d s ; and t h e o v e r s e e i n g o f
standards o f performance, b o t h i n q u a n t i t y ?nd q u a l i t y .
They w i l l n e e d
a b i l i t y t o g i v e guidance and d i r e c t i o n on p o l i c i e s t o t h e i r c h i e f
charged w i t h t h e management o f t h e s e r v i c e .
CONFIDENTIAL
officers
be/
B a s i s f o r membership o f
94*
CONFIDENTIAL authorities
To do t h i s work e f f e c t i v e l y ,
t h e a u t h o r i t i e s must be s m a l l .
a r e a a u t h o r i t y w i l l n o r m a l l y have about f i f t e e n members.
The
The r e g i o n a l
a u t h o r i t y w i l l be about the same s i z e d e p e n d i n g on t h e number o f a r e a s i n
t h e r e g i o n and o t h e r v a r i a b l e f a c t o r s such a s t h e number o f
p r o v i d i n g m e d i c a l and d e n t a l e d u c a t i o n .
Universities
The a u t h o r i t y w i l l be f r e e
to
c o - o p t t o c o m m i t t e e s where t h e y t h i n k t h e c o m m i t t e e s would b e n e f i t from
t h e h e l p and a d v i c e o f p e o p l e who a r e n o t members of t h e a u t h o r i t y .
95*
An important p a r t o f t h e a r e a h e a l t h a u t h o r i t i e s members
1
work w i l l
be t o v i s i t t h e h o s p i t a l s and o t h e r u n i t s f o r t h e management o f which t h e y
w i l l be r e s p o n s i b l e .
A planned programme o f v i s i t i n g w i l l be one means by
which members w i l l be a b l e t o e n l a r g e t h e i r u n d e r s t a n d i n g o f problems
r e q u i r i n g t h e i r a t t e n t i o n and t o check p r o g r e s s made i n d e a l i n g w i t h them.
But a u t h o r i t i e s w i l l n o t n e e d t o r e l y o n l y on t h e i r own members f o r v i s i t i n g .
They w i l l be a b l e t o c o - o p t s u i t a b l e p e o p l e t o h e l p them.
96.
The work t o be done by the members c a l l s f o r g e n e r a l a b i l i t y and
personality.
They w i l l need t o be i n t e r e s t e d i n t h e NHS; t o have an u n b i a s e d ,
q u e s t i o n i n g y e t c o n s t r u c t i v e approach and good judgment; t o s e t h i g h s t a n d a r d s
and p r o v i d e v i g o r o u s l e a d e r s h i p .
A d i v e r s i t y and a proper b a l a n c e o f
a b i l i t y and e x p e r i e n c e are a l s o c a l l e d f o r .
relevant
These n e e d s can b e s t be met
if,
i n t h e main, members a r e c h o s e n f o r t h e i r p e r s o n a l q u a l i t i e s a f t e r a p p r o p r i a t e
c o n s u l t a t i o n s , not e l e c t e d as r e p r e s e n t a t i v e s r e f l e c t i n g the views of
particular i n t e r e s t s .
Membership o f RHAs
97.
The RHAs w i l l form p a r t o f t h e c h a i n o f r e s p o n s i b i l i t y r u n n i n g from
the Secretary of State to the a r e a s .
T h e i r a u t h o r i t y w i l l d e r i v e from t h e
s e l e c t i o n and appointment o f t h e i r chairmen and members by t h e S e c r e t a r y o f
S t a t e , who w i l l be r e q u i r e d b e f o r e making h i s c h o i c e t o c o n s u l t w i t h t h e
a p p r o p r i a t e i n t e r e s t e d o r g a n i s a t i o n s i n c l u d i n g t h e U n i v e r s i t i e s , t h e main
l o c a l a u t h o r i t i e s and t h e main h e a l t h p r o f e s s i o n s .
Membership o f AHAs
8
9 *
The Chairman w i l l be a p p o i n t e d by t h e S e c r e t a r y o f S t a t e ,
c o n s u l t a t i o n w i t h t h e Chairman o f t h e RBA.
after
Because o f t h e n e e d f o r c l o s e
decision-making links with the l o c a l authority s e r v i c e s , l o c a l
authority
members who a r e a c t i v e i n t h e management o f t h e p e r s o n a l s o c i a l
services,
e d u c a t i o n and o t h e r r e l e v a n t s e r v i c e s , s h o u l d have p l a c e s on t h e ABA and
four
members o f i t w i l l t h e r e f o r e be a p p o i n t e d by t h e c o r r e s p o n d i n g
local authority.
Because o f t h e need f o r a c l o s e l i n k w i t h t h e U n i v e r s i t y
p r o v i d i n g m e d i c a l and d e n t a l t e a c h i n g f a c i l i t i e s ,
one p l a c e on t h e AHA
w i l l be f i l l e d on i t s n o m i n a t i o n : t h e r e w i l l be a s e c o n d p l a c e i f
area includes substantial teaching
99*
the
facilities.
The r e m a i n i n g members o f t h e AHA w i l l be chosen and a p p o i n t e d by
t h e ERA.
The RHA w i l l be r e q u i r e d , b e f o r e making i t s c h o i c e , t o
with appropriate organisations.
consult
These o r g a n i s a t i o n s w i l l i n c l u d e t h o s e
r e p r e s e n t a t i v e o f t h e main h e a l t h p r o f e s s i o n s , a s i t i s i n t e n d e d t h a t
AHAs s h o u l d i n c l u d e i n t h e i r membership p e o p l e o f a u t h o r i t y and e x p e r i e n c e
who t h e m s e l v e s a r e members o f t h e h e a l i n g p r o f e s s i o n s .
This i s i n a d d i t i o n
t o t h e AHAs p r o f e s s i o n a l a d v i s o r y machinery and t o i t s c h i e f
officers.
professional
The p r o p o r t i o n o f p r o f e s s i o n a l members w i l l n o t be p r e s c r i b e d ,
and w i l l d i f f e r from a r e a t o a r e a and change from time t o time a c c o r d i n g
t o c i r c u m s t a n c e s , but an AHA w i l l always i n c l u d e d o c t o r s and a t l e a s t one
n u r s e o r midwife - but n o t drawn from s t a f f who a r e a c c o u n t a b l e t o t h e
authority's chief professional
officers.
XI
PROFESSIONAL ADVISORY MACHINERY Strong professional advisory machinery will be built into the new ^OO.
structure. The Act will include provision for this.
each level of management,
It will function at and will ensure that the RHA and AHA and their staffs make decisions in the full knowledge of expert opinion. It will ensure, too, that at all levels the health professions exercise an effective voice in the planning and operation of the NHS. Professional advice for the health authorities 101.
The details will be worked out in consultation with the various
professions in readiness for 1 9 7 4 . Though the detailed arrangements will
vary according to the circumstances of the individual professions, it is
clear that
a. at least the following professions must be covered:
doctors, dentists, opticians, pharmacists, and nurses
and midwives.
b.
the arrangements must include provision for successors
to the local medical, dental, optical and pharmaceutical
committees, since they will, as now, have important statutory and
other functions to perform eg the appointment of members
to the Family Practitioner Committees.
c.
the arrangements should also carry into the reorganised
Service the best of the experience already gained in the
existing service (eg the developing Cogwheel structure,
other satisfactory arrangements at HMC and individual
hospital level, and the advisory systems on professional
matters built up by the RHBs)j and should take account of the interests
Professional advice for the Department
medical, dental and nursing education. WZ
At the national level, the Department of Health and Social o f
t
Security must have available to it expert opinion on a wide range of matters, many of which are highly technical, relating
to the provision of the National Health Service. Advisory bodies will continue to be the main source of this advice. They are either set up as standing bodies or x See paragraph 130
appointed as occasion
requires.
" 0 3 . The main s t a n d i n g a d v i s o r y body i s the C e n t r a l
Health S e r v i c e s C o u n c i l , c r e a t e d i n 1948 t o a d v i s e t h e S e c r e t a r y o f S t a t e
on g e n e r a l m a t t e r s b e a r i n g on t h e s e r v i c e .
S t a n d i n g A d v i s o r y Committees
have been a p p o i n t e d t o a d v i s e t h e C e n t r a l H e a l t h S e r v i c e s C o u n c i l and t h e
S e c r e t a r y o f S t a t e on s p e c i f i c a s p e c t s .
The c o n s t i t u t i o n s and terms o f
r e f e r e n c e o f t h e C o u n c i l and o f t h e A d v i s o r y Committees w i l l be a d j u s t e d a s
n e c e s s a r y t o meet t h e n e e d s of t h e r e o r g a n i s e d and u n i f i e d s e r v i c e .
In 1946
the e l e m e n t s i n t h e c o m p o s i t i o n o f the C e n t r a l Health S e r v i c e s C o u n c i l were
s p e c i f i e d i n t h e A c t , b u t i t i s now proposed t o u s e s u b o r d i n a t e
legislation
f o r t h i s purpose - a s has always been t h e c a s e w i t h t h e S t a n d i n g Committees ­
s o t h a t t h e c o m p o s i t i o n can be a d j u s t e d more f l e x i b l y
t o meet changing c i r c u m s t a n c e s .
As w e l l a s members a p p o i n t e d by v i r t u e of
t h e i r o f f i c i a l p o s i t i o n s a t t h e heads of c e r t a i n p r o f e s s i o n a l b o d i e s ,
l i s t of which i s under r e v i e w , and members w i t h o t h e r h e a l t h
the
service
e x p e r i e n c e , i t i s i n t e n d e d t o i n c l u d e on t h e new C o u n c i l some p e o p l e
s p e c i f i c a l l y a p p o i n t e d t o a d v i s e from t h e p a t i e n t * s v i e w p o i n t .
There w i l l a l s o b e c r o s s - r e p r e s e n t a t i o n w i t h t h e P e r s o n a l S o c i a l
Services
C o u n c i l , s o a s t o s e c u r e r e p r e s e n t a t i o n o f s o c i a l work i n t e r e s t s on t h e
C e n t r a l H e a l t h S e r v i c e s C o u n c i l and o f h e a l t h s e r v i c e i n t e r e s t s on t h e
Personal Social Services Council,
The new - l i k e t h e p r e s e n t -
advisory
b o d i e s w i l l be f r e e t o o f f e r a d v i c e on t h e i r own i n i t i a t i v e a s w e l l a s on
request.
A d v i c e on s t a f f
104.
training
Arrangements axe a l s o b e i n g made f o r g i v i n g e x p e r t a d v i c e t o t h e
S e c r e t a r y o f S t a t e on t h e t r a i n i n g o f NHS s t a f f : d e t a i l s a r e g i v e n i n
S e c t i o n XV.
XII
COMMUNITY HEALTH COUNCILS Expressing local opinion 105.
In planning and running their services, the health authorities
must be in a position to know the views taken of them by the communities for
whom the services are provided. They must also take full account of
those views in the decisions they make. A lively and continuing
interaction between management and the users of services is of direct
benefit to both parties. It helps to make sure that the public has a
full say in what is done in its name, and it helps the managing
authorities by making them better informed on priorities, needs and
deficiencies in service.
106,
The expression of local public opinion can be catered for in
one of two ways.
It can be done indirectly by including in the member­
ship of the health authorities local people serving in a representative
capacity. Or it can be done more directly, through bodies specially
set up for this purpose, with direct links to the authorities. The
Government prefer the second course. It allows each of the interests
- management and the community - to concentrate on its own special function, avoids a confusion between the direction of services and representation of those receiving them, encourages a constructive interplay of ideas and makes possible the expression of a wider cross-section of local opinion than is feasible where the authority itself contains members serving as representatives.
/ Community health councils: membership 107.
Bodies to represent the views of the consumer - the community
health councils - will therefore be established. There will be one for
each of the area's health districts.
43
I t i s n t Lho d i s t r i c t ,
r a t h e r than a t t h e ( o f t e n
a r e a , where t h e r e i s r e a l l o c a l i n t e r e s t .
large)
Special
arrangements w i l l be made where t h e p e o p l e l i v i n g w i t h i n a h e a l t h
district
look f o r a large part of t h e i r s e r v i c e s t o a neighbouring d i s t r i c t
(which
might be a d m i n i s t e r e d by a d i f f e r e n t a r e a h e a l t h a u t h o r i t y ) .
t08.
Each c o u n c i l w i l l be made up of p e o p l e w i t h p a r t i c u l a r
in the h e a l t h s e r v i c e s .
interest
H a l f i t s members w i l l be
a p p o i n t e d by t h e l o c a l government d i s t r i c t c o u n c i l ( s ) , and t h e
r e s t by t h e AHA, m a i n l y on t h e n o m i n a t i o n of v o l u n t a r y
b o d i e s concerned l o c a l l y w i t h t h e NHS and some a f t e r c o n s u l t a t i o n w i t h
other organisations.
No upper o r l o w e r l i m i t o f membership w i l l be
set,
but a t o t a l of between 20 and 30 members would n o r m a l l y be about r i g h t
f o r e n s u r i n g a proper spread o f l o c a l i n t e r e s t s w i t h i n an e f f e c t i v e
c o h e r e n t working u n i t .
and
C o u n c i l s w i l l a p p o i n t t h e i r chairmen from among t h e i r
own members.
Functions
1109.
The c o u n c i l s b a s i c j o b w i l l be t o r e p r e s e n t t o t h e AHA t h e
i n t e r e s t s of the public i n the health service i n i t s d i s t r i c t .
It
will
be f o r e a c h c o u n c i l t o d e c i d e how b e s t t o go about t h i s , but t h e y w i l l
be e x p e c t e d t o i n f l u e n c e a r e a p o l i c y by c o n t r i b u t i n g
t h e i r own i d e a s on how s e r v i c e s s h o u l d be o p e r a t e d and d e v e l o p e d .
h e l p them do t h i s e f f e c t i v e l y ,
To
c o u n c i l s w i l l have powers t o s e c u r e
i n f o r m a t i o n , w i l l have t h e r i g h t t o v i s i t h o s p i t a l s and o t h e r i n s t i t u t i o n s ,
and w i l l have a c c e s s t o t h e a r e a a u t h o r i t y end i n p a r t i c u l a r t o i t s
officers administering d i s t r i c t s e r v i c e s .
senior
Some c o u n c i l members may want t o
take a s p e c i a l i n t e r e s t i n p a r t i c u l a r i n s t i t u t i o n s
or s e r v i c e s or parts
o f t h e i r d i s t r i c t , e s p e c i a l l y where t h e d i s t r i c t s a r e l a r g e .
tJD&*
C o u n c i l s w i l l be w e l l p l a c e d t o b r i n g t o t h e n o t i c e o f t h e AHA and i t s
district staff
p o t e n t i a l c a u s e s o f l o c a l c o m p l a i n t , e s p e c i a l l y t h o s e of a
g e n e r a l n a t u r e , but t h e i r f u n c t i o n w i l l be d i s t i n c t from t h a t o f t h e
AHA s complaints machinery and of the Health Service Commissioner 1
(see Section XX.),
There will be well understood procedures for
the investigation of individual complaints in the reorganised service
but a CHC might well wish, on request, to provide information about
these procedures, to advise complainants how to lodge a complaint and
to provide a "patient's friend" where one is needed. The volume and
type of individual complaints about a service or institution will be
of legitimate concern to councils as a measurement of public
satisfaction.
111.
For their part, the AHA will be expected to consult the CHCs
on its plans for health service developments, and particularly on
proposals for important variations in services affecting the public.
New services, closures of hospitals or departments of hospitals or
their change of use, are examples. The full AHA will
meet representatives of all its community health councils at least
once a year; that meeting would of course be additional to the regular,
1
less formal meetings which will take place between the authority s
members and officers and CHC representatives. The councils will publish
annual reports and may publish other reports; the AHA will be required
to publish replies recording action taken on issues raised in them.
1
Councils expenses
1*1-2.
The AHA w i l l meet the councils' r e a s o n a b l e e x p e n d i t u r e ,
including
expenses incurred by their members, and will provide accommodation for
meetings and secretarial s t a f f .
45 XXII
113.
MRDICAL ANT) DENTAL TEACHING Tim NHS has always given high priority to providing facilities in support oL' medical and dental teaching carried out by the Universities, and in support of associated research. This will continue to be one of the most important priorities at all levels of the reorganised service: national regional, area and district, "Teaching areas" 114-
Some of the areas will have substantial facilities of this kind.
They will be described as "teaching areas" and the AHAs which administer
them will be called AHA(T)S.
Integration witliin the regions 115.
Administrative unification is essential is there is to be a
properly balanced development of community and hospital facilities to
meet the needs of teaching, of research and of services to the public.
Teaching hospitals have in recent years gone a long way in providing
district hospital services. Unification will help them to take this further
and in so doing, will bring great benefit to the districts concerned. At
the same time, facilities for teaching and research are increasingly needed,
not only in hospitals but also in the community health services: here too
the closer union of teaching hospital and community services will be of
benefit. Moreover, administrative unification will enable the staff of
the teaching hospitals to play the full part which they and the Health
Service as a whole would wish them to take in the development of the new
administrative organisation that will be set up in 1974*
116.
For these reasons, the teaching areas will be administered as part of the regions in which they are situated^ 117.
But i n t e g r a t i o n o f t e a c h i n g h o s p i t a l s w i t h i n t h e u n i f i e d NHS must
take a c c o u n t o f t h e s p e c i a l c h a r a c t e r o f undergraduate t e a o h i n g and of
U n i v e r s i t y s p o n s o r e d r e s e a r c h , and o f t h e f a c t t h a t t h e h o s p i t a l s where
t h e y t a k e p l a c e a l s o p r o v i d e s p e c i a l i s e d s e r v i c e s f o r many p e o p l e
outside t h e i r area.
The h o s p i t a l s
1
living
i n d i v i d u a l i d e n t i t y and h i s t o r i c
t r a d i t i o n s a r e v a l u a b l e a s s e t s w h i c h must and w i l l be p r e s e r v e d when t h e
new o r g a n i s a t i o n i s s e t u p .
The r e s t o f t h i s S e c t i o n d e s c r i b e s t h e
arrangements t o a c h i e v e t h e s e i m p o r t a n t
118,
objects.
The t e a c h i n g h o s p i t a l w i l l o b v i o u s l y have a c e n t r a l r o l e i n t h e
h e a l t h s e r v i c e s f o r t h e d i s t r i c t i n which i t i s s i t u a t e d .
The a d m i n i s t r a t i v e
arrangements a t h o s p i t a l and d i s t r i c t l e v e l have s t i l l t o be worked out i n
d e t a i l i n t h e l i g h t o f t h e recommendations o f t h e Management S t u d y .
But
i t i s c l e a r t h a t t h e r e w i l l be i n t i m a t e l i n k s between t h e AHA(T) and t h o s e
responsible f o r the a d m i n i s t r a t i o n of the t e a c h i n g h o s p i t a l .
It is
clear
a l s o t h a t t h e management a t t h e d i s t r i c t l e v e l , a c t i n g f o r t h e A H A ( T ) ,
will
have t h e main r e s p o n s i b i l i t y f o r a l l o p e r a t i o n a l m a t t e r s and w i l l p l a y a
l e a d i n g p a r t i n p l a n n i n g t h e development and improvement o f s e r v i c e s .
It
i s e x p e c t e d t h a t A H A ( T ) s w i l l w i s h t o nominate one o r more o f t h e i r members
t o t a k e a s p e c i a l i n t e r e s t i n t h e s e r v i c e s o f a d i s t r i c t where t h e r e i s a
teaching hospital.
They w i l l be f r e e t o c o - o p t p e o p l e t o g i v e them support
i n t h i s , and t o a s s i s t i n p l a n n e d programmes o f
119,
visiting.
I t i s important t o m a i n t a i n t h e p r e s e n t c l o s e w o r k i n g r e l a t i o n ­
s h i p s between t e a c h i n g h o s p i t a l s and t h e i r a s s o c i a t e d m e d i c a l and d e n t a l
s c h o o l s , and t o e x t e n d t h o s e r e l a t i o n s h i p s t o a l l t h e h e a l t h s e r v i c e s
the d i s t r i c t s .
in
The r e s p o n s i b i l i t y f o r s e c u r i n g t h i s , day i n and day o u t ,
must r e s t a t t h e l o c a l l e v e l .
A j o i n t committee between t h e AHA(T) and t h e
m e d i c a l o r d e n t a l s c h o o l may a l s o be found u s e f u l .
47
Where, i n London,
s t a t u t o r y arrangements e x i s t f o r BG r e p r e s e n t a t i o n on s c h o o l C o u n c i l s ,
s i m i l a r arrangements w i l l be made f o r AHA(T) r e p r e s e n t a t i o n .
120.
The AHA(T) i t s e l f w i l l have t e a c h i n g and r e s e a r c h i n t e r e s t s
p r o m i n e n t l y i n mind i n i t s o p e r a t i o n a l r e s p o n s i b i l i t y f o r t h e a r e a and
i n t h e work i t does on p l a n n i n g t h e improvement and development o f t h e
NHS.
The AHA(T)'S membership w i l l demonstrate t h i s .
The AHA w i t h o u t
s u b s t a n t i a l t e a c h i n g and r e s e a r c h f a c i l i t i e s w i l l have one member
nominated by t h e U n i v e r s i t y , but t h e AHA.(T) w i l l have t w o .
The AHA(T)
w i l l a l s o have a t l e a s t two a d d i t i o n a l members w i t h t e a c h i n g h o s p i t a l
e x p e r i e n c e - more i f t h e a r e a i n c l u d e s more than one t e a c h i n g h o s p i t a l
( o r group o f h o s p i t a l s o f a k i n d t h a t h a s h i t h e r t o been d e s i g n e d a s a
single teaching hospital).
121.
The AHA(T)S w i l l e x e r t a s t r o n g i n f l u e n c e a t t h e r e g i o n a l
level,
where t h e RHAS r e s p o n s i b i l i t i e s w i l l be much w i d e r than t h o s e o f t h e
e x i s t i n g RHB, and w i l l i n c l u d e p r o v i s i o n o f support f o r t e a c h i n g and
research.
The RHA w i l l i n c l u d e a member a p p o i n t e d by t h e S e c r e t a r y of
S t a t e a f t e r c o n s u l t a t i o n w i t h t h e U n i v e r s i t y (more t h a n one member i f
t h e r e i s more than one U n i v e r s i t y c o n c e r n e d ) .
122.
The D e p a r t m e n t s r e v i e w o f r e g i o n a l p l a n s and e s t i m a t e s t o e n s u r e
c o n s i s t e n c y w i t h n a t i o n a l p o l i c i e s and p r i o r i t i e s , w i l l pay p a r t i c u l a r
a t t e n t i o n t o t h e b a l a n c e between t e a c h i n g and n o n - t e a c h i n g a r e a s .
will receive in i t s financial allocation a specific identified
f o r t e a o h i n g and r e s e a r c h .
The RHA
allowance
I t w i l l a l s o be r e q u i r e d t o s e t up a committee
t o a d v i s e i t on i t s r e s p o n s i b i l i t i e s i n r e l a t i o n t o m e d i c a l and d e n t a l
undergraduate e d u c a t i o n and r e s e a r c h ; t h i s committee w i l l c o n t a i n members
c o - o p t e d from t h e U n i v e r s i t y ( o r U n i v e r s i t i e s ) and t h e AHA(T)S.
123.
R e g i o n a l h e a l t h a u t h o r i t i e s w i l l have important
responsibilities
f o r h e l p i n g t o ensure t h a t t h e r e a r e s a t i s f a c t o r y arrangements w i t h i n t h e
48 new nervine for postgraduate medical and denfcal education and training.
It i s envisaged that they will be advised on the discharge of these
responsibilities by regional postgraduate education committees, as are
regional hospital boards at present, and that these bodies should be
distinct from the committees advising on the provision required for
undergraduate teaching.
124.
These arrangements should make for a fully integrated service
in which the teaching hospitals will play as vital a part as they do in
the hospital service as at present organised.
Special interim provisions 125.
Teaching hospitals have traditionally been centres of excellence
in acute medicine. Increasingly they have widened their interests to
include aspects of non-acute conditions. In future, the integrated
services of the district and the teaching area will be able to benefit
from their capacity for general excellence and for high standards.
The teaching hospitals' contribution to the reorganised service will
undoubtedly be a growing one, but during the early years there is bound
to be anxiety about the possible effects of new administrative relation­
ships. There i s therefore a need for additional safeguards during those
years, as reassurance that full weight will be given to the importance of
the teaching and research functions as well as to the essential service
role of these distinguished hospitals
a
126.
The scope of the safeguards needed is still being discussed, but
two have already teen decided upon. On the first appointment of AHA(T)S,
the members appointed for their teaching hospital experience will be
appointed by the Secretary of State from among the members of existing
BGs and University HMCs.
Similarly, on its first appointment, the RHA.'s
49 CONFIDENTIAL
1.1'Ho.hj.ng 'ui(l research committee will include members drawn from the
t present BGs and University HMCs. 50
XIV
127.
A SOUND MANAGEMENT STRUCTURE
The Government c o n s i d e r s t h a t t h e s e arrangements - f o r a r e a ,
r e g i o n a l and c e n t r a l a d m i n i s t r a t i o n , f o r s t r o n g a d v i s o r y machinery,
and f o r t h e e x p r e s s i o n o f l o c a l o p i n i o n - p r o v i d e a sound s t r u c t u r e
w i t h i n which t h e h e a l t h p r o f e s s i o n s can p r o v i d e t h e p u b l i c w i t h an
e f f i c i e n t and humane s e r v i c e .
Administration; statutory provisions
128.
At p r e s e n t , s t a t u t o r y r e s p o n s i b i l i t y f o r a d m i n i s t e r i n g t h e
NHS i s d i v i d e d between t h e S e c r e t a r y o f S t a t e ( a c t i n g t h r o u g h
r e g i o n a l and l o c a l b o d i e s ) f o r t h e h o s p i t a l s e r v i c e s , t h e
c o u n c i l s f o r t h e f a m i l y p r a c t i t i o n e r s e r v i c e s and l o c a l
f o r t h e o t h e r community p e r s o n a l h e a l t h s e r v i c e s .
executive
authorities
In future,
there
w i l l be a c l e a r l i n e of r e s p o n s i b i l i t y f o r t h e whole NHS from t h e
S e c r e t a r y o f S t a t e t o t h e RHAs and t h r o u g h them t o t h e AHAs, w i t h
c o r r e s p o n d i n g a c c o u n t a b i l i t y from a r e a t o r e g i o n t o c e n t r e .
The o v e r a l l
r e s p o n s i b i l i t y which w i l l r e s t on t h e S e c r e t a r y o f S t a t e makes i t
necessary
t h a t , i n a d d i t i o n t o making s t a t u t o r y r e g u l a t i o n s and i s s u i n g g u i d a n c e , he
s h o u l d be a b l e t o g i v e formal d i r e c t i o n s t o RHAs and AHAs; RHAs w i l l have t h e
same power o f formal- d i r e c t i o n i n r e l a t i o n , t o t h e AHAs.
These d i r e c t i o n s may be
g e n e r a l , c o v e r i n g a l l a u t h o r i t i e s , o r t h e y may b i n d o n l y one a u t h o r i t y ,
i n r e l a t i o n t o e i t h e r a g e n e r a l o r a p a r t i c u l a r m a t t e r . The power o f formal
d i r e c t i o n s h o u l d however be needed o n l y i n t h e most e x c e p t i o n a l c i r c u m s t a n c e s . $29.
T h i s framework w i l l be f l e x i b l e s o t h a t p r a c t i c e s may be changed i n t h e l i g h t o f e x p e r i e n c e and a l t e r e d
A d m i n i s t r a t i o n ; d e l e g a t i o n , c l i n i c a l freedom
130,
N a t i o n a l and r e g i o n a l p l a n n i n g i s e s s e n t i a l .
circumstances. But i t i s
far
from t h e Government's i n t e n t i o n t h a t t h e NHS s h o u l d c o n t i n u a l l y be
a d m i n i s t e r e d o r s u p e r v i s e d on t h e b a s i s o f r e g u l a t i o n s and d i r e c t i o n s
from c e n t r e o r r e g i o n .
O b j e c t i v e s and p r i o r i t i e s w i l l be approved and
51 r*" rformanoo m o n i t o r e d , but t h e a u t h o r i t y d o i n g t h e job i t s e l f
be l e f t
l.o g e t on w i t h i t , w i t h a minimum o f i n t e r f e r e n c e .
will
This
w i l l a p p l y a s between t h e c e n t r a l Department and the RHA and a s
between t h e RHA and t h e AHA.
Financial administration
131.
As t o t h e funds needed f o r RHA and AHA s e r v i c e s , t h e Department
w i l l be r e s p o n s i b l e t o P a r l i a m e n t f o r e x p e n d i t u r e .
But s u b j e c t
to
such d i r e c t i o n s j , r e g u l a t i o n s and g u i d a n c e a s may be n e c e s s a r y , i t
d e l e g a t e f i n a n c i a l r e s p o n s i b i l i t y t o RHAs, and RHAs w i l l
d e l e g a t e i t t o AHAs.
will
similarly
More d e t a i l i s g i v e n i n S e c t i o n XvT.
S u p e r v i s i o n of d e l e g a t e d a u t h o r i t y
132.
planning,
Th
e
f i r s t requirement f o r e f f e c t i v e s u p e r v i s i o n i s good
so t h a t comprehensive p l a n s , which t a k e a c c o u n t o f a v a i l a b l e
r e s o u r c e s , are prepared w i t h i n t h e AHAs and a r e r e v i e w e d and approved by RHAs
and i n more summary form by t h e Department.
I f o m i s s i o n s can be s p o t t e d
and put r i g h t a t t h e p l a n n i n g s t a g e , t h e n t h e r e can be t h e maximum
d e l e g a t i o n of a u t h o r i t y i n t h e a c t u a l conduct o f the j o b , and the
need f o r much more d e t a i l e d i n t e r v e n t i o n l a t e r on can be a v o i d e d .
Secondly,
s u p e r v i s i o n e n t a i l s t h e m o n i t o r i n g o f performance t o ensure
t h a t planned s t a n d a r d s o f s e r v i c e and e f f i c i e n c y are b e i n g a c h i e v e d .
Performance can be monitored i n v a r i o u s wayss by the c o l l e c t i o n and
a n a l y s i s o f r e g u l a r s t a t i s t i c a l i n f o r m a t i o n , by s p e c i a l l y commissioned
r e p o r t s and e n q u i r i e s , by v i s i t i n g and c o n t a c t s between t h e s t a f f
t h e Department and f i e l d a u t h o r i t i e s ,
by s y s t e m a t i c
of
visiting,
i n s p e c t i o n and a d v i c e such a s are c a r r i e d out by t h e D e p a r t m e n t s
a u d i t o r s o r by t h e H o s p i t a l A d v i s o r y S e r v i c e ,
and by t h e
o b s e r v a t i o n and a n a l y s i s o f p r a c t i c e by which t h e
52
self-critical
professions
m o n i t o r t h e i r own work.
F i n a l l y , s u p e r v i s i o n requires follow-up of
p l a n s t o e n s u r e t h a t a g r e e d a c t i o n s a r e b e i n g t a k e n and t o c o n s i d e r
their
133.
effect.
I n the r e o r g a n i s e d s e r v i c e , t h e r e w i l l be a more s y s t e m a t i c
and comprehensive p l a n n i n g p r o c e s s than now e x i s t s .
The Department
w i l l a n n u a l l y prepare guidance on n a t i o n a l p o l i c y o b j e c t i v e s
for
AHAs and EHAs who w i l l t h e n draw up t h e i r p l a n s f o r t h e
development of t h e i r s e r v i c e s t o meet t h e s e o b j e c t i v e s t o g e t h e r w i t h
t h e i r own l o c a l p r i o r i t i e s .
I t i s intended t o
s e e k methods of
o b t a i n i n g improved
i n f o r m a t i o n and more e f f e c t i v e measurement o f n e e d s and of
performance.
Such measurement i s e x c e p t i o n a l l y d i f f i c u l t i n h e a l t h
c a r e and b e t t e r s t a t i s t i c a l i n d i c a t o r s have t o be d e v i s e d .
All
a u t h o r i t i e s w i l l n e e d t o s e e k ways o f u s i n g t h i s i n f o r m a t i o n more
e f f e c t i v e l y to a s s e s s the r e a l progress of the s e r v i c e i n achieving
i t s o b j e c t i v e s and t o i d e n t i f y o p p o r t u n i t i e s and p r o b l e m s .
The
r e o r g a n i s a t i o n of t h e Department w i l l , a s h a s b e e n e x p l a i n e d , p r o v i d e
i t t o have c l o s e r and more r e g u l a r c o n t a o t t h a n i n t h e p a s t w i t h the
for
health
a u t h o r i t i e s , which s h o u l d l e a d t o a b e t t e r mutual u n d e r s t a n d i n g o f
problems and o b j e c t i v e s . And t h e H o s p i t a l A d v i s o r y S e r v i c e w i l l
continue
t o p r o v i d e v a l u a b l e i n f o r m a t i o n and a d v i c e t o t h e S e c r e t a r y of S t a t e
and t o t h e s e r v i c e i t s e l f .
The D e p a r t m e n t s f u n c t i o n o f
general
s u p e r v i s i o n w i l l be m a i n l y d i r e c t e d towards t h e a c t i v i t i e s of t h e
r e g i o n a l h e a l t h a u t h o r i t i e s , -who w i l l be e x p e c t e d t o s u p e r v i s e
a c t i v i t i e s of t h e a r e a h e a l t h a u t h o r i t i e s i n t h e same way.
53 the
134*
RllA and AHA members are there to see that the right questions are
asked and answered in the preparation, operation and review of plans; and to
ensure a full awareness of health needs as a basis for the design of policy,
the settlement of priorities and the provision of a good standard of service.
They are not there to do the work that their officers are trained to do.
Hot only would this be a waste of time and effort; officers can be expected
to give of their best only if they are entrusted with a wide measure of
responsibility, and can enjoy a feeling of pride and personal achievement
when a good job is done,
135*
The success of the service will depend not only on the work of
clinicians and other professional staff but also on the quality of the
whole range of administrative staff.
Organisation of work
136.
It is important that organisation structures, functions and
procedures should be clearly laid down to a greater extent than in the
past, and this will be done.
137*
Organisation structures will be specified with sufficient
flexibility to take account of the varying circumstances of the new
health authorities.
138.
Job descriptions should indicate clearly the criteria by which performance will be assessed. This applies alike to the chairman and members of the authority and to their officers, so that responsibility for giving drive and leadership as well as for executive work is not left in doubt. 139*
In recent years, as a product largely of some important studies
and reports, there have been changes in the organisation of the work
of NHS staff - medical, nursing and of other professions, particularly
in the hospital service. For example, hospital clinicians have been
organising themselves in many hospital groups in Divisions based on
clinical specialties and in association with general practitioners
along lines recommended in the "Cogwheel Report"* - with the aim of
* First Report of the Joint Working Party on the Organisation of Medical Work in Hospitals, HMSO 1967. CONFIDENTIAL
CONFIDENTIAL organising their own work better, making known their requirements and priorities as collectively decided to the hospital authority and reviewing hospital activity more effectively. The nursling services also arc being reorganised, under Chief Nursing Officers for hospital groups, on the lines of the recommendations of the "Salmon Report"*. Similar principles are being applied to nursing staff of local authorities. Hospital pharmaceutical services are being reorganised in accordance with bhe Noel Hall Report**. 140*
The intention is to develop these principles of organisation
and adapt them to the unified NHS. The management study will be
making proposals for this.
Specialists in community medicine 141.
Unification will bring together into one service medical
administrators now working in the public health services and those in
the hospital service. Their functions will continue to be carried
out after reorganisation and doctors from both these spheres will
have a central part in the planning and management of the unified service, in the Department, in the regions and in the areas and districts. 142.
As specialists in what is now recognised within the profession
as community medicine, their concern will be with assessing need for health services, evaluating the effectiveness of existing services and planning the best use of health resources. Equally, they will concern themselves with developing preventive health services, with the links between the health and the local authority personal social, public health and education services, and with providing the medical advice and help which local authorities will need for the administration 55
.
­
*Report of the Committee on Senior Nursing Staff Structure, HMSO 1966
**Report of the Working Party on the Hospital Pharmaceutical Service, HMSO 1970
of those services,
143,
The Working Party on Medical Administrators^ under
1
Dr R B Hunter s chairmanship, lias described the work of the
specialist in community medicine at all levels of a unified health
service. Their report points to the especially important responsibility
which these specialists will have within the district management for
imrotinc the functional integration of health care.
144*
Their skills will complement those of other health service
administrators and of the clinicians. These groups will together
form a partnership in management of the new service.
56 *Report of the forking Party on Medical Administrators, HMSO 1972 CONFIDENTIAL XV
145.
THE STAFF OF THE SERVICE There are many references elsewhere in this White Paper to the
present and future contribution of the staff of the service. Any large
undertaking naturally depends for its success on the loyal and efficient
support of its staff and the manner in which they identify themselves with
its objectives. This is as true of the NHS as of any other organisation. It is
the staff who provide the service, and the buildings, equipment and supplies
are simply
the medium through which their skills can be exercised.
The staff of the NHS authorities - hospital and local health authorities
and Executive Councils - deserve high praise for the way in which they
have performed their work and, despite the administrative barriers^
largely co-operated with, each other.
They must take credit for rendering so intelligently and humanely the services for which they have been responsible since 1948. The integrated NHS will enable them to gain wider experience of the Service and make fuller use, for the benefit of the patient, of its various parts than has so far been possible^ and that will improve patient care. Personnel management 146.
The National Health Service is highly labour-intensive, nearly
IQfo of the revenue costs being incurred on salaries and wages. Moreover,
the staff employed in the service combine a range of skills wider than in
most other organisations. The service therefore needs particularly
discerning and skilled personnelnamagement at all levels from the centre
outwards. This implies not only the employment of properly trained staff
in personnel departments but the recognition that every manager or supervisor
has a personnel
function. Good staff management demands good
manpower information and work is being done on this both in the Department
CONFIDENTIAL and e l s e w h e r e . The managers of t h e r e o r g a n i s e d NHS a t a l l l e v e l s w i l l be
encouraged t o g i v e c l o s e r a t t e n t i o n t o t h i s s u b j e c t and w i l l have b e t t e r
r e s o u r c e s t o h a n d l e i t t h a n t h e i r p r e d e c e s s o r s have h a d .
Staffing
147*
studies
The development o f t h e s e r v i c e w i l l be a s s i s t e d by t h e r e s u l t s
of s t u d i e s , - t o some o f which r e f e r e n c e was made i n S e c t i o n XIV, - a l r e a d y
completed or c u r r e n t l y i n p r o g r e s s , o f the r o l e and f u n c t i o n s of
engaged i n t h e s c i e n t i f i c and t e c h n i c a l s e r v i c e s ,
staff
b u i l d i n g maintenance,
p h a r m a c e u t i c a l s e r v i c e s i n h o s p i t a l s , and i n t h e n u r s i n g and m i d w i f e r y
s e r v i c e s i n h o s p i t a l s and t h e community.
148.
These s t u d i e s w i l l h e l p i n a d a p t i n g p r o f e s s i o n a l and o c c u p a t i o n a l
t r a i n i n g t o t h e needs o f a modern i n t e g r a t e d h e a l t h s e r v i c e .
In particular,
the c o n t e n t and t h e o r g a n i s a t i o n of t h e t r a i n i n g and e d u c a t i o n of n u r s e s
and midwives w i l l be reviewed i n t h e l i g h t o f t h e recommendations of t h e B r i g g s
Committee on N u r s i n g .
Management t r a i n i n g
'49*
P r o f e s s i o n a l and o c c u p a t i o n a l t r a i n i n g w i l l be complemented by
management t r a i n i n g : t h a t i s , t r a i n i n g t o e q u i p a l l t h e d e c i s i o n - m a k e r s
with
an u n d e r s t a n d i n g o f t h e needs of t h e s e r v i c e a s a whole and o f i t s s t a f f ,
w i t h t h e s k i l l s e n a b l i n g them t o make t h e b e s t u s e o f t h e a v a i l a b l e
Most management t r a i n i n g w i l l n e e d t o be m u l t i - p r o f e s s i o n a l .
resources.
I t w i l l need
a l s o t o t a k e a c c o u n t o f t h e c l o s e r e l a t i o n s h i p between t h e o b j e c t i v e s
t h e N a t i o n a l H e a l t h S e r v i c e and t h o s e of t h e l o c a l a u t h o r i t y s o c i a l
T h i s w i l l accordingly form a p a r t o f management t r a i n i n g a t a l l
and
of
services.
levels.
I n a d d i t i o n , i t i s i n t e n d e d t o arrange a r e g u l a r s e r i e s o f s e m i n a r s f o r
s e n i o r p e o p l e o v e r the whole range of s e r v i c e s f o r which t h e S e c r e t a r y
of S t a t e i s
responsible.
A d v i s o r y machinery
150.
Various Committees h a v e a l r e a d y p r o v i d e d v a l u a b l e a d v i c e about
training.
In p a r t i c u l a r the N a t i o n a l S t a f f "Committee, f o r h o s p i t a l
58
staff
administrative
CONFIDENTIAL and clerical staff and the National Nursing Staff Committee for hospital nurses
and midwives, have done valuable work not only on training but also in career
development, in encouraging movement between various branches of the hospital
administrative service, in advising on selection and promotion procedures, and
in developing staff appraisal systems and systematic career counselling.
Unification means that comprehensive arrangements for all aspects of the personnel
1
function, including training must now be developed. The Department s own
resources are being strengthened for this purpose. The work done by the NSC
and the NNSC will be built upon, developed to meet the needs of an integrated
health service and extended to other groups of staff. It is therefore proposed,
in consultation with the interested bodies, to reconstitute the existing
Committees and to constitute others so as to create a linked series of staff
advisory committees to provide co-ordinated advice to the Secretary of State.
It is also proposed to establish an NHS Training Council, as a new advisory
body working with the staff advisory committees on the training aspects of the
work.
Movement and Interchange of staff
151*
The efficiency of the NHS and career development will both benefit from
movement of staff between the different levels of administration:
between
region, area, family practitioner committee, district and unit, and between
the different branches (administration, finance, supply and so on) at the
various levels.
152.
The same applies between the Central Department and the NHS. Staff
in the Department and the NHS need to know more of each other's work. The
Department are studying the arrangements previously made for interchange of
staff and will be consulting with the interests concerned on ways in which
such arrangements might be improved and expanded.
Pay and conditions of service
153*
Rates of pay and conditions of service in the new structure will
continue to be settled through national machinery. A new review body
has been set up to advise the Government on the remuneration of doctors and
dentists. Management and staff will need to negotiate changes in the
CONFIDENTIAL
constitution of the present whitley Councils in order to meet the changes in the service and in particular to provide for the representation of the new management bodies and of staff whose pay was previously settled outside the NHS whitley system. NHS employment policies 154*
measures outlined above are all intended to contribute to the development of clear and comprehensive employment policies for the reconstructed NHS covering recruitment, training, career development and retirement policies in the interest of good management and the full realisation of staff potential. 155,
As in the past, there will be consultation with staff"organisations on matters on which their experience and their concern to secure the best interests of their members will come into play. XVI
1^)0"
FINANCIAL ADMINISTRATION
The change i n a d m i n i s t r a t i v e s t r u c t u r e w i l l n o t mean a change
i n t h e methods o f f i n a n c i n g t h e NHS e x c e p t i n t h e c a s e o f s e r v i c e s
from l o c a l a u t h o r i t i e s .
transferred
The c o s t o f t h o s e s e r v i c e s , and o f t h e h e a l t h
a u t h o r i t i e s ' o t h e r e x p e n d i t u r e , w i l l be f i n a n c e d mainly by t a x a t i o n and met
from.moneys v o t e d by P a r l i a m e n t .
The g e n e r a l arrangements f o r c h a r g i n g
f o r c e r t a i n NHS s e r v i c e s w i l l not be a f f e c t e d . ­
157*
RHAs.
The Department w i l l make c a p i t a l and revenue a l l o c a t i o n s
to
Prom t h e s e , t h e RHAs w i l l meet the c o s t o f t h e i r own s e r v i c e s
and w i l l a l l o c a t e money t o AHAs t o meet t h e c o s t o f a r e a s e r v i c e s
i n c l u d i n g t h e c o s t o f t h e community h e a l t h c o u n c i l s .
Payments made
t o p r a c t i t i o n e r s under t h e terms o f t h e i r c o n t r a c t s w i l l be s e p a r a t e l y
funded by t h e Department.
1 5 8 .
R e g i o n a l and a r e a h e a l t h a u t h o r i t i e s w i l l be r e q u i r e d t o
prepare and m a i n t a i n a medium terra " r o l l - f o r w a r d
0
plan c o v e r i n g a
4 - y e a r p e r i o d t o g e t h e r w i t h i n d i c a t i o n s o f l i k e l y t a r g e t s f o r t h e main c a p i t a l
d e v e l o p m e n t s " o v e r a l o n g e r p e r i p d . A u t h o r i t i e s - w i l l be n o t i f i e d of
provisional
f i n a n c i a l c e i l i n g s f o r each o f t h e s u c c e e d i n g f o u r y e a r s s o t h a t p l a n s
may be e x p r e s s e d i n t h e form of f i n a n c i a l e s t i m a t e s , c o v e r i n g b o t h
r e v e n u e and c a p i t a l
expenditure.
The a l l o c a t i o n of funds by
t h e r e g i o n a l a u t h o r i t i e s w i l l be c l o s e l y i n t e g r a t e d w i t h t h e p l a n n i n g
p r o c e s s e s so t h a t t h e p l a n s a r e based r e a l i s t i c a l l y on t h e l e v e l s o f
funds l i k e l y t o be made a v a i l a b l e .
To encourage t h e most
efficient
u s e o f r e s o u r c e s and f l e x i b i l i t y i n t h e e x e c u t i o n of p l a n n e d d e v e l o p m e n t s ,
a u t h o r i t i e s w i l l have freedom, w i t h i n l i m i t s , t o u s e funds
f o r c a p i t a l e x p e n d i t u r e t o meet revenue
allocated
expenditure and vice versa. Arrangements will also be worked out to enable unspent revenue allocations to be carried over from one year to the next. In addition, authorities will be given a more direct financial interest in land holdings and land transactions. 159.
Improved accounting and financial s y s t e m s a r e
being d e v i s e d .
T n e
estimates produced as
part of the planning process will be the framework for a budgeting
system designed both to give overall control and to provide functional
budgets which will help individual managers to exercise detailed control
over resources and to assess the cost-effectiveness of departments and
services against any recommended standards. Financial monitoring will
form an important part of the monitoring of performance
so that RHAs and AHAs will be able to compare actual results against estimates and budgets.
It will also enable the Department to be satisfied that efficient financial control and management is maintained throughout all authorities, and that funds are used to the best advantage and in conformity with national policies. The Department will continue existing arrangements for carrying out a statutory audit of the authorities' accounts. 160.
The allocations of available funds to health authorities will be designed progressively to reduce the disparities between the resources available to different regions, and to achieve standards end improvements in services with due regard to national, regional and area priorities. The new information systems and other methods of assessment and review of services should help to ensure that the bases used for allocating funds meet these objectives with increasing effectiveness. 161.
The transfer of services will relieve local authorities
of expenditure and this will have to be taken into account when
assessing the level of grant to be paid by the central Government
to local authorities after April, 1974*
The r e o r g a n i s e d S e r v i c e :
other issues
XVII
162.
VOLUNTARY SERVICES Voluntary service has always played an important part in the
development of health and welfare services in this country. Many
voluntary organisations are already active in both the health and
social services. Unification of health services and the alignment
of area health authority boundaries with those of the local
authorities responsible for personal social services, will enable
voluntary bodies to see more clearly how their present services in each
area, fit in with the range of needs of people both in and out of
hospital, and in this way, will help them to work still more
effectively.
They will be encouraged, in close co-operation with
the area health and local authorities, to increase and extend their
activities. And they will, through their membership of community
health councils, influence the way in which district and area health
services are developed.
163*
The resources of voluntary organisations and individual
volunteers must, a s far as is possible, be matched to the needs of the
community for their services. With this object in view, the recent
growth in the number of organisers co-ordinating voluntary help in
hospitals will continue. Research is going on into similar methods
of co-ordination in the wider field of voluntary work in the community.
There may he scope for AHAs and local authorities to make joint
appointment of organisers to co-ordinate voluntary help, eg for the
elderly or mentally ill or handicapped, in both hospital and community.
This emphasis on co-ordination arises from the great variety of needs
and resources and its purpose is not in any way to limit the independence
of voluntary bodies but to provide an outlet for their continuing
expansion.
I64.
Good working r e l a t i o n s h i p s must a l s o be p r e s e r v e d and
s t r e n g t h e n e d i n e a c h community.
Individual hospitals w i l l s t i l l
a f o c u s f o r a wide range o f v o l u n t a r y s e r v i c e .
provide
Of p a r t i c u l a r v a l u e
i s s e r v i c e d i r e c t e d t o n e e d s o f l o n g - s t a y p a t i e n t s - v i s i t i n g and
befriending, helping r e l a t i v e s to v i s i t ,
occupying the p a t i e n t s
1
day
and k e e p i n g them i n c o n t a c t w i t h t h e e v e r y d a y l i f e o f t h e community.
O u t s i d e t h e h o s p i t a l s , t h e r e a r e many o t h e r n e e d s f o r v o l u n t a r y h e l p .
Examples a r e v i s i t i n g t h e e l d e r l y and t h e d i s a b l e d i n t h e i r own homes
and h o s t e l s ; and t o a growing e x t e n t , p r o v i d i n g c a r s e r v i c e s f o r t h o s e
who need h e l p t o t r a v e l t o d o c t o r s
1
s u r g e r i e s , h e a l t h centres or h o s p i t a l
o u t - p a t i e n t d e p a r t m e n t s , t o v i s i t f r i e n d s and r e l a t i v e s i n h o s p i t a l o r
t o attend s o c i a l
165.
clubs.
The RHAs and AHAs w i l l be a b l e t o make g r a n t s i n s u p p o r t o f
v o l u n t a r y b o d i e s which p r o v i d e and promote s e r v i c e s w i t h i n t h e g e n e r a l
scope of the a u t h o r i t i e s ' r e s p o n s i b i l i t i e s .
Financial help for national
a c t i v i t i e s w i l l c o n t i n u e t o come from t h e c e n t r a l Department.
XVIII TIIK PRIVATE SECTOR $
Hole of private sector
t£6,
The Oovernment recognises the contribution made by the private
sector of medicine to the sum of health care, through a wide variety
of private hospitals, nursing homes and other institutions and through
individual practitioners. It thinks it right for people to have an
opportunity to exercise a personal choice to seek treatment privately.
The existence of facilities for private treatment, both within and
outside the NHS, provides this opportunity. The private sector
can also act as a stimulus to enterprise, development and
high standards of service, and has a part to play
in maintaining this country's position as a medical centre of world
importance, from which the NHS benefits. For its part the Government
will continue to make available facilities in NHS hospitals for
private patients, without prejudice to the needs of those - the vast
majority - who wish to be treated as NHS patients and who are the
hospitals' primary concern.
MO A
The Government also acknowledges the tradition of service to
the community rendered by the long established voluntary institutions,
including those run by religious orders. These institutions could
continue to make a particularly important contribution towards the
care and welfare of geriatric patients and patients needing care and support in the final stages of fatal illness. /
Contractual arrangements
168,
Wherever it is compatible with the proper planning of services for an area, the Government wishes to encourage the use by the NHS of voluntary facilities provided under contractual arrangements. These facilities would be regarded as forming part of the total health resources of an area, not just as sources of temporary help. 67
Denominational Hospitals
T69*.
There will be no change in the arrangements which preserved
the character of certain hospitals and their association with
particular religious denominations when they were transferred to
the NHS in 1 9 4 8 .
CONFIDENTIAL XIX
170.
ENDOWMENTS
The h o s p i t a l a u t h o r i t i e s a r e t r u s t e e s o f s u b s t a n t i a l sums
g i v e n t o them by t h e p u b l i c .
and s p e c i a l p u r p o s e s .
Much o f t h i s money was g i v e n f o r l o c a l
I n t r a n s f e r r i n g t h e s e t r u s t s t o t h e new
a u t h o r i t i e s , i t i s r i g h t and n e c e s s a r y t o p r e s e r v e b o t h t h e l o c a l
a d m i n i s t r a t i o n and t h e p u r p o s e s of t h e s e g i f t s a s f a r a s i t
is
p o s s i b l e t o do s o .
171.
The funds now h e l d and a d m i n i s t e r e d by BMCs w i l l be t r a n s f e r r e d
t o t h e a p p r o p r i a t e AHA.
To p r e s e r v e t h e a d v a n t a g e s of l o c a l
administration,
t h e AHA w i l l be a b l e t o e s t a b l i s h c o m m i t t e e s , of t h o s e i n t h e l o c a l i t y who
a r e c o n c e r n e d , t o a d v i s e i t on t h e s p e n d i n g o f t h e f u n d s .
The f u t u r e
a d m i n i s t r a t i o n o f funds h e l d by BGs - some o f which a r e v e r y s u b s t a n t i a l
i s s t i l l under d i s c u s s i o n .
­
The BGs o f t h e London p o s t g r a d u a t e t e a c h i n g
h o s p i t a l s w i l l r e t a i n t h e i r endowments a s l o n g a s t h e Boards remain i n
existence (see Section X I I l ) .
172,
I n s p e n d i n g endowment moneys, t h e a u t h o r i t i e s w i l l be r e q u i r e d
t o r e s p e c t t h e s p e c i a l and l o c a l p u r p o s e s f o r which t h e funds were
originally given.
Thus endowments h e l d f o r s p e c i a l p u r p o s e s w i l l
continue
t o be used o n l y f o r p u r p o s e s w i t h i n t h e s c o p e o f t h e t r u s t ; and t h o s e
held f o r the general purposes of a p a r t i c u l a r h o s p i t a l only f o r the
purposes of t h a t h o s p i t a l .
Endowments a t p r e s e n t h e l d f o r t h e g e n e r a l
p u r p o s e s o f a h o s p i t a l a u t h o r i t y ( a s d i s t i n c t from t h o s e o f a p a r t i c u l a r
h o s p i t a l ) w i l l be u s e d o n l y f o r t h e h o s p i t a l s a t p r e s e n t c o n t r o l l e d and
managed by t h e h o s p i t a l a u t h o r i t y c o n c e r n e d and f o r , h e a l t h s e r v i c e s
a s s o c i a t e d w i t h them ( f o r example, r e s e a r c h and l o c a l h e a l t h c e n t r e s ) .
173.
The H o s p i t a l Endowments Fund w i l l be a v a i l a b l e t o H e a l t h
A u t h o r i t i e s f o r u s e f o r h o s p i t a l and a s s o c i a t e d p u r p o s e s .
69
174*
The new a u t h o r i t i e s w i l l have powers t o a c c e p t f r e s h
t o h e l p them i n any p a r t o f t h e i r work.
gifts
F i n a n c i a l h e l p from v o l u n t a r y
s o u r c e s has an i m p o r t a n t p a r t t o p l a y i n t h e H e a l t h S e r v i c e , and e v e r y
encouragement w i l l be g i v e n t o l o c a l l y o r g a n i s e d f u n d - r a i s i n g by
voluntary organisations.
When i t i s d i r e c t e d t o s p e c i f i c
local
o b j e c t s approved by t h e h e a l t h a u t h o r i t i e s , i t i s a u s e f u l means of
s p e e d i n g up p r o g r e s s .
pioneering.
I t a l s o e n c o u r a g e s l o c a l i n n o v a t i o n and
Independent funds are b a d l y n e e d e d , n o t o n l y by t h e
a c u t e , c h i l d r e n ' s and o t h e r h o s p i t a l s which a t p r e s e n t t e n d t o
attract
most of t h e p u b l i c ' s g i f t s , but a l s o f o r t h e g e r i a t r i c and p s y c h i a t r i c
services.
They a r e n e e d e d , n o t f o r p a t i e n t s . ' b a s i c r e q u i r e m e n t s , but
f o r r a i s i n g s t a n d a r d s and t o encourage t h e i n v e n t i v e n e s s and
imagination that are important i n t h e s e r v i c e s t h e y p r o v i d e .
CONFIDENTIAL
XX HANDLING COMPLAINTS 175,
For t h e i n v e s t i g a t i o n o f c o m p l a i n t s , each h e a l t h a u t h o r i t y s h o u l d have
arrangements which work w e l l and which command t h e c o n f i d e n c e o f t h e p u b l i c .
Arrangements a l r e a d y e x i s t i n most l o c a l a u t h o r i t i e s .
In Executive Councils,
there are l o n g - e s t a b l i s h e d s t a t u t o r y procedures f o r i n v e s t i g a t i n g
against contractor p r a c t i t i o n e r s .
As t o t h e h o s p i t a l s ,
complaints
the S e c r e t a r y o f
S t a t e f o r S o c i a l S e r v i c e s and t h e S e c r e t a r y of S t a t e f o r Wales s e t up an
independent committee, i n February 1 9 7 1 , w i t h Mr M i c h a e l D a v i e s QC, a s
its
Chairman, t o undertake a thorough r e v i e w o f t h e i r arrangements f o r h a n d l i n g
c o m p l a i n t s , t o p r o v i d e t h e h o s p i t a l s e r v i c e w i t h p r a c t i c a l g u i d a n c e , and
t o make recommendations.
The Committee i s e x p e c t e d t o r e p o r t l a t e r
this
year.
176.
But however good t h e a r r a n g e m e n t s , some c o m p l a i n a n t s w i l l remain
dissatisfied,
and i t i s important t h a t t h e y s h o u l d f e e l t h a t t h e y can s e e k t h e
h e l p o f an i n d e p e n d e n t t h i r d p a r t y .
has
As a l r e a d y announced, the Government
t h e r e f o r e d e c i d e d t h a t a H e a l t h S e r v i c e Commissioner s h o u l d be
e s t a b l i s h e d to i n v e s t i g a t e complaints against National Health Service
authorities.
The f u l l t e x t o f t h e s t a t e m e n t w h i c h t h e S e c r e t a r y o f S t a t e
f o r S o c i a l S e r v i c e s made i n t h e House of Commons on 22 February 1972 i s
reproduced i n Appendix I I .
177*
The appointment o f a H e a l t h S e r v i c e Commissioner i s an important
e x t e n s i o n o f t h e ombudsman p r i n c i p l e i n t h e p u b l i c s e r v i c e .
The
P a r l i a m e n t a r y Commissioner f o r A d m i n i s t r a t i o n was a p p o i n t e d i n 1967 w i t h
a r e m i t c o v e r i n g Government Departments ( i n c l u d i n g what i s now t h e Department
o f H e a l t h and S o o i a l S e c u r i t y , and t h e S p e c i a l H o s p i t a l s , but n o t t h e N a t i o n a l
H e a l t h S e r v i c e ) , and t h e Government h a s
a l s o announced i t s i n t e n t i o n o f
i n t r o d u c i n g a c o m p l a i n t s machinery f o r l o c a l
178.
government.
The l e g i s l a t i o n n e c e s s a r y t o e s t a b l i s h t h e H e a l t h S e r v i c e Commissioner
w i l l form p a r t of t h e NHS R e o r g a n i s a t i o n B i l l , but t h e Commissioner w i l l
be a b l e t o s t a r t work b e f o r e the u n i f i e d s e r v i c e
comes i n t o
operation
on 1 A p r i l 1974, though u n t i l t h a t date h i s j u r i s d i c t i o n w i l l not e x t e n d
to h e a l t h s e r v i c e s p r o v i d e d a t p r e s e n t by l o c a l a u t h o r i t i e s .
unification,
After
h i s terms of r e f e r e n c e w i l l c o v e r t h e whole of t h e NHS, b u t
he w i l l n o t i n v e s t i g a t e c o m p l a i n t s t h a t i n h i s o p i n i o n r e l a t e t o t h e
e x e r c i s e of c l i n i c a l judgment by d o c t o r s and o t h e r s t a f f , and he w i l l
not d e a l w i t h c o m p l a i n t s f o r which s t a t u t o r y p r o c e d u r e s a l r e a d y e x i s t
( e g t h o s e about g e n e r a l m e d i c a l and d e n t a l p r a c t i t i o n e r s , p h a r m a c i s t s and
o p t i c i a n s , which w i l l c o n t i n u e t o be d e a l t w i t h under t h e s e r v i c e committee
p r o c e d u r e ) , o r which he t h i n k s t h e complainant c o u l d r e a s o n a b l y pursue t h r o u g h
the c o u r t s o r b e f o r e some t r i b u n a l .
179.
The complainant w i l l have d i r e c t a c c e s s t o t h e H e a l t h S e r v i c e
Commissioner.
The Commissioner w i l l n o t however i n v e s t i g a t e a complaint u n t i l he
i s s a t i s f i e d t h a t t h e h e a l t h a u t h o r i t y concerned h a s had a r e a s o n a b l e o p p o r t u n i t y t o
i n v e s t i g a t e i t and r e p l y t o t h e oomplainant who, d e s p i t e t h i s i s s t i l l
dissatisfied.
I t i s p l a i n l y important t h a t t h e h e a l t h a u t h o r i t y s h o u l d i t s e l f have t h e
o p p o r t u n i t y t o i n v e s t i g a t e a c o m p l a i n t about a s e r v i c e f o r which i t
is
r e s p o n s i b l e , and i n t h e g r e a t m a j o r i t y o f c a s e s t h e i n t e r n a l p r o c e d u r e s
can be e x p e c t e d t o s a t i s f y the c o m p l a i n a n t .
I t i s o n l y when the
complainant
remains d i s s a t i s f i e d t h a t t h e r e may be s c o p e f o r an i n v e s t i g a t i o n by t h e
H e a l t h S e r v i c e Commissioner.
180.
Complaints t o the H e a l t h S e r v i c e Commissioner w i l l n o t have t o
be made by t h e p a t i e n t h i m s e l f ,
a l t h o u g h no doubt most o f them w i l l b e .
There w i l l be c a s e s where t h e p a t i e n t i s unable t o a c t f o r h i m s e l f ,
when t h a t happens, t h e c o m p l a i n t may be
made
f o r him.
and
This i s an
important s a f e g u a r d f o r t h o s e who, b e c a u s e of t h e n a t u r e of t h e i r
infirmity,
a r e u n a b l e t o speak f o r t h e m s e l v e s ; i t w i l l e n a b l e a wrong s u f f e r e d ,
example, by a m e n t a l l y handicapped p e r s o n t o be brought t o l i g h t .
for
I n such
t h e complaint can be made by a r e l a t i v e o r f r i e n d o f t h e p a t i e n t o r by a
member o f t h e h o s p i t a l
staff.
case3,
XXI
*81.
SPECIAL HOSPITALS The S e c r e t a r y o f S t a t e i s d i r e c t l y r e s p o n s i b l e f o r t h e
control
and management of t h e s p e c i a l h o s p i t a l s which a r e p r o v i d e d under t h e
Mental H e a l t h Act 1959 f o r p a t i e n t s d e t a i n e d under t h a t Act who, i n
h i s o p i n i o n , r e q u i r e t r e a t m e n t under c o n d i t i o n s o f s p e c i a l
security
because o f t h e i r d a n g e r o u s , v i o l e n t o r c r i m i n a l p r o p e n s i t i e s
s
These h o s p i t a l s r e c e i v e p a t i e n t s from a l l p a r t s o f England and W a l e s .
I n a d d i t i o n t o t h e i r t h e r a p e u t i c f u n c t i o n s , t h e maintenance o f
s e c u r i t y f o r t h e p r o t e c t i o n o f t h e p u b l i c i s an e s s e n t i a l
o f t h e i r work.
I t i s intended that the Secretary of State
feature
shall
r e t a i n d i r e c t r e s p o n s i b i l i t y f o r t h e i r c o n t r o l and management, but
w i t h power t o d e l e g a t e s u c h r e s p o n s i b i l i t y t o a r e g i o n a l o r a r e a
health authority or a s p e c i a l l y constituted joint health authority
i f f u t u r e developments s h o u l d make t h i s d e s i r a b l e a t any t i m e .
The S e c r e t a r y of S t a t e h a s no p r e s e n t i n t e n t i o n o f changing t h e
arrangements f o r d i r e c t c o n t r o l by t h e Department.
XXII
182.
ARRANGEMENTS FOR LONDON The Londoner n e e d s i n t e g r a t e d h e a l t h s e r v i c e s , c l o s e l y a s s o c i a t e d
w i t h t h e p e r s o n a l s o c i a l and o t h e r l o c a l a u t h o r i t y s e r v i c e s , no l e s s
people l i v i n g elsewhere.
The arrangements i n G r e a t e r London w i l l
than
therefore
he b a s e d on t h e g e n e r a l r e g i o n a l and a r e a s t r u c t u r e adopted f o r t h e r e s t
of the country.
S p e c i a l f e a t u r e s o f London a r e a
183.
There are however e x c e p t i o n a l f e a t u r e s i n t h e h e a l t h and r e l a t e d
s e r v i c e s i n London which c a l l f o r a d j u s t m e n t s t o t h e s t r u c t u r e .
Among t h e s e
f e a t u r e s are t h e a l r e a d y e s t a b l i s h e d p a t t e r n o f l o c a l government b o u n d a r i e s
and s e r v i c e s , t h e way i n which h o s p i t a l s - i n c l u d i n g t h e v e r y l a r g e number of
undergraduate and p o s t g r a d u a t e t e a c h i n g h o s p i t a l s - a r e d i s t r i b u t e d , and t h e
fact
t h a t e x e c u t i v e c o u n c i l s a d m i n i s t e r f a m i l y p r a c t i t i o n e r s e r v i c e s o v e r much w i d e r
a r e a s t h a n t h o s e o f t h e i n d i v i d u a l London b o r o u g h s .
In recognition of
these
f e a t u r e s , and t a k i n g a c c o u n t o f t h e c o n s u l t a t i o n s r e f e r r e d t o i n paragraph 15 ­
which a r e c o n t i n u i n g - c e r t a i n s p e c i a l arrangements w i l l be made i n t h e London
area.
184.
These s p e c i a l arrangements t a k e a c c o u n t o f t h r e e important a s p e c t s
o f t h e s i t u a t i o n i n London:
( a )
London borough b o u n d a r i e s must be u s e d i n forming AHAs s o t h a t
t h e r e can be c o l l a b o r a t i o n between t h e NHS and borough s e r v i c e s ;
( b )
t h e s e b o u n d a r i e s are i n t h e main u n r e l a t e d t o many o f t h e
e x i s t i n g h e a l t h s e r v i c e s , and t h e n a t u r a l h e a l t h
districts
o v e r l a p them;
( c )
some i m p o r t a n t h e a l t h s e r v i c e s - n o t a b l y t h e f a m i l y p r a o t i t i o n e r
and ambulance s e r v i c e s - n e e d u n i t s of a d m i n i s t r a t i o n
than e i t h e r t h e borough o r t h e h e a l t h
Special
185.
larger
district.
arrangements
The s p e c i a l arrangements a r e t h e s e :
( a )
There w i l l be f o u r RHAs.
Each i s l i k e l y t o c o n t a i n
territory
i n s i d e and o u t s i d e G r e a t e r London, and t e r r i t o r y i n i n n e r and i n
o u t e r London.
74
CONFIDENTIAL
CONFIDENTIAL an a d v i s o r y c o - o r d i n a t i n g working group w i l l be s e t up on l i n e s
s i m i l a r t o t h e J o i n t Working Group which now e x i s t s t o a d v i s e
on h o s p i t a l s e r v i c e s in London.
The group w i l l s e c u r e
co-ordinated
p l a n n i n g o f f a c i l i t i e s f o r m e d i c a l and d e n t a l t e a c h i n g and r e s e a r c h
and t h e l o c a t i o n o f r e g i o n a l and s u b - r e g i o n a l
specialities;
H e a l t h a r e a s w i l l be formed out o f s i n g l e London Boroughs o r
groups of b o r o u g h s .
The b o u n d a r i e s have n o t y e t been s e t t l e d .
The l o c a l a u t h o r i t y p l a c e s on t h e AHA ( w h i c h may be more t h a n t h e
f o u r mentioned i n paragraph 98) w i l l be shared between t h e boroughs
on an e q u i t a b l e
basis;
t h e h e a l t h d i s t r i c t s , each of which w i l l have a community h e a l t h
c o u n c i l , w i l l have b o u n d a r i e s which w i l l n o t a l w a y s f o l l o w t h e
borough b o u n d a r i e s w i t h i n t h e h e a l t h a r e a ;
t h e G r e a t e r London Ambulance S e r v i c e w i l l n o t be s p l i t up between
t h e RHAs o r AHAs but w i l l c o n t i n u e t o be a d m i n i s t e r e d a s a
single
unit.
I t i s an a c c e p t e d aim t h a t each p o s t g r a d u a t e t e a c h i n g h o s p i t a l
s h o u l d become c l o s e l y a s s o c i a t e d w i t h o t h e r h o s p i t a l s and h e a l t h
services in i t s vicinity.
But u n t i l t h i s a s s o c i a t i o n i s
close
enough t o make ifc d e s i r a b l e f o r t h e p o s t g r a d u a t e h o s p i t a l t o be
a d m i n i s t e r e d by t h e AHA(T), t h e S e c r e t a r y o f S t a t e w i l l ,
c o n s u l t a t i o n w i t h London U n i v e r s i t y ,
after
c o n t i n u e i t s Board o f
Governors i n b e i n g f o r an a p p r o p r i a t e t r a n s i t i o n a l
period.
During t h i s t r a n s i t i o n a l p e r i o d t h e Board w i l l c o n t i n u e t o be
a p p o i n t e d a s a t p r e s e n t , e x c e p t t h a t t h e members now nominated
by t h e RHB w i l l be nominated by t h e RHA..
The Board w i l l have a
d i r e c t r e l a t i o n s h i p w i t h and w i l l g e t i t s money from t h e
Department,
75
central
CONFIDENTIAL Family p r a c t i t i o n e r committees
186.
Area h e a l t h a u t h o r i t i e s and f a m i l y p r a c t i t i o n e r c o m m i t t e e s must
correspond on a o n e - t o - o n e b a s i s i n o r d e r t o g e t maximum b e n e f i t
i n t e g r a t i o n of the h e a l t h s e r v i c e s .
as in the r e s t of the country.
from
T h i s a p p l i e s a s much i n G r e a t e r London
The replacement o f t h e f i v e E x e c u t i v e
C o u n c i l s which c o v e r G r e a t e r London and p a r t s o f t h e s u r r o u n d i n g a r e a s
by a d i f f e r e n t number o f f a m i l y p r a c t i t i o n e r c o m m i t t e e s w i l l g i v e r i s e
to
c e r t a i n p r a c t i c a l p r o b l e m s , and t h e c e n t r a l Department w i l l g i v e a l l t h e
h e l p i t can i n overcoming them, i n c o n s u l t a t i o n w i t h t h e
interests
concerned.
Boundaries and p a t i e n t s
187.
No p a r t of t h e s e s p e c i a l arrangements w i l l p r e v e n t Londoners
c r o s s i n g boundaries t o t h e i r family doctor o r t o a h o s p i t a l o u t s i d e the
h e a l t h a r e a i n which t h e y l i v e .
I n London, a s i n t h e r e s t o f t h e c o u n t r y ,
a d m i n i s t r a t i v e b o u n d a r i e s w i l l be d e s i g n e d t o h e l p , n o t t o h i n d e r t h e
patient
0
75A CONFIDENTIAL XXIII
188.
RUNNING THE SERVICE UNTIL 1974 I t i s important t h a t t h e NHS s h o u l d c o n t i n u e t o d e v e l o p w i t h o u t
any l o s s o f momentum, and t h a t t h e a d m i n i s t r a t i v e changes on 1 A p r i l 1974
s h o u l d n o t cause i n t e r r u p t i o n o r d e l a y .
T h i s means t h a t a l l t h e
existing
h e a l t h a u t h o r i t i e s s h o u l d s e e t h e i r work a s g o i n g on beyond t h a t d a t e ,
even
though t h e y w i l l n o t t h e m s e l v e s c o n t i n u e t o e x i s t i n t h e i r p r e s e n t form.
Local h e a l t h a u t h o r i t y
189.
services
The l o c a l h e a l t h a u t h o r i t y s e r v i c e s have been i m p r e s s i v e l y d e v e l o p e d
i n recent years.
The new h e a l t h a u t h o r i t i e s w i l l be a b l e t o t a k e o v e r a
f l o u r i s h i n g range o f community-based s e r v i c e s i f t h e pace o f development d o e s
not f a l t e r in the period before u n i f i c a t i o n .
The Government h a s made p r o v i s i o n
f o r i n c r e a s i n g p u b l i c e x p e n d i t u r e on t h e community h e a l t h and p e r s o n a l
services.
social
I n t h e c a s e o f f a m i l y p l a n n i n g , f i n a n c i a l support was g i v e n f o r a
t r e b l i n g o f e x p e n d i t u r e i n t h e y e a r s 1971/2 and 1972/3.
F i n a n c i a l terms more
f a v o u r a b l e f o r a u t h o r i t i e s than i n t h e p a s t f o r r e n t i n g h e a l t h c e n t r e p r e m i s e s
t o g e n e r a l p r a c t i t i o n e r s have b e e n announced.
190.
The work o f e x i s t i n g s t a f f s o f l o c a l h e a l t h a u t h o r i t i e s - whether
o p e r a t i o n a l o r a d m i n i s t r a t i v e and whether o r n o t p r o f e s s i o n a l l y q u a l i f i e d
w i l l i n c r e a s e i n i m p o r t a n c e and s c o p e .
­
M e d i c a l O f f i c e r s o f H e a l t h can l o o k
forward t o g r e a t e r o p p o r t u n i t i e s i n m e d i c a l a d m i n i s t r a t i o n i n t h e w i d e s t
sense,
and t r a i n i n g i s b e i n g p r o v i d e d ( s e e S e c t i o n XXTV) t o e q u i p them and o t h e r
m e d i c a l a d m i n i s t r a t o r s t o t a k e advantage o f t h e s e o p p o r t u n i t i e s .
Nursing s t a f f
i n t h e community w i l l a l s o have a w i d e r span o f work, b o t h i n p r e v e n t i v e
work and i n c l i n i c a l c a r e o f p a t i e n t s .
191.
,
Members and s e n i o r o f f i c e r s o f most l o c a l h e a l t h
authorities
a t t e n d e d t h e r e g i o n a l c o n f e r e n c e s h e l d i n l a t e 1971 and e a r l y 1972
which t h e S e c r e t a r y o f S t a t e f o r S o c i a l S e r v i c e s and h i s M i n i s t e r i a l
76 health
c o l l e a g u e s h e l d , on t h e n e e d t o e n s u r e t h a t s t a n d a r d s
o f l o c a l h e a l t h s e r v i o e s and morale and I n t e r e s t s o f
staff
are m a i n t a i n e d and s t r e n g t h e n e d i n t h e i n t e r i m p e r i o d .
I n February 1972
( C i r c u l a r 13/72), t h e S e c r e t a r y of S t a t e made a number o f recommendations
f o r improving t h e e f f e c t i v e n e s s o f t h e l o c a l h e a l t h s e r v i c e s w i t h
p a r t i c u l a r e m p h a s i s on deployment of n u r s i n g s t a f f s .
Local h e a l t h
a u t h o r i t i e s were urged, f o r example, t o c o n t i n u e t o encourage schemes f o r t h e
a s s o c i a t i o n o f n u r s i n g s t a f f w i t h group g e n e r a l p r a c t i c e s and t o put i n t o
e f f e c t t h e r e c e n t recommendations about management s t r u c t u r e and
management t r a i n i n g o f n u r s i n g s t a f f i n p a r a l l e l w i t h what h a s been
i n p r o g r e s s f o r some t i m e on t h e h o s p i t a l s i d e f o l l o w i n g t h e Salmon
report.
They were a l s o a s k e d t o make w i d e r u s e o f a n c i l l a r y h e l p and
o f t h e s k i l l o f SENs so a s t o e n a b l e h e a l t h v i s i t o r s and home n u r s e s t o
be d e p l o y e d more e f f e c t i v e l y .
I t i s hoped, t o o , t h a t l o c a l h e a l t h
a u t h o r i t i e s w i l l m a i n t a i n t h e i m p e t u s a l r e a d y g i v e n t o t h e improvement
i n t h e s t a n d a r d o f equipment and t r a i n i n g of t h e ambulance s e r v i c e .
77 C O N FIDE N-TIA t
CONFIDENTIAL
XXIV
PREPARING FOR
1974
Joint Liaison Committees 192*
There is a great deal of preparatory work to be done if NHS reorganisation is to be carried through smoothly, and without interrupting continuity in the provision and development of services for patients. 1'93*
The new area and regional authorities will be appointed as
soon as possible after the necessary legislation is passed. They will
therefore be in existence, in "shadow" form, for some months before
they take over responsibility for administering the NHS from the
existing authorities on 1 April 1974.
They will have much to do
in this short time.
194*
The task of the shadow authorities will be made easier if
as much preparatory work as possible is done before their appointment.
This work will fall largely to the existing NHS authorities. It
divides into two main parts. First there is work that can and should
be done by the existing authorities themselves; examples are the
preparation for each new area of statements about existing resources,
developments in hand and current forward plans; and about rights,
liabilities and endowments to be transferred to the new authorities
in 1974.
Secondly, there are matters which can be settled only by the
new shadow authorities when they are established in 1973, but on which
preliminary assessments can be carried out in advance. Examples are
the pattern of health districts within each new area, and the management
structure and the staffing and accommodation requirements.
195*
The existing authorities cannot do this work on their own. They
need guidance and help; they must consult together; and their efforts
must be co-ordinated. For these purposes joint liaison committees are
in the process of being established.
There
will normally be
ne
0
such committee for each new health area, composed of representatives - all or most of them senior officers - from each existing authority; and one for each 78
CONFIDENTIAL
net? h e a l t h r e g i o n , composed o f r e p r e s e n t a t i v e s of e a c h a r e a j o i n t
liaison
committee and o f t h e HHB.
196,
These j o i n t l i a i s o n committees w i l l work i n c o n s u l t a t i o n w i t h
s i m i l a r c o m m i t t e e s t h a t are b e i n g s e t up f o r l o c a l government
reorganisation.
They w i l l have a s p e c i a l r e s p o n s i b i l i t y f o r e n s u r i n g t h a t NHS s t a f f
are
f u l l y c o n s u l t e d , and a r e k e p t f u l l y informed about NHS r e o r g a n i s a t i o n
by t h e i r e x i s t i n g e m p l o y i n g a u t h o r i t i e s .
Training for
197*
reorganisation
Arrangements have b e e n made and announced f o r t h e h o l d i n g o f
i n t e g r a t e d t r a i n i n g c o u r s e s l a s t i n g about f o u r w e e k s , a t
Universities
and o t h e r c e n t r e s , t o p r e p a r e s e n i o r s t a f f f o r t h e i r new r e s p o n s i b i l i t i e s
and o p p o r t u n i t i e s .
These c o u r s e s , and o t h e r s p e c i a l c o u r s e s d e s i g n e d
t o complement t h e i n t e r - p r o f e s s i o n a l c o u r s e s , have a l r e a d y s t a r t e d .
a d d i t i o n , i t i s p r o p o s e d s h o r t l y t o arrange a s e r i e s o f s h o r t
In
conferences
o r s e m i n a r s f o r t h e most s e n i o r s t a f f i n e a c h r e g i o n , f o l l o w i n g p u b l i c a t i o n
o f t h i s White P a p e r ; and l o c a l arrangements f o r t r a i n i n g w i l l be made by
the j o i n t l i a i s o n committees.
NHS S t a f f
198*
Commission
NHS r e o r g a n i s a t i o n w i l l b r i n g t o g e t h e r under a s i n g l e management,
s t a f f p r e v i o u s l y employed by a v a r i e t y o f b o d i e s .
For many, t h e i r work w i l l
change l i t t l e o r n o t a t a l l , e x c e p t t h a t t h e y w i l l have a new e m p l o y i n g
authority.
But t h e r e w i l l a l l t h e same be problems o f r e d e p l o y m e n t ; and t h e r e
must be a r r a n g e m e n t s f o r f i l l i n g p a r t i c u l a r p o s t s under t h e new a u t h o r i t i e s .
i s of the f i r s t
importance t h a t t h e s e m a t t e r s s h o u l d be h a n d l e d - and f e l t by a l l
concerned t o be h a n d l e d - w i t h t h e g r e a t e s t p o s s i b l e f a i r n e s s f o r t h e
concerned.
It
staff
The Government h a s a l r e a d y made c l e a r i t s i n t e n t i o n t o s e t up a
NHS S t a f f Commission r e s p o n s i b l e f o r a d v i s i n g on t h e p r o c e d u r e s t o be
f o l l o w e d f o r f i l l i n g p o s t s and on t h e arrangements f o r t h e t r a n s f e r o f
and f o r s a f e g u a r d i n g t h e i r i n t e r e s t s d u r i n g t h e p e r i o d o f
79 staff,
reorganisation.
CONFIDENTIAL .
—
The Commission would a l s o have t h e duty o f c o n s i d e r i n g arrangements
appeals.
for
As e x p l a i n e d i n a P a r l i a m e n t a r y announcement on
29 November 1 9 7 1 , t h e Commission cannot be s e t up f o r m a l l y u n t i l
l e g i s l a t i o n has been p a s s e d .
Meanwhile, an A d v i s o r y Committee - a s
foreshadowed i n t h a t announcement - h a s been a p p o i n t e d and h a s s t a r t e d
work.
The r i g h t s o f t r a n s f e r r e d s t a f f w i l l be m a i n t a i n e d , and a s
199-*
s t a t e d i n t h e White Paper on t h e Reform of L o c a l Government^
the
Government i s examining the p r e s e n t arrangements f o r c o m p e n s a t i o n f o r
l o s s o f o f f i c e with r e g a r d t o t h e i r i m p l i c a t i o n s f o r t h e whole o f p u b l i c
employment.
Other m a t t e r s
200*
Many s t a t u t o r y i n s t r u m e n t s w i l l need r e v i s i o n , and some new
ones w i l l have to be made.
There w i l l be c o n s u l t a t i o n s about them w i t h
the i n t e r e s t e d b o d i e s .
201.
In a d d i t i o n t o t h e arrangements f o r the t r a n s f e r of s t a f f ,
it
w i l l be n e c e s s a r y t o t r a n s f e r t h e ownership of p r o p e r t y , r e a l and p e r s o n a l ,
from t h e l o c a l h e a l t h and e d u c a t i o n a u t h o r i t i e s and the E x e c u t i v e C o u n c i l s
t o the Secretary of S t a t e .
v e s t s i n him.
Property used for h o s p i t a l purposes already
R i g h t s and l i a b i l i t i e s
(including outstanding
a u t h o r i t y l o a n d e b t ) w i l l s i m i l a r l y be t r a n s f e r r e d .
local
There w i l l be
d o u b t f u l c a s e s t o s e t t l e , a p p o r t i o n m e n t s t o be made, and t r a n s i t i o n a l
arrangements t o be n e g o t i a t e d .
F i n a l l y i t w i l l be n e o w s s a r y t o a l l o c a t e
t h e p r o p e r t y (and where a p p r o p r i a t e t h e r i g h t s and l i a b i l i t i e s )
new a u t h o r i t i e s f o r u s e i n t h e e x e r c i s e o f t h e i r f u n c t i o n s .
80
*
Cmnd. 4 2 7 6 , paragraph 9 4 .
to the
CONFIDENTIAL The Commission would a l s o have t h e duty o f c o n s i d e r i n g arrangements
appeals.
for
As e x p l a i n e d i n a P a r l i a m e n t a r y announcement on
29 November 1 9 7 1 , t h e Commission cannot be s e t up f o r m a l l y u n t i l
l e g i s l a t i o n has been p a s s e d .
Meanwhile, an A d v i s o r y Committee - a s
-
foreshadowed i n t h a t announcement - has been a p p o i n t e d and h a s s t a r t e d
work.
The r i g h t s of t r a n s f e r r e d s t a f f w i l l be m a i n t a i n e d , and a s
199*
s t a t e d i n t h e White Paper on t h e Reform o f L o c a l Government*,
the
Government i s examining t h e p r e s e n t arrangements f o r compensation f o r
l o s s o f o f f i c e w i t h r e g a r d t o t h e i r i m p l i c a t i o n s f o r t h e whole of p u b l i c
employment.
Other m a t t e r s
"
200*
1
Many s t a t u t o r y i n s t r u m e n t s w i l l need r e v i s i o n ,
ones w i l l have to be made.
and some new
There w i l l be c o n s u l t a t i o n s about them w i t h
the i n t e r e s t e d b o d i e s .
201.
In a d d i t i o n t o t h e arrangements f o r the t r a n s f e r of s t a f f ,
it
w i l l be n e c e s s a r y t o t r a n s f e r t h e ownership of p r o p e r t y , r e a l and p e r s o n a l ,
from t h e l o c a l h e a l t h and e d u c a t i o n a u t h o r i t i e s and the E x e c u t i v e C o u n c i l s
to the Secretary of S t a t e .
v e s t s i n him.
P r o p e r t y u s e d for h o s p i t a l p u r p o s e s a l r e a d y
R i g h t s and l i a b i l i t i e s
(including outstanding
a u t h o r i t y l o a n d e b t ) w i l l s i m i l a r l y be t r a n s f e r r e d .
local
There w i l l be
d o u b t f u l c a s e s t o s e t t l e , a p p o r t i o n m e n t s t o be made, and t r a n s i t i o n a l
arrangements t o be n e g o t i a t e d .
F i n a l l y i t w i l l be n e c e s s a r y t o a l l o c a t e
t h e p r o p e r t y (and where a p p r o p r i a t e t h e r i g h t s and l i a b i l i t i e s ) t o t h e
new a u t h o r i t i e s f o r u s e i n t h e e x e r c i s e o f t h e i r f u n c t i o n s .
80
*
Cmnd. 4 2 7 6 , paragraph 9 4 .
XXV
202.
CONCLUSION
I n t h e f i n a l a n a l y s i s , h e a l t h oare depends on t h e
effeotive
d e l i v e r y a t t h e r i g h t t i m e and p l a c e o f t h e s k i l l s and d e v o t i o n o f t h o s e
providing the s e r v i c e s required.
We a r e i n d e e d f o r t u n a t e i n t h i s c o u n t r y
i n t h e q u a l i t y o f t h e s t a f f o f o u r h e a l t h t e a m s , and we h a v e good r e a s o n
t o be proud o f t h e a c h i e v e m e n t o f t h e N a t i o n a l H e a l t h S e r v i c e .
203.
N e v e r t h e l e s s , no one would c l a i m t h a t i t i s p e r f e c t .
The proposed
r e o r g a n i s a t i o n o f f e r s t h e chance t o e s t a b l i s h a framework w i t h i n which a
b e t t e r i n t e g r a t e d and improved s e r v i c e can be o f f e r e d t o t h e p u b l i c .
204,
How i n f a c t w i l l t h e p u b l i c b e n e f i t from r e o r g a n i s a t i o n ?
A more
informed judgment o f p r i o r i t i e s w i l l c o n c e n t r a t e more o f t h e a v a i l a b l e
r e s o u r c e s where t h e y a r e most n e e d e d .
There w i l l be b e t t e r
p r o v i s i o n f o r t h e i r h e a l t h and s o c i a l n e e d s .
co-ordinated
P r o f e s s i o n a l s k i l l s w i l l be
grouped i n t o teams t o meet t h e n e e d s o f p a r t i c u l a r c a t e g o r i e s o f p a t i e n t s
- t h e o l d , t h e h a n d i c a p p e d , t h e a o u t e l y i l l , mothers and c h i l d r e n ,
mentally siok.
the
The community h e a l t h c o u n c i l s w i l l be a means o f e n s u r i n g
t h a t t h e s e r v i c e i s run w i t h f u l l r e g a r d t o t h e p u b l i c ' s v i e w s .
Improved
arrangements w i l l be made f o r e n q u i r i n g i n t o c o m p l a i n t s .
205.
R e o r g a n i s a t i o n w i l l be o f e q u a l b e n e f i t i n h e l p i n g t h o s e who p r o v i d e
or manage h e a l t h s e r v i c e s t o improve t h e q u a l i t y o f c a r e g i v e n t o t h e p u b l i c .
The h e a l t h p r o f e s s i o n s w i l l have t h e s u p p o r t o f a w e l l o r g a n i s e d NHS f o r t h e
e x e r c i s e o f t h e i r p r o f e s s i o n a l s k i l l s and w i l l be f r e e d from some o f t h e
f r u s t r a t i o n s which t h e l a c k o f t h i s i n t h e p a s t h a s c a u s e d .
Furthermore, t h e y w i l l make an i m p o r t a n t c o n t r i b u t i o n t o t h e management
o f t h e s e r v i c e 1 t h e g o v e r n i n g a u t h o r i t i e s w i l l i n c l u d e members of t h e main
h e a l t h p r o f e s s i o n s and w i l l r e a c h t h e i r d e c i s i o n s on t h e b a s i s o f a d v i c e
from s t r o n g p r o f e s s i o n a l a d v i s o r y oommittees and from t h e i r c h i e f
professional
officers.
Those o f t h e p r o f e s s i o n s who a r e independent
contractors
w i l l be s t r o n g l y r e p r e s e n t e d on s p e c i a l committees f o r a d m i n i s t e r i n g t h e i r
contractual r e l a t i o n s h i p with the s e r v i c e .
206.
The s t a f f o f t h e NHS, i n c l u d i n g t h e p r o f e s s i o n a l s t a f f , w i l l
in
a u n i f i e d s e r v i c e have w i d e r scope and o p p o r t u n i t i e s t h a n i s now t h e
case.
They w i l l be f u l l y c o n s u l t e d about t h e c h a n g e s , and c a r e w i l l be
t a k e n , by t h e e s t a b l i s h m e n t of a S t a f f Commission and i n o t h e r w a y s , t o
s a f e g u a r d t h e i r i n t e r e s t s when the changes a r e b e i n g made.
The members o f t h e new h e a l t h a u t h o r i t i e s , and t h e i r a d m i n i s t r a t i v e
207.
staff,
w i l l be a b l e t o d e v e l o p comprehensive s e r v i c e s w i t h o u t
running
i n t o t h e a r t i f i c i a l a d m i n i s t r a t i v e b a r r i e r s which now d i v i d e t h e
sectors
o f what s h o u l d be a s i n g l e s e r v i c e .
full
The a d m i n i s t r a t o r w i l l have
scope f o r p e r s o n a l i n i t i a t i v e w i t h i n c l e a r l y a l l o c a t e d
responsibilities.
T h i s w i l l g i v e him t h e s a t i s f a c t i o n o f b e i n g a b l e t o do a w o r t h w h i l e j o b
w e l l , o f s e c u r i n g v a l u e f o r money and p r o v i d i n g a framework and t h e
n e c e s s a r y s u p p o r t f o r an e f f i c i e n t and s e n s i t i v e h e a l t h
208.
servioe.
T h i s White Paper p r o p o s e s a framework which w i l l c o - o r d i n a t e
the
many and v a r i e d s k i l l s o f a l l t h o s e who work i n t h e N a t i o n a l H e a l t h
S e r v i c e and w i l l f o c u s them on t h e n e e d s o f t h e i n d i v i d u a l c i t i z e n o f
oountry.
this
I.
CONFIDENTIAL
NATIONAL HEALTH SERVICE REORGANISATION
:
APPENDIX I
; ENGLAND r
Boundaries for the Area and Regional Health Authorities outside London
;v
Regional Health
jAuthority
Area Health Authorities
(Corresponding to the local government counties and
metropolitan districts)
Number of Area Health Authorities Cumbria, Durham, Northumberland, Teesside and the
5 metropolitan districts in Tyneside
9
Humberside^North Yorkshire and the 5 metropolitan
districts in West Yorkshire
7
Derbyshire, Leicestershire, Lincolnshire, Nottinghamshire and the 4 metropolitan districts
in South Yorkshire
8
4
Cambridgeshire, Norfolk and Suffolk 3
5*
Bedfordshire and Hertfordshire 2/
6* Essex
/ 7* East Sussex and Kent
2/
8* Surrey and West Sussex
2/ 9
Dorset, Hampshire and Wiltshire 3
Berkshire, Buckinghamshire, Northamptonshire and
Oxfordshire
4
Avon, Cornwall, Devon, Gloucestershire and Somerset 5
1
2
3
10 11 12 13
H Hereford and Worcester, Salop, Staffordshire,
Warwickshire and the 7 metropolitan districts in
West Midlands
Cheshire and the 4 metropolitan districts in
Kerseyside
Lancashire and the 9 metropolitan d i s t r i 6 t s in
Greater Manchester
j 11
5
10
72
/ Outside London I0TE
phe names and boundaries shown in column 2 above and on the attached map are those
published in the Local Government Bill (as amended by Standing Committee D) and are
still subject to change in Parliament.
^
T I O N A L HEALTH SERVICE REOfc
(BOUNDARIES FOR THE AREA AND REGIONAL HEA C UMBRIA
M ERSEYSIDE
IONAL HEALTH AUTHORITIES OUTSIDE LONDON YIMES IDE
Regional Health Authority
Area Health Authority YORK
NORTH
Jf
LANCASHIRE
14
x
-( ^
MERSEYSIDE
"vWEST
YORKSHIRE
.- "
e
c
X
bGREATER f
a MANCHESTER,
V 11 SOUTH
YORKSHll
LINCOLNSHIRE
STAFFORDSHIRE
NORFOLK
LEICESTERSHIRE
CAMBRIDGESHIRE
WARWICKSHIRE)
SUFFOLK
AND
WORCESTER
GLOUCESTERSHIRE
ESSEX
OXFORDSHIRE
BERKSHIRE
WILTSHIRE
KENT
SURREY,
HAM PSHIRE
WEST
DORSET
MILES
10 KILOMETRES
SUSSEX
EAST
SUSSEX
APPENDIX I I
STATEMENT IN THE HOUSE OF COMMONS ON 22 FEBRUARY 1 9 7 2 .
BY THE SECRETARY OF STATE FOR SOCIAL SERVICES
HEALTH SERVICE COMMISSIONER
The Government have d e c i d e d t h a t t h e r e should he a H e a l t h S e r v i c e
Commissioner a s p a r t o f t h e arrangements f o r d e a l i n g w i t h c o m p l a i n t s
i n t h e N a t i o n a l H e a l t h S e r v i c e . A l t h o u g h the g r e a t m a j o r i t y o f
c o m p l a i n t s are s a t i s f a c t o r i l y d e a l t w i t h by h e a l t h a u t h o r i t i e s , t h e r e
a r e some t h a t t h e c i t i z e n s h o u l d be a b l e t o r e f e r t o an e n t i r e l y
i n d e p e n d e n t p e r s o n i f he remains d i s s a t i s f i e d w i t h the a c t i o n t a k e n
by t h e H e a l t h S e r v i c e a u t h o r i t y . A commissioner would s e r v e t h i s
i n d e p e n d e n t f u n c t i o n and would r e i n f o r c e t h e r i g h t s of t h o s e who u s e
t h e H e a l t h S e r v i c e , w i t h o u t d e t r a c t i n g from t h e r e s p o n s i b i l i t i e s o f
t h e H e a l t h S e r v i c e a u t h o r i t i e s o r r e f l e c t i n g on t h e v a l u e of t h e work
done by t h e s t a f f of t h e s e r v i c e .
There w i l l be a H e a l t h S e r v i c e Commissioner f o r England, one f o r
Wales and one f o r S c o t l a n d , b u t , i n i t i a l l y a t l e a s t , t h e t h r e e p o s t s
w i l l be h e l d by t h e same p e r s o n . T h i s i s an important e x p a n s i o n o f
t h e machinery f o r t h e independent i n v e s t i g a t i o n o f c o m p l a i n t s f o r
which t h e P a r l i a m e n t a r y Commissioner f o r A d m i n i s t r a t i o n r e p r e s e n t s
a proven p r e c e d e n t . I t would be premature f o r t h e commissioner t o
be d e s i g n a t e d now. The Government t h i n k , however, t h a t t h e work o f
t h e H e a l t h S e r v i c e Commissioner and of t h e P a r l i a m e n t a r y Commissioner
f o r A d m i n i s t r a t i o n should be c l o s e l y a s s o c i a t e d , and t h e y r e c o g n i s e
t h a t t h e r e are s t r o n g arguments f o r c o n s i d e r i n g whether t h e s e p o s t s
s h o u l d a l l be h e l d by the same p e r s o n . B e f o r e r e a c h i n g a d e c i s i o n on
t h i s , t h e v i e w s of t h e S e l e c t Committee on t h e P a r l i a m e n t a r y Commissioner
f o r A d m i n i s t r a t i o n w i l l be s o u g h t . Appointment o f t h e commissioner
w i l l be by Her M a j e s t y by L e t t e r s P a t e n t . I n t h i s and i n h i s t e n u r e
o f o f f i c e , he w i l l f o l l o w t h e p r e c e d e n t s e t by t h e P a r l i a m e n t a r y
Commissioner f o r A d m i n i s t r a t i o n , and w i l l e n j o y t h e same degree o f
i n d e p e n d e n c e i n c a r r y i n g out h i s f u n c t i o n s . The H e a l t h S e r v i c e
a u t h o r i t i e s w i l l c o n t i n u e t o be r e s p o n s i b l e f o r i n v e s t i g a t i n g c o m p l a i n t s
made t o them, a s p a r t of t h e i r g e n e r a l management r e s p o n s i b i l i t i e s .
The commissioner w i l l c o n s i d e r o n l y t h o s e c o m p l a i n t s made by o r on
b e h a l f o f p a t i e n t s which have a l r e a d y b e e n made t o t h e r e s p o n s i b l e
a u t h o r i t i e s and n o t been r e s o l v e d t o t h e c o m p l a i n a n t ' s s a t i s f a c t i o n .
C o m p l a i n a n t s , o r t h o s e a c t i n g f o r them, w i l l i n £11 c a s e s d e a l d i r e c t l y
w i t h the commissioner.
The commissioner w i l l be r e s p o n s i b l e f o r i n v e s t i g a t i n g a c t i o n s
t a k e n by o r on b e h a l f o f t h e H e a l t h S e r v i c e a u t h o r i t i e s where i t i s
c l a i m e d t h a t an i n d i v i d u a l p e r s o n has s u f f e r e d i n j u s t i c e o r h a r d s h i p
t h r o u g h m a l a d m i n i s t r a t i o n , o r through a f a i l u r e t o p r o v i d e n e c e s s a r y
t r e a t m e n t and c a r e . He w i l l n o t , however, d e a l w i t h c o m p l a i n t s from
s t a f f about t h e i r pay and c o n d i t i o n s o f s e r v i c e , o r w i t h c o m p l a i n t s
c o n c e r n i n g c o n t r a c t s o r o t h e r commercial t r a n s a c t i o n s . Nor w i l l he
i n v e s t i g a t e t h e a c t i o n s o f g e n e r a l m e d i c a l and d e n t a l p r a c t i t i o n e r s ,
85 r
p h a r m a c i s t s , o p h t h a l m i c m e d i c a l p r a c t i t i o n e r s and o p t i c i a n s , a l l o f
whom are n o t employees o f t h e H e a l t h S e r v i c e but a r e i n c o n t r a c t
with i t .
A s t a t u t o r y procedure a l r e a d y e x i s t s f o r examining c o m p l a i n t s
a g a i n s t them, and t h i s w i l l c o n t i n u e , w i t h o u t t h e i n v o l v e m e n t o f t h e
c o m m i s s i o n e r . I n S c o t l a n d t h e commissioner w i l l n o t d e a l w i t h c o m p l a i n t s
f a l l i n g w i t h i n t h e j u r i s d i c t i o n of t h e Mental Welfare Commission.
T o g e t h e r w i t h my r i g h t h o n . F r i e n d s t h e S e c r e t a r i e s o f S t a t e f o r
S c o t l a n d and f o r W a l e s , I have had t h o r o u g h and c o n s t r u c t i v e d i s c u s s i o n s
w i t h r e p r e s e n t a t i v e s o f t h e m e d i c a l p r o f e s s i o n about c o m p l a i n t s b e a r i n g
on the r e l a t i o n s h i p between c l i n i c i a n s and p a t i e n t s . We have d e c i d e d
t h a t t h e c o m m i s s i o n e r should be p r e c l u d e d from i n v e s t i g a t i n g any a c t i o n
taken i n t h e c o u r s e o f d i a g n o s i s , t r e a t m e n t o r c l i n i c a l care o f an
i n d i v i d u a l p a t i e n t w h i c h , i n t h e c o m m i s s i o n e r s o p i n i o n , was t a k e n s o l e l y
i n t h e e x e r c i s e o f c l i n i c a l judgment.
1
I n c a s e s coming w i t h i n h i s j u r i s d i c t i o n , t h e P a r l i a m e n t a r y Commissioner
f o r A d m i n i s t r a t i o n d o e s n o t l o o k i n t o c o m p l a i n t s when t h e complainant has
or had a r i g h t o f a p p e a l t o a t r i b u n a l o r a remedy by way o f p r o c e e d i n g s
i n a c o u r t o f l a w , u n l e s s he i s s a t i s f i e d t h a t i n t h e p a r t i c u l a r circum­
s t a n c e s o f t h e c a s e i t i s u n r e a s o n a b l e t o e x p e c t t h e complainant t o r e s o r t
or have r e s o r t e d t o i t . The H e a l t h S e r v i c e Commissioner w i l l f o l l o w t h e
same p r a c t i c e ; I would e x p e c t t h a t he would need t o u s e h i s d i s c r e t i o n t o
i n v e s t i g a t e t h i s t y p e o f c a s e o n l y on r a r e o c c a s i o n s .
The procedure under which t h e Commissioner w i l l conduct i n v e s t i g a t i o n s
w i l l be s i m i l a r t o t h a t observed by t h e P a r l i a m e n t a r y Commissioner f o r
A d m i n i s t r a t i o n . He w i l l be r e q u i r e d t o s e n d a r e p o r t o f t h e r e s u l t s o f
i n v e s t i g a t i o n s t o t h e complainant, t o any p e r s o n complained a g a i n s t and
t o t h e r e s p o n s i b l e h e a l t h a u t h o r i t i e s . He w i l l make an annual r e p o r t ,
and may make s p e c i a l r e p o r t s , t o t h e S e c r e t a r y o f S t a t e , who w i l l be
r e q u i r e d t o l a y them b e f o r e both Houses o f P a r l i a m e n t .
L e g i s l a t i o n w i l l be r e q u i r e d t o e n a b l e t h e H e a l t h S e r v i c e
Commissioner t o be a p p o i n t e d .
Appendix III MANAGEMENT STUDY INTRODUCTION This Appendix outlines, for general information, some ideas being developed in
the study, s e t up by the Secretary of State
on the detailed management
arrangements in the regions, areas and districts of the reorganised NHS.
These management arrangements relate to all that has to be done in the health
service - the medical as well as the other functions. The study is being
carried out with active participation by staff from various branches of the
NHS.
The eventual recommendations
to the Secretary of S t a t e
will be the
subject of formal consultation with the interests concerned before
decisions are t a k e n .
PRINCIPLES 2.
The ideas on management arrangements are being developed in accordance with principles stated in the Consultative Document. The principles are: 2.1 that there is to be a fully integrated health service in which every aspect of health care is provided,so far as is possible, locally and according to the needs of the people. 2.2 "that throughout the new administrative structure there should be
a clear definition and allocation of responsibilities;
that there
should be maximum delegation downwards, matched by accountability
upwards; and that a sound management structure should be created
at all levels."
3.
(Consultative Document, paragraph 6 ) .
The management arrangements are being designed to fit within the organisational framework described in outline in the Consultative Document and in more detail in the main body of the White Paper. The salient features are: 3.1 Delegation downwards (with corresponding accountability upwards) from the Secretary of State to Regional Health Authorities (RHA), and from the Regional Health Authorities to Area Health Authorities (AHA).
AHASwill be accountable to the RHA and the RHA w i l l be accountable to the
Secretary of State for the effectiveness and efficiency of the services
provided.
3.2 Area Health Authorities coterminous geographically with the new local authorities which are being set up outside London. 87 4.
Two further principles have guided the study in the development of management arrangements: 4.1 The clinical autonomy of doctors and dentists responsible for the diagnosis and treatment of patients must be fully preserved. 4.2 To allow for the exercise of professional discretion in their work, professional people are most suitably managed by members of their own professions. 5.
The study has also taken into account the changes recommended in
organisation and processes for the Central Department, the proposals made
by the Hunter Working Party on medical administrators and the deliberations
of the Working Party one collaboration with local government.
ACCOUNTABILITY BETWEEN AUTHORITIES 6.
It is proposed to achieve delegation downwards with accountability upwards
between levels of statutory authority with the help of a planning and monitoring
process. This process mentioned in various places in the White Paper,
would be more systematic than now exists and cover much more than f
just capital planning. 7.
The purpose of planning is to ensure that major decisions, including
resource allocations, are made by statutory authorities in advance in the
light of available facts and after examining alternative courses. Implementation
of the decisions can then be delegated, and monitored against the plans.
- -
8.
The process would consist of an annual planning cycle updating a rolling
ten-year plan - a four-year plan based on notified financial targets and a
less detailed projection for a further six years. During the cycle decisions
would be made by the statutory authorities at Area and Region and by the
Central Department after a process of critical appraisal and agreement at
each level.
/
9. Plans would be formulated for the Area and its operational districts within policy guidance put forward by the Central Department and the statutory NHS authorities. This guidance would consist of -
9*1
A summary of the policy statements made during the year, setting priorities between them. 9.2 An indication of the likely availability of resources for each Region. 9.3 Suggested target standards of care and service provision. 10.
The plans for district health services should be based on a consideration^ in the light of the resources available, of the needs of people for health care of various kinds. Programmes for meeting needs should be drawn up for "patient groups" - such us the mentally ill, the handicapped, the elderly, mothers and children - as well as for preventive work and for those acutely ill and in need of primary care (through the family practitioner services) or secondary care (through the hospital and specialist services).
These
programmes should be translated into operational plans for health services that would include targets for performance and budgets for money, manpower and other resources.
In this way it should be possible to provide more continuity of care for individual patients - in prevention, assessment, treatment and rehabilitation ­
and to effect changes in the balance of care (from hospital to community) more readily than is possible under the present system in which the shape of services tends to be determined rather by the institutional framework within which they are provided than by objective .appraisal of means of meeting needs. 11.
The AHA would pull together plans for its districts with plans for Area-wide services and ensure that they are co-ordinated with the plans of the matching local authorities for complementary services. The RHA would be responsible for developing strategic plans and priorities, for planning services and medical specialties that need a wider than Area approach and for ensuring that Area plans are balanced in terms of resources usage and standards of provision. 12.
Performance would be monitored by higher levels against the plans in terms of spending against budgets, achievement of operating targets, and completion of planned activities. As one means of monitoring performance, and to give improved financial and budgetary control, a new accounting system is being developed which will relate expenditure to the functions and services provided, and require budgets for each to be controlled by management. The system will also serve the planning process by providing some analysis of costs by patient groups. AREA ORGANISATION: DISTRICTS 13.
The size of Areas has been determined by the need to establish effective planning and operational links with the matching local authorities which are to provide related services. Areas vary between some with a population of around 200 thousand and several with a population of well over 1 million. In
devising an organisational structure, the district has been taken as the unit within which each AHA should seek to integrate services operationally. The
district is seen as a geographic unit within which it is possible to satisfy the greater part of the populations health care needs. The district would be small enough for professional representative machinery to be effective within it, it should contain at least one district general hospital or its equvalent and it would usually have a population of between 200,000 and 500,000. The present distribution of district general hospitals and of groups of hospitals
fulfilling that function indicates that about one in three of the Areas outside
London will consist of a single district, another one in 3 will have 2 districts,
and of the rest only 4 areas will have as many as 5 districts. The variations
will be reflected in the organisational arrangements.
14.
Operational activities will be largely decentralised to districts, and
it is within the district organisation that those practitioners with clinical
autonomy must come together with other professions to organise and provide
for the delivery of health services. The district organisation is therefore
being designed to
1^.1 Achieve integration of all health services available within it
14.2
Bring the representatives of the medical profession and the heads of services together tofflakethe important district decisions jointly.-­
1 4 . 3 Enable district officers to participate not only in the running of services but in helping to shape them. 15*
Methods of achieving accountability for activities within a district will
differ according to whether the activity is organised in 15.1 a "hierarchical" system (eg. nursing, administration, medical
administration, hospital pharmacy) in which the staff are organised
by rank and act on the authority of those of higher rank who are
appointed as their superiors.
15.2 a non-hierarchical system (hospital consultants *nd contractors for family practitioner services). 16.
Non-hierarchically organised professions will co-ordinate their
activities through different forms of representative machinery.
The arrange­
ments will differ according to whether the professional people who carry it out have
16.1 a contract of employment (eg. consultants working in hospitals) or
16.2 contract for services with the Family Practitioner Committee
(contractors for general medicaldental and ophthalmic services
and for pharmaceutical services) . In either case the arrangements for co-ordination with other services should take the form of representative committees. In the case of contractors, the object would be to enable them to contribute their ideas to plans for services in the district and, by giving them an insight into the agreed plans, to adapt t h e i r own work a c c o r d i n g l y .
In t h e c a a e o f c o n s u l t a n t s ,
t h e r e would be t h e
f u r t h e r o b j e c t of c o - o r d i n a t i n g t h e i r demands on r e s o u r c e s i n a c c o r d a n c e w i t h
the plans f o r s e r v i c e s within the Area.
These o b j e c t s ^ c o u l d be a c h i e v e d by o r g a n i s a t i o n i n d i v i d i o n s a c c o r d i n g t o
c l i n i c a l s p e c i a l t i e s a l o n g l i n e s a l r e a d y s u c c e s s f u l l y adopted i n t h e h o s p i t a l
service
17.
("Cogwheel").
The heads of t h e h i e r a r c h i c a l l y o r g a n i s e d s e r v i c e s and
r e p r e s e n t a t i v e s o f t h e n o n - h i e r a r c h i c a l l y o r g a n i s e d p r o f e s s i o n s would come
t o g e t h e r a s a d i s t r i c t management team (DMT).
The DMT would ensure t h a t
p l a n s and a c t i v i t i e s w i t h i n t h e d i s t r i c t a r e c o - o r d i n a t e d .
This team might
c o n s i s t of
17.1
Two e l e c t e d medical r e p r e s e n t a t i v e s ­ one from t h e s p e c i a l i s t s ,
one from t h e g e n e r a l p r a c t i t i o n e r s , a c t i n g a s t h e l i n k w i t h
n o n - h i e r a r c h i c a l l y o r g a n i s e d members o f t h e m e d i c a l and d e n t a l
profession.
17.2
A medical o f f i c e r
(community p h y s i c i a n ) a c c o u n t a b l e f o r t h e
a s s e s s m e n t o f community h e a l t h n e e d s , f o r t h e s u r v e i l l a n c e of
the
d i s t r i c t wide p r o v i s i o n o f h e a l t h c a r e , f o r t h e working o f teams
f o r p a t i e n t groups and f o r some s e r v i c e s t o l o c a l
17*3
A n u r s i n g o f f i c e r r e s p o n s i b l e f o r t h e management o f t h e n u r s i n g
s e r v i c e s b o t h i n s i d e and o u t s i d e
17*4
authorities.
hospitals
A finance o f f i c e r responsible for providing the
management team and o t h e r s w i t h the n e c e s s a r y
district
financial
i n f o r m a t i o n , g u i d a n c e and a d v i c e .
17.5
An a d m i n i s t r a t o r r e s p o n s i b l e f o r a d m i n i s t r a t i v e
co-ordination
and s u p p o r t b o t h f o r t h e team i t s e l f and throughout t h e
including a l l i n s t i t u t i o n a l
district
services.
Other heads o f s e r v i c e s would a t t e n d m e e t i n g s when m a t t e r s a f f e c t i n g
their
s e r v i c e s were t o be d i s c u s s e d and i n a d i s t r i c t w i t h undergraduate m e d i c a l
t e a c h i n g r e s p o n s i b i l i t i e s a r e p r e s e n t a t i v e of t h e m e d i c a l s c h o o l would be a
member o f t h e team.
18.
The team would be a c o n s e n s u s g r o u p , t h a t i s , a l l d e c i s i o n s i t makes
would have t o be unanimous. I t would t h e r e f o r e need t o be c o - o r d i n a t e d ,
p r e f e r a b l y by appointment o r e l e c t i o n o f one o f i t s members a s chairman.
I n c a s e s where agreement cannot be r e a c h e d , m a t t e r s would have t o b e r e f e r r e d
to higher a u t h o r i t y .
services.
The team would t h u s have o p e r a t i o n a l c o n t r o l o f d i s t r i c t
I t would be r e s p o n s i b l e f o r . a c h i e v i n g o b j e c t i v e s - a c c o r d i n g - t o
agreed
p l a n s and would have b u d g e t a r y . r e s p o n s i b i l i t e s . '
19.
Within t h e d i s t r i c t ,
teams drawn from t h e p r o f e s s i o n s concerned would work
t o g e t h e r t o ensure t h a t p l a n s a r e p r e p a r e d t h a t e n s u r e i n t e g r a t i o n of a l l
CONFIDENTIAL
services.
Teams t o prepare programmes f o r " p a t i e n t groups" c o u l d be formed of
r e p r e s e n t a t i v e s from s p e c i a l i s t c a r e , g e n e r a l p r a c t i t i o n e r s , m e d i c a l
officers,
n u r s e s b o t h i n h o s p i t a l and o u t s i d e , p a r a m e d i c a l , and s o c i a l w o r k e r s ,
a d m i n i s t r a t o r s , e t c . Other teams c o u l d l o o k a t t h e development o f p r e v e n t i v e
c a r e s e r v i c e s , primary c a r e s e r v i c e s , and a c u t e s p e c i a l t i e s .
In t h i s way
p l a n s c o u l d be based on a d e t e r m i n a t i o n o f needs and c o u l d i n c l u d e c o n t r i b u t i o n s
from a l l t h e p r o f e s s i o n s and s e r v i c e s c o n c e r n e d .
The community p h y s i c i a n would have an important r o l e t o p l a y i n t h i s work ­
i n i d e n t i f y i n g o p p o r t u n i t i e s f o r improvement i n t h e p r o v i s i o n o f s e r v i c e s ;
i n h e l p i n g t o ensure c o n t i n u i t y o f c a r e a s p a t i e n t s move between d i f f e r e n t
s e c t i o n s of t h e s e r v i c e ; i n a s s i s t i n g i n t h e c o - o r d i n a t i o n of p a t i e n t group
teams; and i n h e l p i n g t o c o - o r d i n a t e the work o f t h e h e a l t h a u t h o r i t y and
the s o c i a l s e r v i c e s
authority.
AREA ORGANISATION:
AREA STAFF
20.
I n an Area w i t h two o r more d i s t r i c t s , Area s t a f f would be r e q u i r e d t o
put t o g e t h e r Area p l a n s , t o manage s e r v i c e s t o be p r o v i d e d t o t h e d i s t r i c t s ,
eg s u p p l i e s , t o p r o v i d e t h e s e c r e r a r i a t o f t h e A u t h o r i t y and t h e FPC and t o
p r o v i d e s e r v i c e s t o t h e m a t c h i n g Local A u t h o r i t y .
Some of t h e Area s t a f f
would
g i v e p r o f e s s i o n a l and t e c h n i c a l d i r e c t i o n t o s t a f f i n d i s t r i c t s where o p e r a t i o n a l
c o n t r o l i s e x e r c i s e d through t h e d i s t r i c t management t e a m s .
Area s t a f f who were
p r o f e s s i o n a l heads would undertake some o f the p e r s o n n e l management o f
s t a f f i n the d i s t r i c t s .
professional
I n t h e l a r g e r Areas t h e RRA c o u l d d e l e g a t e t o t h e ABA,
f o r management by Area s t a f f ,
some f u n c t i o n s which t h e RHA would u s u a l l y p r o v i d e
as a service t o smaller Areas.
21.
The c h i e f o f f i c e r s of t h e Area s t a f f ,
by coming t o g e t h e r a s a team.
2 1 . 1
A medical o f f i c e r ,
would c o - o r d i n a t e t h e i r
The Area team would c o n s x s t
activities
of:
responsible for organising the provision of
p r o f e s s i o n a l a d v i c e t o t h e AHA and i t s o f f i c e r s ,
for general
r e l a t i o n s w i t h t h e m e d i c a l s t a f f under c o n t r a c t o f employment
and f o r s e r v i c e s t o t h e matching l o c a l a u t h o r i t y .
2 1 . 2
A n u r s i n g o f f i c e r r e s p o n s i b l e f o r p r o v i d i n g a d v i c e on n u r s i n g
m a t t e r s t o t h e AHA and i t s o f f i c e r s ,
f o r communicating p o l i c y
io n u r s e s i n d i s t r i c t s and f o r o r g a n i s i n g e d u c a t i o n and t r a i n i n g
f a c i l i t i e s f o r n u r s e s i n t h e Area and f o r e n s u r i n g t h e p r o v i s i o n
o f n u r s i n g s e r v i c e s t o t h e matching L o c a l A u t h o r i t y .
2 1 . 3
A finance o f f i c e r ,
r e s p o n s i b l e f o r p r o v i d i n g a d v i c e on a l l
f i n a n c i a l m a t t e r s t o t h e AHA and i t s o f f i c e r s ,
co-ordinating
preparation of t h e f i n a n c i a l e s t i m a t e s , preparing the s t a t u t o r y
accounts,
providing
accountancy and cashier services, control systems and financial information to management, measuring expenditure against agreed budgets, and providing financial supervision and internal audit for financial propriety. 21.^
An administrator, responsible for administrative co-ordination
and support for the team itself and throughout the Area, for
providing support to other officers in their personnel management and
planning functions, for some services delivered on an Area wide
basis such as supplies, ambulance, etc, and for secretariat
services to the AHA, the Family P r a c t i t i o n e r Committee and
o t h e r committees i n t h e A r e a .
22.
Heads of services not included in the team would attend meetings when
matters affecting their services were to be discussed.
Those who were heads
of professions would also have access-to-the AHA and its Chairman.
23.
In an Area which was not divided Into districts, the Area Team would also
perform the functions of the BMT, joined by the elected medical representative,
members and - if with teaching responsibilities - by a representative of the
medical school.
Zh.
The district teams would be accountable for operational services within
districts, either through the Area Team of officers or directly to the AHA.
The arrangement to be adopted might depend on such factors- as the size of
the Area and the number of districts in it. The lines of accountability
would need to be clearly set out in job descriptions.
REGIONAL ORGANISATION 25.
As at Area, so at Region, there would be a team of officers accountable to
the RHA for the co-ordination of work delegated to officers. This team would
be responsible for Regional planning, f
o r
allocation of resources, for monitoring
AHAs'performance, and for delivering certain services, such as blood transfusion services, on a regional basis. A proportion of the RHA'a staff will be engaged in architectural and engineering design and quantity surveying for the capital works programme for the Region and providing professional support to Areas for building and engineering maintenance and operation. To co-ordinate these activities, both for new works and for maintenance, it is proposed that there should be a works officer
the Regional Team. appointed to each Region who would be a member of 26.
The team might accordingly consist of:
2 6 . 1 A medical officer, responsible for organising the provision of professional advice to the RHA and its officers and for communicating policy to medical officers in Areas. 2 6 . 2 A nursing officer responsible for providing
advice on nursing matters to the RHA and its officers and for
communicating policy to nursing officers in Areas.
2 6 . 3 A works officer, responsible for the direction and co-ordination of
building, engineering and quantity surveying.
-­
2 6 . 4 A finance officer responsible for providing financial advice to
the RHA and its officers, and for co-ordinating financial
practice and systems throughout the Areas.
2 6 . 5 An administrator responsible for administrative co-ordination and for
administrative support to the RHA and its officers and for some services provided on a regional b?sis. Heads of services not included in the teams would attend meetings of the team when
matters affecting their services were to be discussed, and those who were heads of professions would have access to the RHA and its chairman. 27.
The capital building programme for the Region would be one of the products
of the comprehensive planning process outlined in paragraphs 7 - 1 1 above.
Thus the need for new buildings will be identified and examined alongside
all other possible potential measures for improvement of services. For each
project included in the programme a team (Project Team), including doctors
and nurses, would be set up to brief the designers. The Project Teams would
draw upon advice from staff belonging to the AHAs concerned.
28.
RHA officers would not have direct authority over the AHA or its
officers.
They would however
have monitoring responsibilities and be
authoritative spokesmen for the RHA in their own fields. As such they
would be able to interpret RHA policy to AHA officers, subject to
resolution between the RHA and AHA of any conflicts.
Department of Health and Social Security London SB1 23 June 1972