IIS 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
C P ( 7 2 ) 80
GOVERNMENT
C O P Y NO
6 b
14 July 1972
CABINET
REORGANISATION OF THE NATIONAL HEALTH S E R V I C E IN W A L E S 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 W a l e s 1.
I p r o p o s e to publish a White P a p e r on National 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 W a l e s c o m p l e m e n t a r y to that p r o p o s e d b y the
S e c r e t a r y of S t a t e f o r S o c i a l S e r v i c e s i n r e s p e c t of E n g l a n d .
A draft
is attached.
It h a s b e e n c l e a r e d b y t h e H o m e a n d S o c i a l A f f a i r s
Committee.
2.
NHS r e o r g a n i s a t i o n i n E n g l a n d and W a l e s w i l l b e d e a l t with
under the s a m e B i l l and w i l l b e e f f e c t i v e f r o m the s a m e date,
1 April 1974.
The a d m i n i s t r a t i v e p a t t e r n will be e s s e n t i a l l y the
s a m e i n W a l e s a s in England after a l l o w i n g for the s m a l l e r s c a l e w h i c h
m a k e s it u n n e c e s s a r y to i n t e r p o s e a R e g i o n a l Health A u t h o r i t y b e t w e e n
the eight A r e a H e a l t h A u t h o r i t i e s ( A H A s ) and the W e l s h Office.
An
all-Wales National Health Service agency (Welsh Health Technical
S e r v i c e s O r g a n i s a t i o n ) w i l l c a r r y out s p e c i a l i s t e x e c u t i v e and m a n a g e ­
m e n t f u n c t i o n s i n c l u d i n g d e s i g n a n d e x e c u t i o n of m a j o r c a p i t a l w o r k s b u t
i t w i l l n o t b e r e s p o n s i b l e f o r g e n e r a l o v e r s i g h t of A H A s ' p l a n n i n g a n d
operations.
It w i l l b e a p p o i n t e d b y t h e S e c r e t a r y of S t a t e f o r W a l e s
and, like the A H A s , w i l l b e d i r e c t l y accountable to h i m .
3.
In a l l t h i s , t h e d r a f t W h i t e P a p e r r e a f f i r m s t h e p r o p o s a l s of the
C o n s u l t a t i v e D o c u m e n t o n NHS R e o r g a n i s a t i o n i n W a l e s i s s u e d i n J u n e 1973­
foUowing 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 C o m m i t t e e and the Cabinet
(CM(71) 19th and 24th C o n c l u s i o n s ) .
The Welsh p r o p o s a l s reflect those
f o r E n g l a n d a s r e g a r d s t h e s c o p e of t h e r e o r g a n i s e d N H S , t h e
c o m p o s i t i o n of A H A s , t h e p a y m e n t of c h a i r m e n a n d t h e s e t t i n g up of
C o m m u n i t y H e a l t h C o u n c i l s and p r o f e s s i o n a l a d v i s o r y m a c h i n e r y .
A p r o p o s a l in the C o n s u l t a t i v e D o c u m e n t to s e t up a n e w a d v i s o r y W e l s h
H e a l t h C o u n c i l h a s b e e n d r o p p e d i n f a v o u r of c o n t i n u i n g t o r e l y a s
n e c e s s a r y on the existing W e l s h Council.
There m a y be a need for
r e v i e w w h e n the C o m m i s s i o n on the Constitution r e p o r t s .
1
4.
A s noted l a s t y e a r , the p r o p o s a l s i m p l y s o m e i n c r e a s e in the
n u m b e r of C i v i l S e r v a n t s b u t s h o u l d m a k e a b e t t e r u s e of o v e r a l l
public manpower.
Additional s h o r t - t e r m administrative costs
a r i s i n g o u t of t h e r e o r g a n i s a t i o n h a v e b e e n p r o v i d e d f o r i n C m n d . 4 8 2 9 .
l
5.
I 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 the p u b l i c a t i o n of t h e W h i t e
Paper in early August.
P T
W e l s h Office
14 July 1972
DRAFT WHITE PAPER ON NATIONAL HEALTH SERVICE REORGANISATION IN WALES Contents Paragraphs PART
I
SCOPE AND RELATIONS WITH LOCAL GOVERNMENT Introduction - Unification - the Consultative Document
PART
PART
PART
II
III
IV
1-3
Services within the National Health Service
4-5
Collaboration with Local Government
6-9
DIRECTLY ACCOUNTABLE AREA HEALTH AUTHORITIES Functions of the Area Health Authorities
10
Direct Delegation: No intermediate tier
11-13
Membership of Area Health Authorities
14-15
Medical and Dental Teaching and Research
16
Professional Advisory Machinery
17-18
Community Health Councils
19-22
The Organisation of Area Health Authorities
23-27
Family Practitioner Services
28-30
CENTRAL ORGANISATION The Secretary of State and the Welsh Office
31
Participation in central decisions
32-35
Central professional advice
36
Advice from the Welsh Council
37-38
Welsh Health Technical Services Organisation
39-42
Financial Administration
43-44
,
THE STAFF OF THE SERVICE New opportunities
45
Training
46-47
The National Health Service Staff Commission for Wales 48
Paragraphs PART V
OTHER MATTERS Voluntary help
^9
Gifts and endowments
50
Patients complaints:
the Health Service Commissioner
PART VI
51
Preparing for reorganisation
52
CONCLUSION
53-5^
DRAFT WHITE PAPER ON NATIONAL HEALTH SERVICE REORGANISATION IN WALES PART
I THE REORGANISED SERVICE:
SCOPE AND
RELATIONS
WITH LOCAL GOVERNMENT
Introduction 1
This White Paper describes the Government's proposals for reorganising the administration of the National Health Service in Wales. The proposals take into account comments received on the Green Paper issued by the previous administration in March 1970 and on the Consultative Document of June 1971. Well over a hundred written comments were received on each occasion and over the past year discussions have been held with a number of the principal interested bodies. The Government have now reached firm decisions on the main administrative structure for a reorganised health service. These decisions can be seen as a logical development from the ideas which were outlined in the proposals of the previous administration and which have since been tested and refined in the light of widespread discussion. Some important modifications to the original proposals, concerning the membership of the new health authorities and the means of ensuring that they are responsive to those they erve, are designed to s
increase the efficiency of the health service in the best interests of the people. Study of the detailed arrangements for management organisation within the new structure is proceeding. They will be mainly a matter for subordinate legislation and administrative guidance which will follow the passage of the main legislation. 2
That there is need for such a reorganisation is widely accepted. The present institutions have served well, but the
time has come when they should be welded together into a unified whole so that in the planning and allocation of resources and in the day to day responsibility for providing health care the service may respond in a balanced and coherent way to the overall needs of those whom it serves. Much has been done already, by goodwill and co-operation between authorities and individuals, to overcome the administrative barriers between the three present arms of the service but further progress will best be secured by removing them altogether. 1 3
In November 1 9 7 0 the Government announced their intention to
introduce legislation to bring about unification of the service on
1 April 1 9 7 ^ , simultaneously with the reorganisation of local government.
This legislation is now in preparation. The Government's plans provide
for the new health authorities to work closely with corresponding local
authorities in co-ordinating the development and operation of their
inter-related services. At the central government level the
Secretary of State for Wales already discharges his responsibilities
for both groups of services through the unified organisation of the
Welsh Office.
Services within the National Health Service k
Reorganisation of the health service will bring together, under eight Area Health Authorities matching the boundaries of the proposed new counties, the family practitioner services now administered by the Executive Councils, the hospital and specialist services now administered by the V/elsh Hospital Board and the Hospital Management Committees, the school health service and the personal health services now administered by the local authorities. These latter include epidemiological work and general surveillance of community health; vaccination and immunisation; medical, nursing and other arrangements for the prevention of illness and for care and after-care; health visiting, home nursing and midwifery;
ambulance services;
maternity and child health care; family planning; and the provision of health centres. The new health authorities will also become responsible for the registration of nursing homes. 5
The Government are satisfied that the future of the school health
service will best be safeguarded by bringing it within the National
Health Service: there would be p. risk of problems arising from
professional isolation if it were separately administered from all other
personal health services. Area Health Authorities will provide local
education authorities with necessary medical, dental, nursing and allied
resources and advice to enable them to discharge their continuing
responsibilities for identifying and meeting the special educational
needs which disability or handicap may bring as well as for school
2 hygiene and health instruction. There will be arrangements for joint planning and co-ordination (see paragraph 8) and there is no reason why the teaching and health professions should not continue to work harmoniously together within the school regimen. Area Health Authorities will also work in close co-operation with the local education and social service departments of the new county councils in the provision of a co-ordinated child guidance service. Collaboration with Local Government 6
A major reason for the decision that each Area Health Authority should match a new county council was to facilitate close collaboration between them and between the Area Health Authority and the councils of the new districts which each county will comprise. As foreshadowed in the Consultative Document, a working party covering England and Wales and broadly representative of local government, the NHS and central government is studying how best to promote such collaboration. 7
The working party has already made a number of important
recommendations and although consultations on them with the interested
local authority and health organisations have not yet been completed it
is evident that there is a mutual will to ensure joint identification of needs of common concern and full co-operation in determining and pursuing the best ways of meeting them. Subject to these consultations it is proposed that health and local authorities in Wales, as in England, should be placed under a general obligation to collaborate and should be given wide powers to provide each other generally with goods and services. It will be a part of the responsibility placed by the Secretary of State on Area Health Authorities to provide all necessary medical and allied services and advice to local authorities in the fields of education, personal social services, environmental health and other services, and x
to make available medical officers to carry out certain specific statutory functions of local authorities. Conversely AHAs will need help from local authorities. For example, whatever the outcome of the review of the future of hospital social work which is currently proceeding they will need the advice and help of staff of the social service department of the county councils. Health and local authorities will also need to co-operate in the field of health education, for which both will have powers. 3 8
The working party has recommended that statutory joint consultative
committees should be set up in each area to advise the authorities on
the planning and operation of services of common concern. One such
committee, containing county council and health authority representatives,
might be concerned with school health and with co-ordination of health
and personal social services; another, including representatives of
the Area Health Authority and of each district council, with co-ordination
between the NHS and environmental health and housing. The committees
would be supported by groups of senior officers. Local authorities
would also be recommended to co-opt to their relevant committees
members or officers of the AHA; AHAs themselves will always include
members of the matching County Council (see paragraph I 5 ) .
To underline
the importance of joint consultative committees it is proposed that
there shall be statutory provision for them.
9
The working party is continuing its study of the details of the
arrangements and is to remain in being to advise on guidance to the
new authorities.
PART
II DIRECTLY
ACCOUNTABLE
MEMBERSHIP, FUNCTIONS, ORGANISATION
AREA
AND
HEALTH AUTHORITIES: SUPPORTING
STRUCTURES
Functions of Area Health Authorities 10
There must be a strategy for health for Great Britain as a whole and, consistently with this, a strategy for Wales for which the Secretary of State for Wales id.ll be responsible. But this broad strategic framework shov]d itself be built up from the advice of those with direct experience of health problems and responsibility for meeting them. Within it, an integrated health service can best be provided if real responsibility for planning and running it is carried out by a unified administration as close as possible to the people being se" vsd. The Secretary of State i n look directly to the eight Area Health w
Authorities to secure these aims. They will have the key role* Assisted and complemented by professional advisory bodies they will, through the formulation of their own planning proposals and through k regular central consultations at both chairman and officer level, contribute fully to the development of the pattern of health services for Wales as a whole. They will be direct agents of the Secretary of State answerable to him for the efficient planning, organisation and administration of integrated health services within their areas and will carry a prime responsibility for the quality of the health tare provided for the people they respectively serve. In some expert and technical fields it is clear that a degree of centralisation will make the most effective use of available resources and for this a central supporting agency will be created; and there must be overall co-ordination, leadership and ultimate control by the Secretary of State who is accountable, through Parliament, for the provision and efficient running of the health service in Wales. While there must be flexibility to respond over the years to experience of the most effective way to administer the services in the interests of the Principality, the Government will make sure that the authority and status of the AHAs is maintained by giving them all the responsibility which they can reasonably exercise. In this way they will best attract and retain men and women of vision and ability to lead them as members and as senior officers; and by this means they will best serve their communities. Direct Delegation: No Intermediate Tier 11
Both the Consultative Document and the Green Paper of March 1970 proposed that as -£te number of Area Health Authorities in Wales would be small enough to permit it, they should be directly responsible to the Secretary of State without the interposition of an intermediate all-Wales authority. There has been debate on this.
Some have argued that if an all-Wales authority were introduced v/hich was responsible for strategic planning and co-ordination and for supervision &r monitoring of AHAs it would put the efficiency of the Area Health Authorities to the test and ensure better planning and the adoption of better standards of service. Others are convinced that an intermediate tier would be to the detriment of the service. They see such an institution as too remote from the people and areas to be served, as interposing an unnecessary tier between the Secretary of State who has overall responsibility to Parliament and 5
the people and the Area Health Authorities who have the responsibility of planning and running the service. They also suggest that there would be problems of blurred and overlapping responsibilities and that the reduction in status and responsibilities of Area Health Authorities would adversely affect their ability to attract and retain members and staff of high quality. 12
The decision that Area Health Authorities shall be directly
accountable to the Secretary of State for planning and running their
services has been taken after careful consideration of these contrasting
views. The Government readily acknowledge that the policies and standards
of service in the National Health Service should be open to serious
examination both from within the Service and from outside. But this does
not require the introduction of a special body between the Area Health
Authorities and the Welsh Office. It can be effected by giving strength
to the Area Health Authorities and to the advisory machinery, and by
constructive examination by the Welsh Office on behalf of the Secretary
of State. Moreover there is wide agreement that the interests of
patients and communities will best be served by arrangements designed to
enhance the quality and responsibility of local management where the
voice of the public will be directly heard through the Community Health
Councils (see paragraphs
19-22).
It is with these considerations in mind
that the Government have decided that it would be better not to create
an intermediate tier but to put the AHAs in direct relationship to the
Secretary of State.
13
This decision in no way implies criticism of the Welsh Hospital Board.
The Government pay tribute to the valuable service which the Board has
given and the energy and dedication which its chairman, members and
officers have throughout brought to their tasks. But the circumstances x
have changed since the Welsh Hospital Board was set up as one of a number of regional hospital boards accountable to a single health Minister for England and Wales. The transfer of ministerial responsibility for the conduct of the health service in the Principality to the Secretary of State for Wales gives effect to the view that ministerial concern with and accountability for the service in Wales should be closer and more 6
direct than had been practicable under the former arrangements. This principle would be difficult to reconcile with an administrative system in which the central responsibility for overall co-ordination of planning, for allocating resources and for monitoring the performance of operational authorities was delegated to an agent authority.
In the different circumstances of England an intermediate tier is appropriate. In Wales reorganisation of the service should recognise the smaller scale and turn it to advantage. Membership of Area Health Authorities Ik
The health service is a complex enterprise. Each Area Health Authority will employ a large staff and administer an annual budget running into millions of pounds. Good management is essential to make the best use of these resources for the benefit of patients and the community;
and this must be the dominant consideration in determining the composition of Area Health Authorities. To work effectively they must be compact and their membership must combine relevant experience, power of analysis, judgment and leadership and vigorous concern for making the service work well. A proper balance of these personal qualities can best be ensured if most members are chosen pfter appropriate consultations, rather than serving as representatives reflecting the views of particular interests. 15
The Area Health Authority will normally have about 1 5 members.
Its chairman will be appointed by the Secretary of State. Four members
will be appointed by the matching County Council to help foster close
links with their related service . Two in South Glamorgan and one in
s
each other Area will be appointed by the Secretary of State on the
nomination of the University of Wales to ensure representation of the
Welsh National School of Medicine, The remaining members will be chosen
and appointed by the Secretary of State after consultation with
appropriate organisations, including those representing the main health
professions; where an Area has significant working links with another
medical school this will also be reflected in the consultations. In all Areas some of these members will be chosen from the healing professions and although the proportion will not be prescribed, and may vary with 7
time and place, it is intended that there shall always be doctors and at
least one nurse or midwife in the membership of each Authority. Though
they will be entitled to the usual allowances members will as now be
volunteers serving in an unpaid capacity, but because financial
considerations might impede chairmen from meeting the heavy demands
which will be made on their time, legislation will make it possible to
remunerate them on a part-time basis; the same financial provisions will
apply to the chairmen and members of the Welsh Health Technical Services
Organisation and any other health authority which may be set up for
particular functions (see paragraph ^ 0 ) .
Medical and Dental Teaching and Research
16
The close partnership between the health service and the medical and
dental schools of the University of Wales will continue and the importance
of the facilities provided in support of medical and dental teaching and
of associated research will be recognised.
The extent of the specialised
services provided by the University Hospital of Wales for patients from
all parts of the Principality v/ill be reflected in the allocation of
resources to South Glamorgan Area Health Authority. As already indicated
(paragraph 1 5 ) , the University will nominate two members to this Authority.
In addition the Secretary of State will ensure that members with teaching hospital experience are among those members chosen and appointed by him. Total membership of the Authority will need to be greater than that of other AHAs to reflect the special teaching functions. The Welsh National School of Medicine is, of course, already represented on the recently formed Welsh Committee for post-graduate medical and dental education, which in the continued discharge of its functions will maintain close contact with the Welsh Office and with AHAs.
There will similarly be links between Welsh Office, AHAs and professional bodies and committees concerned with nursing and other training. Professional Advisory Machinery
17
The administrative structure of the health service exists to
enable the healing professions to bring their skills to the people in
the most effective way.
It cannot work properly without the expert
8 advice of the professions. Although members of the healing professions will be included in the membership of Area Health Authorities they will be there in a personal capacity rather than as spokesmen of the collective views of the professions. Each Area Health Authority will therefore require strong professional advisory machinery, v/hich the professions will be invited to set up and which will be statutorily recognised.
It will enable the professions to participate in the formulation and implementation of policy, offering a regular channel through which expert advice on matters of principal and of detail can be proferred and sought. 18
The detailed arrangements will be worked out with the individual
professions and will vary from one to another. They will include
provision for successors to the present local medical, dental,
pharmaceutical and optical committees, to carry out statutory functions
in relation to the family practitioner services, including appointment
of members to the Family Practitioner Committee (see para 2 8 ) .
It is
very desirable that they should also enable the advice of those working
in general pragtice and those working in hospitals to be concerted. The
arrangements should build on the best of existing experience - for
example on the means by which concensus medical views emerge within the
hospital service - and so far as possible there should be a representative
structure at district level (see paragraphs 2k and 2 5 ) as well as at
area level. Doctors, dentists, nurses and midwives, pharmacists and
opticians are already considering these matters.
Community Health Councils
19
It is important that Area Health Authorities should act in full
understanding of the views and wishes of the people they serve and that
there should be effective representational machinery to this end. The
previous administration proposed that this should be achieved by looking
to members of the AHA to act in a representative capacity and through the
creation in some Areas of district committees combining AHA members and
local people and playing some undefined part in managing the service.
The Government believes that this would have led to confusion.
It is
better to set up bodies which specifically represent local views and
can bring these views to bear on management. 9
20
Each AHA w i l l t h e r e f o r e be r e q u i r e d t o s e t up one or more
Community H e a l t h C o u n c i l s f o r t h i s p u r p o s e ,
where s e r v i c e s a r e
a d m i n i s t e r e d through h e a l t h d i s t r i c t s one must be s e t up f o r each such
d i s t r i c t , w i t h d i s c r e t i o n f o r more i f l o c a l c i r c u m s t a n c e s p o i n t t o t h e
need.
Membership w i l l normally be between 20 and 3 0 , h a l f
being
a p p o i n t e d by t h e r e l a t e d l o c a l government d i s t r i c t c o u n c i l s , most o f
t h e remainder on t h e n o m i n a t i o n of l o c a l v o l u n t a r y b o d i e s concerned
w i t h t h e s e r v i c e and some a f t e r c o n s u l t a t i o n w i t h o t h e r i n t e r e s t e d
local organisations.
21
C o u n c i l s w i l l a p p o i n t t h e i r own chairmen.
The C o u n c i l 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 , t h e r i g h t
to
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 managed by the AHA, and ready
a c c e s s t o t h e A u t h o r i t y and i t s s e n i o r o f f i c e r s i n t h e d i s t r i c t and a r e a .
C o u n c i l s w i l l be f r e e t o arrange t h e i r a f f a i r s s o t h a t
particular
members t a k e a s p e c i a l i n t e r e s t i n i n d i v i d u a l l o c a l i t i e s and h o s p i t a l s .
The AHA w i l l c o n s u l t t h e C o u n c i l on i t s g e n e r a l development p l a n s and
p a r t i c u l a r l y on important p r o p o s a l s t o vary t h e p a t t e r n o f t h e s e r v i c e ,
i n c l u d i n g c h a n g e s i n u s e , or c l o s u r e , of h o s p i t a l s .
Apart from r e g u l a r
i n f o r m a l m e e t i n g s , the f u l l AHA w i l l f o r m a l l y meet r e p r e s e n t a t i v e s
o f a l l i t s Community H e a l t h C o u n c i l s a t l e a s t a n n u a l l y .
Each C o u n c i l
w i l l be e x p e c t e d t o p u b l i s h an annual r e p o r t and t h e AHA t o p u b l i s h a
r e c o r d of i t s c o n s i d e r a t i o n of t h e i s s u e s r a i s e d i n i t .
The AHA w i l l
p r o v i d e accommodation and s e c r e t a r i a l s t a f f and w i l l meet e x p e n s e s o f
t h e C o u n c i l and i t s members.
22
These arrangements w i l l g i v e Community H e a l t h C o u n c i l s e v e r y
opportunity t o represent e f f e c t i v e l y the i n t e r e s t s of the l o c a l p e o p l e .
I t i s e x p e c t e d t h a t t h e y w i l l adopt a p o s i t i v e r o l e i n r e v i e w i n g t h e
adequacy o f l o c a l s e r v i c e s and making recommendations f o r t h e i r improvement.
Given a c o n s t r u c t i v e and r e a l i s t i c approach t h e y w i l l e x e r t
strong
i n f l u e n c e on t h e AHA's p o l i c i e s and p r a c t i c e s and w i l l p l a y an important
p a r t i n h e l p i n g t o make a b e t t e r
service.
10
The O r g a n i s a t i o n o f Area H e a l t h A u t h o r i t i e s 23
The C o n s u l t a t i v e Document promised a s t u d y i n t o t h e b e s t m a n a g e r i a l arrangements w i t h i n Area H e a l t h A u t h o r i t i e s .
I t was s t a r t e d l a s t y e a r by a s t u d y group working under the d i r e c t i o n of a S t e e r i n g Comirittee which i n c l u d e s members from t h e t h r e e p r e s e n t arms of t h e s e r v i c e and from t h e Welsh O f f i c e .
T e n t a t i v e i d e a s have b e e n f o r m u l a t e d and embodied i n a document d i s t r i b u t e d w i d e l y a t t h e end of A p r i l among t h o s e working i n t h e h e a l t h s e r v i c e i n Wales.
These i d e a s a r e now b e i n g d e v e l o p e d and m o d i f i e d a s n e c e s s a r y i n t h e l i g h t o f a s e r i e s o f d i s c u s s i o n s throughout Wales d e s i g n e d t o produce recommendations t o t h e S e c r e t a r y o f S t a t e which take a c c o u n t of t h e c i r c u m s t a n c e s o f t h e various prospective health areas.
l a t e summer.
and d e c i s i o n .
Recommendations a r e e x p e c t e d i n t h e They w i l l be m a i n l y m a t t e r s f o r a d m i n i s t r a t i v e g u i d a n c e B e f o r e f i n a l d e c i s i o n s a r e taken on them t h e r e w i l l be formal c o n s u l t a t i o n s w i t h r e p r e s e n t a t i v e b o d i e s . 2k
The c l o s e r t o t h e p a t i e n t t h a t management of t h e i n t e g r a t e d
service
can be brought t h e b e t t e r t h e p r o s p e c t s o f g e t t i n g t h e r i g h t c a r e a t t h e
r i g h t t i m e and i n t h e most e f f e c t i v e way.
The Area H e a l t h A u t h o r i t y
t h e s m a l l e s t u n i t which can e f f e c t i v e l y c a r r y r e s p o n s i b i l i t y f o r
is
integrated
planning, in c o l l a b o r a t i o n with corresponding l o c a l a u t h o r i t i e s ;
and
t h e r e w i l l need t o be c l o s e c o n t a c t and j o i n t p l a n n i n g between n e i g h b o u r i n g
a u t h o r i t i e s , since patients w i l l often cross administrative
f o r p a r t i c u l a r forms of c a r e .
boundaries
Many day t o day d e c i s i o n s on how c a r e can
b e s t be p r o v i d e d and o r g a n i s e d w i l l be taken very much c l o s e r t o
i n d i v i d u a l p a t i e n t s - eg by g e n e r a l p r a c t i t i o n e r s and by c l i n i c i a n s ,
n u r s e s and a d m i n i s t r a t o r s working i n h o s p i t a l s and i n t h e community.
But a t t h i s l e v e l t h e r e must i n e v i t a b l y be some s p e c i a l i s a t i o n o f
f u n c t i o n and, though t h e r e a r e a l r e a d y arrangements t o h e l p them f i t
s e r v i c e s t o g e t h e r , more formal and comprehensive management
co-ordination
must be c a r r i e d o u t on a r a t h e r l a r g e r s c a l e i n o r d e r t o a c h i e v e
i n t e g r a t i o n i n t h e deployment and o p e r a t i o n o f s e r v i c e s .
full
I n some c a s e s
t h i s may n e e d t o be done on a f u l l Area b a s i s b e c a u s e o f t h e p h y s i c a l
p a t t e r n i n which one o f t h e components - t h e h o s p i t a l s e r v i c e already s e t .
is
But i n o t h e r s t h e main h e a l t h n e e d s o f t h e m a j o r i t y o f
t h e p o p u l a t i o n a r e met w i t h i n two o r more l o c a l i t i e s s m a l l e r than t h e
11 their
Area itself. Where appropriate it is proposed that Area Health Authorities shall operate their services on the pattern of these health "districts", which will be served by general practitioners, community health services and a district general hospital or one or more major acute hospitals carrying out nearly equivalent functions; the preliminary work of the management study has already sufficiently demonstrated the potential advantages. 25
Health districts will not be a separate formal level of authority below the Area Health Authority; rather they will be decentralised units of its administration exercising, at officer level, substantial delegated management responsibilities for the operation of the service. They cannot be wholly self-sufficient and will be actively controlled and co-ordinated by the AHA and its chief officers to secure consistency of standards and effective and economical use of resources. 26
The ideas now under examination by the Steering Committee contemplate
that Area Health Authorities would manage their services through chief
officers acting together as a co-ordinated team. Where day to day
administration of services was through two or more health districts
there would be delegation to district teams. The nucleus at each level
would be a medical officer, a nursing officer, a finance officer and
and administrator;
clinicians would also play a direct part in
management, through the inclusion of members of the representative
medical committee on the district team. Other heads of services would
join team meetings when their services were involved and would have
the same access to the Authority on professional matters. Subject to
reserving to itself the key decisions on policies, plans and resource
allocation and to exercising overall control the Authority would aim at the greatest possible delegation; responsibilities and accountability at all levels would be closely defined. 12 27
Area Health Authorities will appoint and employ all their own staff. This will include consultants and other senior medical and dental staff for whom the appointment procedures will be on the lines of those now operated in the hospital service. The clinical freedom of individual members of all the healing professions will of course be fully preserved. Family Practitioner Services 28
General medical and dental practitioners, ophthalmic medical practitioners, opticians and pharmacists will continue to provide their services as independent contractors. Each Area Health Authority will be required by statute to set up a Family Practitioner Committee to enter into and administer contracts with individual practitioners in accordance with nationally determined terms of service and unchanged statutory disciplinary arrangements. The Committee, which will appoint its own chairman, will have 3 0 members, 1 1 appointed by the AHA
(including at least one members of the AHA itself), h by the County
Council and 1 5 by professional committees for the area. Of these
professional members 8 will be doctors, 3 dentists, 2 pharmacists,
1 an opthalmic optician and 1 a dispensing optician.
29
On matters concerning the contracts of practitioners the Committee will deal direct with the Welsh Office. But for the full benefits of integration to be achieved, matters involving other parts of the services must be the responsibility of the Area Health Authority. These will include, for example, arrangements to enable family doctors to have access to hospital diagnostic facilities and to be associated with the provision of hospital services and preventive medicine; general arrangements for nursing and other skilled staff employed by the AHA or by the local authority to work with family doctors; and the planning of health centres and of other changes in the pattern of services. The AHA will of course consult the Family Practitioner Committee and the professional committees fully in these matters before making decisions. 13
30
Staff serving the Family Practitioner Committee will be employed
by the AHA, appointments of senior staff being made after
consultation with the Committee, Some staff may make this work their
career; but others will benefit from the opportunities for wider
experience and the flexibility will enhance the Committee's prospects
of attracting the right people to its service.
Ik PART
III
CENTRAL
ORGANISATION
The S e c r e t a r y o f S t a t e and t h e Welsh O f f i c e
31
The S e c r e t a r y o f S t a t e , a c t i n g through t h e Welsh O f f i c e , w i l l p r o v i d e
AHAs w i t h c e n t r a l p o l i c y g u i d a n c e , determine n a t i o n a l p r i o r i t i e s ,
c o - o r d i n a t e a r e a p l a n s i n t o a c o h e r e n t o v e r a l l p l a n and a l l o c a t e
r e s o u r c e s between t h e d i f f e r e n t a r e a s .
This w i l l include p r o v i s i o n
f o r p a r t i c u l a r AHAs t o a d m i n i s t e r t h e b l o o d t r a n s f u s i o n s e r v i c e s and
the r a r e r s p e c i a l i t i e s s u c h a s r a d i o t h e r a p y o r c a r d i a c and t h o r a c i c
s u r g e r y , which need t o be p l a n n e d on an a l l - W a l e s b a s i s .
Complements
of s c a r c e c a t e g o r i e s o f s t a f f w i l l n e e d t o be c o n t r o l l e d t o ensure t h a t
they are s u i t a b l y deployed.
The S e c r e t a r y o f S t a t e must a l s o m a i n t a i n
g e n e r a l f i n a n c i a l and c o s t c o n t r o l and s a t i s f y h i m s e l f t h a t t h e AHAs,
a s h i s a g e n t s , a r e p r o v i d i n g a c c e p t a b l e s t a n d a r d s of c a r e i n accordance
w i t h a g r e e d p l a n s and i n c o l l a b o r a t i o n w i t h l o c a l a u t h o r i t i e s and t h a t
t h e y a r e managing t h e s e r v i c e e f f i c i e n t l y and humanely.
P a r t i c i p a t i o n i n Central Decisions
32
R e f e r e n c e h a s a l r e a d y b e e n made t o t h e importance which t h e
Secretary of S t a t e a t t a c h e s t o securing that the health s e r v i c e
p a r t i c i p a t e s e f f e c t i v e l y i n t h e c e n t r a l p r o c e s s e s o f p o l i c y making
and d e c i s i o n and t o e n s u r i n g t h a t h i s c e n t r a l c o n t r o l i s s o e x e r c i s e d
t h a t i t d o e s n o t undermine t h e a u t h o r i t y and r e s p o n s i b i l i t y o f AHAs.
There w i l l be a v e r y c l o s e , c o n t i n u i n g r e l a t i o n s h i p between AHAs and
t h e Welsh O f f i c e w i t h f l e x i b l e arrangements f o r r e g u l a r
a t chairman and o f f i c e r l e v e l ;
discussions
e x p e r t p a n e l s w i l l be brought t o g e t h e r
a s n e c e s s a r y for c o n s i d e r a t i o n of p a r t i c u l a r problems.
AHAs c o l l e c t i v e l y
w i l l be f u l l y a s s o c i a t e d w i t h f o r m u l a t i o n o f t h e p r i n c i p l e s on which
r e s o u r c e s w i l l be a l l o c a t e d from y e a r t o y e a r .
Within a g r e e d p o l i c i e s
and o v e r a l l p l a n s AHAs w i l l have wide d i s c r e t i o n t o t a k e account o f
l o c a l c i r c u m s t a n c e s and n e e d s .
S i m i l a r l y i n t h e development o f a c e n t r a l
i n t e l l i g e n c e and management i n f o r m a t i o n s y s t e m t o a s s i s t AHAs i n
d i s c h a r g i n g t h e i r management r e s p o n s i b i l i t i e s e f f e c t i v e l y and i n
15 e v a l u a t i n g a l t e r n a t i v e means o f m e e t i n g n e e d s , i t i s e x p e c t e d t h a t
t h e y w i l l b o t h c o n t r i b u t e i n i t i a t i v e s t o t h e c e n t r e and be p o s i t i v e l y ­
associated with d e c i s i o n s .
33
I t i s i n t e n d e d t h a t m o n i t o r i n g by AHAs o f t h e i r own performance
and o v e r a l l m o n i t o r i n g by t h e S e c r e t a r y o f S t a t e s h a l l
progressively
be b a s e d on t h e s y s t e m a t i c c o l l e c t i o n and a n a l y s i s o f s t a t i s t i c a l and
o t h e r management i n f o r m a t i o n t o a s s e s s performance a g a i n s t agreed p l a n s ,
t h e m s e l v e s s y s t e m a t i c a l l y c o n c e i v e d and e x p r e s s e d .
For t h i s ,
f i n a n c i a l i n f o r m a t i o n s y s t e m s a r e b e i n g d e v e l o p e d and more
improved
effective
y a r d s t i c k s o f need and performance w i l l need t o be worked o u t .
w i l l t a k e time t o p e r f e c t .
They
There w i l l always be a c l o s e need f o r
p e r s o n a l c o n t a c t s and v i s i t s by AHAs w i t h i n t h e i r a r e a s and Departmental
o f f i c e r s w i l l s i m i l a r l y need t o have p e r s o n a l knowledge o f p r o b l e m s .
V i s i t i n g and a d v i c e by c e n t r a l a u d i t o r s and by t h e H o s p i t a l A d v i s o r y
Service w i l l a l s o continue to play a valuable part.
But a s more
s y s t e m a t i c management i n f o r m a t i o n i s d e v e l o p e d such arrangements w i l l
i n c r e a s i n g l y be s e e n i n t h e i r t r u e c o n t e x t o f s u p p o r t i n g t h e AHA i n
its
own management r o l e .
Jtk
R e o r g a n i s a t i o n w i l l b r i n g about changes i n t h e r o l e o f t h e
Welsh O f f i c e which w i l l have i m p l i c a t i o n s f o r i t s s t a f f i n g and i n t e r n a l
organisation.
I t must s u p p o r t t h e S e c r e t a r y o f S t a t e i n h i s new
a c c o u n t a b i l i t y f o r t h e a d m i n i s t r a t i o n o f s e r v i c e s t r a n s f e r r e d from l o c a l
authorities.
I t w i l l a l s o be d i s c h a r g i n g major f u n c t i o n s o f
co-ordination
and r e s o u r c e a l l o c a t i o n (but n o t l a r g e l y e x e c u t i v e f u n c t i o n s - s e e p a r a s
39-^1) which, for h o s p i t a l s e r v i c e s , are c u r r e n t l y delegated t o the
Welsh H o s p i t a l Board.
The d i r e c t Welsh O f f i c e c o n c e r n w i t h t h e problems
o f AHAs and t h e i n t i m a t e l i n k s which i t w i l l m a i n t a i n w i t h them w i l l
r e q u i r e some i n c r e a s e i n i t s s t a f f r e s o u r c e s .
At t h e same time i t must
e n s u r e t h a t i t s own approach t o AHAs f u l l y r e f l e c t s t h e i n t e g r a t i o n
which r e o r g a n i s a t i o n o f t h e s e r v i c e i s d e s i g n e d t o a c h i e v e . The
p r o s p e c t i v e s t a f f i n g and s t r u c t u r e r e q u i r e m e n t s of t h e Welsh O f f i c e a r e
b e i n g examined s o t h a t t h e a p p r o p r i a t e changes may be made.
16
I n any
n e c e s s a r y augmentation o f i t s s t a f f t h e Welsh O f f i c e w i l l s e e k t o draw
t o t h e f u l l e s t e x t e n t p r a c t i c a b l e on s t a f f a t p r e s e n t s e r v i n g i n t h e
Health S e r v i c e .
These m a t t e r s and terms o f t r a n s f e r w i l l be d i s c u s s e d
w i t h t h e s t a f f a s s o c i a t i o n s and w i t h t h e S t a f f Commission ( s e e
paragraph 4 9 ) .
35
The h e a l t h s e r v i c e i n Wales cannot e f f e c t i v e l y be planned and
operated i n i s o l a t i o n .
N e i t h e r p a t i e n t s nor t h e h e a l t h p r o f e s s i o n s
w i s h t o be c o n f i n e d by a d m i n i s t r a t i v e b o u n d a r i e s ;
and Wales can b e n e f i t
g r e a t l y from t h e a d d i t i o n a l s t r e n g t h , knowledge and e x p e r i e n c e which
comes from p a r t i c i p a t i n g i n arrangements which c o v e r England and W a l e s ,
o r Great B r i t a i n , a s a w h o l e .
Broad h e a l t h p o l i c y w i l l t h e r e f o r e
continue
t o be c o n c e i v e d , and pay and c o n d i t i o n s o f s e r v i c e f o r s t a f f and
p r a c t i t i o n e r s t o be s e t t l e d ,
on a n a t i o n a l b a s i s w i t h Welsh p a r t i c i p a t i o n ;
s i m i l a r l y t h e r e w i l l be common p o l i c i e s i n s t a f f t r a i n i n g and j o i n t
s t a f f advisory machinery.
F i n a n c i a l , s t a t i s t i c a l and management
i n f o r m a t i o n and c o n t r o l s y s t e m s w i l l a l s o be c l o s e l y c o m p a t i b l e and
t h e r e w i l l be c o - o r d i n a t i o n o f r e s e a r c h o f a l l k i n d s and s h a r i n g o f
its
results;
is
s u p p l i e s w i l l be o r g a n i s e d on a n a t i o n a l b a s i s where t h i s
advantageous.
I n a l l s u c h r e s p e c t s t h e Welsh O f f i c e w i l l c o n t i n u e
to
o p e r a t e i n c l o s e c o n s u l t a t i o n w i t h t h e Department o f H e a l t h and S o c i a l
Security.
Central P r o f e s s i o n a l Advice
36
J u s t a s Area H e a l t h A u t h o r i t i e s n e e d t h e e x p e r t a d v i c e o f t h e
p r o f e s s i o n s , so does the S e c r e t a r y of S t a t e .
In the formulation of
n a t i o n a l p o l i c i e s he w i l l , j o i n t l y w i t h t h e S e c r e t a r y o f S t a t e
for
S o c i a l S e r v i c e s , have t h e a d v i c e o f 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 i t s e x p e r t S t a n d i n g A d v i s o r y Committees whose c o n s t i t u t i o n w i l l be
a d j u s t e d t o meet t h e n e e d s o f t h e r e o r g a n i s e d s e r v i c e .
In the application
o f n a t i o n a l p o l i c i e s t o t h e c i r c u m s t a n c e s o f Wales he and h i s
officers
w i l l l o o k f o r p r o f e s s i o n a l a d v i c e t o committees 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 i n W a l e s .
The arrangements f o r t h i s w i l l
be worked out w i t h t h e p r o f e s s i o n s , who a r e a l r e a d y l o o k i n g a t t h e
17 also
considerations.
For example, i n t h e m e d i c a l p r o f e s s i o n t h e a l l - W a l e s
a d v i s o r y Committee w i l l need t o r e f l e c t a b a l a n c e o f t h e i n t e r e s t s o f
g e n e r a l p r a c t i c e , s c h o o l h e a l t h and community work, and h o s p i t a l
s p e c i a l i t i e s including the rarer ones;
i t must a l s o c o v e r t h e i n t e r e s t
i n m e d i c a l manpower and m e d i c a l e d u c a t i o n and r e s e a r c h .
A d v i c e from t h e Welsh C o u n c i l
37
The C o n s u l t a t i v e Document s u g g e s t e d t h a t f o r s t r a t e g i c a d v i c e on
g e n e r a l h e a l t h m a t t e r s i n Wales t h e S e c r e t a r y o f S t a t e s h o u l d l o o k t o a
new Welsh H e a l t h C o u n c i l r e f l e c t i n g a wide r a n g e o f h e a l t h i n t e r e s t s
a l l p a r t s of Wales.
T h i s p r o p o s a l met an i n d i f f e r e n t r e s p o n s e .
in
Doubts
were e x p r e s s e d whether t h e c r e a t i o n o f s u c h a body iras j u s t i f i e d .
The
p r o p o s a l h a s b e e n r e c o n s i d e r e d i n t h e l i g h t o f t h e s e comments and o f t h e
development o f t h e p r o p o s a l s f o r t h e i n v o l v e m e n t o f t h e h e a l t h p r o f e s s i o n s
and t h e Area H e a l t h A u t h o r i t i e s i n c e n t r a l p r o c e s s e s .
The arrangements
w i l l be f u l l y adequate t o e n s u r e t h a t t h e S e c r e t a r y o f S t a t e r e c e i v e s
informed a d v i c e r e f l e c t i n g t h e s e v i e w p o i n t s ;
t h e r e remains t h e q u e s t i o n
o f e n s u r i n g t h a t h e a l t h p o l i c i e s are c o n s i d e r e d a g a i n s t a wider background.
The Welsh C o u n c i l h a s r e p r e s e n t e d t h a t i t s own c o n c e r n w i t h g e n e r a l
q u e s t i o n s o f e c o n o m i c s , t r a n s p o r t , p l a n n i n g and t h e environment - and
p a r t i c u l a r l y i t s concern with s o c i a l s e r v i c e matters - p l a c e s i t i n a
b e t t e r p o s i t i o n t o p r o v i d e s u c h a p e r s p e c t i v e t h a n a body whose r e m i t
was c o n f i n e d t o t h e h e a l t h s e r v i c e a l o n e .
38
The Government a c c e p t t h e f o r c e o f t h e s e arguments.
Subject,
t h e r e f o r e , t o r e v i e w i n t h e e v e n t of any s u b s t a n t i a l change i n the
c h a r a c t e r and r o l e o f t h e Welsh C o u n c i l f o l l o w i n g c o n s i d e r a t i o n o f t h e
recommendations o f t h e Commission on t h e C o n s t i t u t i o n 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 t i n u e t o s e e k s t r a t e g i c a d v i c e f r o m ' t h e Welsh Council which
a l r e a d y h a s a H e a l t h and S o c i a l S e r v i c e s P a n e l , r a t h e r than from a
s e p a r a t e l y c o n s t i t u t e d body.*
18 Welsh H e a l t h T e c h n i c a l S e r v i c e s
39
Organisation
I n a l l t h e main a r e a s o f p l a n n i n g and d e c i s i o n t h e Government a r e
s a t i s f i e d o f t h e a d v a n t a g e s o f v e r y s u b s t a n t i a l d e l e g a t i o n t o Area H e a l t h
Authorities.
But f o r a number o f s p e c i a l i s e d and t e c h n i c a l s u p p o r t i n g
t a s k s the balance of advantage w i l l s t i l l l i e i n the i n c r e a s e d
which can be s e c u r e d by a d e g r e e o f c e n t r a l i s a t i o n .
t h e d e s i g n and e x e c u t i o n o f major c a p i t a l works;
efficiency
These w i l l
include
the systematic
e v a l u a t i o n o f c o n t r a c t i n g arrangements f o r s u p p l i e s , t h e n e g o t i a t i o n
o f c e n t r a l c o n t r a c t s where t h e S e c r e t a r y o f S t a t e j u d g e s them a p p r o p r i a t e
and t h e p r o v i s i o n o f e x p e r t a d v i c e t o t h e s u p p l i e s o f f i c e r s whom AHAs
w i l l t h e m s e l v e s employ; a computer-based c e n t r a l management i n f o r m a t i o n
s e r v i c e and s u c h o t h e r s p e c i a l i s t management s e r v i c e s a s a r e judged
a p p r o p r i a t e from t i m e t o t i m e .
hO
A Welsh H e a l t h T e c h n i c a l S e r v i c e s O r g a n i s a t i o n (WHTSO) w i l l be
c r e a t e d t o c a r r y out f u n c t i o n s of t h i s k i n d .
t o t h a t o f AHAs and t h e Welsh O f f i c e .
I t s r o l e w i l l be complementary
For example i t s c e n t r a l computer
s e r v i c e w i l l p r o v i d e comparative s t a t i s t i c a l m a t e r i a l t o augment t h e
management i n f o r m a t i o n which each AHA i t s e l f p r o d u c e s and w i l l a l s o be
u s e d by t h e Welsh O f f i c e i n support o f i t s c e n t r a l i n t e l l i g e n c e and
monitoring functions.
In i t s t e c h n i c a l f i e l d s WHTSO w i l l be r e s p o n s i b l e
f o r g u i d i n g AHAs on b e h a l f o f t h e S e c r e t a r y o f S t a t e and f o r p r o v i d i n g
him w i t h e x p e r t a s s e s s m e n t s o f c u r r e n t a r r a n g e m e n t s .
Study o f t h e e x t e n t
t o which WHTSO s h o u l d b e . c h a r g e d w i t h p a r t i c u l a r f u n c t i o n s on i t s
inception i s s t i l l proceeding.
I t may be a d v a n t a g e o u s t o b r i n g t h e
work o f t h e Welsh J o i n t P r i c i n g Committee under t h e wing o f WHTSO w i t h
arrangements t o s a f e g u a r d t h e i n t e r e s t s o f c h e m i s t s and d o c t o r s ;
w i l l be d i s c u s s e d w i t h t h e b o d i e s c o n c e r n e d .
this
Approval and p r i c i n g o f
d e n t a l e s t i m a t e s w i l l c o n t i n u e t o be c a r r i e d out on an England and Wales
b a s i s by t h e D e n t a l E s t i m a t e s Board.
19 *f1
The f u n c t i o n o f WHTSO i n r e l a t i o n t o the d e s i g n and e x e c u t i o n
o f c a p i t a l works w i l l be o f major i m p o r t a n c e .
The AHAs w i l l d e v e l o p
t h e i r p l a n s f o r c a p i t a l programmes y e a r by y e a r f o r t h e approval o f t h e
Secretary of S t a t e .
But t h e d e t a i l e d p l a n n i n g , d e s i g n and e x e c u t i o n o f
any s u b s t a n t i a l c a p i t a l work c a l l s f o r e x p e r t teams o f s c a r c e
specialists
who r e q u i r e a c o n t i n u i t y and span o f v/ork and e x p e r i e n c e which cannot be
p r o v i d e d on an a r e a by a r e a b a s i s .
be c o n c e n t r a t e d i n WHTSO.
I t i s proposed t h a t t h e s e s k i l l s
shall
I t w i l l be r e s p o n s i b l e d i r e c t l y t o t h e
S e c r e t a r y o f S t a t e f o r major works but r e s p o n s i b i l i t y f o r l e s s complex
works o f d e f i n e d t y p e s , f o r which t h e r e i s adequate c e n t r a l guidance
m a t e r i a l on d e s i g n and c o s t , w i l l a s f a r a s p o s s i b l e be d e l e g a t e d t o
AHAs who w i l l make u s e o f t h e e x p e r t s t a f f o f WHTSO a s n e c e s s a r y .
p r e c i s e arrangements a r e s t i l l under s t u d y .
The
There w i l l be p r o v i s i o n f o r
AHAs t o make u s e o f d e s i g n c a p a c i t y which l o c a l a u t h o r i t i e s may make
a v a i l a b l e and f o r c o n t i n u i n g u s e o f p r i v a t e c o n s u l t a n t s
consistently
w i t h e f f i c i e n t employment o f t h e c e n t r a l team.
k2
The Welsh H e a l t h T e c h n i c a l S e r v i c e s O r g a n i s a t i o n w i l l be headed by a
s m a l l Board c o n s i s t i n g o f a chairman and some 5 t o 7 members a p p o i n t e d by
the Secretary of S t a t e .
I t i s e n v i s a g e d t h a t t h e Board would be c o n c e r n e d
p r i m a r i l y w i t h t h e management o f i t s own o r g a n i s a t i o n and i t s
e f f i c i e n c y and w i t h e n s u r i n g t h a t i t k e e p s a b r e a s t o f t h e
t e c h n i c a l d e v e l o p m e n t s and i s a b l e t o meet demands.
internal
latest
The d e t a i l e d work
on i n d i v i d u a l p r o j e c t s would f a l l t o i t s p r o f e s s i o n a l o f f i c e r s who s h o u l d
be g i v e n t h e maximum freedom t o work i n d i r e c t r e l a t i o n s h i p w i t h
o f AHAs and t h e Welsh O f f i c e .
officers
The s t a f f i n g s t r u c t u r e o f t h e o r g a n i s a t i o n
i s under s t u d y .
Financial Administration
kj)
/
F i n a n c e f o r t h e r e o r g a n i s e d s e r v i c e w i l l come a l m o s t
from c e n t r a l government;
entirely
charges t o p a t i e n t s for c e r t a i n s e r v i c e s
c o n t i n u e t o meet a s m a l l p a r t o f t h e o v e r a l l c o s t .
will
The r e l i e f t o l o c a l
a u t h o r i t i e s o f e x p e n d i t u r e on t r a n s f e r r e d s e r v i c e s w i l l be taken i n t o
20
a c c o u n t i n t h e c a l c u l a t i o n o f g r a n t t o them.
The S e c r e t a r y o f S t a t e
w i l l a l l o c a t e r e v e n u e and c a p i t a l funds t o Area H e a l t h A u t h o r i t i e s ,
w i t h p r o v i s i o n f o r s e p a r a t e f u n d i n g o f payments t o f a m i l y p r a c t i t i o n e r s .
P r o v i s i o n a l forward f i n a n c i a l c e i l i n g s w i l l be n o t i f i e d t o g e t h e r w i t h
p r o v i s i o n a l a p p r o v a l s f o r c a p i t a l schemes s o t h a t AHAs may prepare
r o l l i n g p l a n s on a r e a l i s t i c b a s i s .
A l l o c a t i o n s w i l l t a k e account o f
s p e c i a l r e s p o n s i b i l i t i e s and o f s e r v i c e s p r o v i d e d t o p a t i e n t s from
o t h e r a r e a s ; g e n e r a l l y , t h e y w i l l s e e k p r o g r e s s i v e l y t o promote good and
comparable s t a n d a r d s o f c a r e f o r a l l t h e p e o p l e o f t h e P r i n c i p a l i t y .
Finance w i l l be p r o v i d e d d i r e c t l y t o t h e Welsh H e a l t h T e c h n i c a l S e r v i c e s
O r g a n i s a t i o n f o r t h e c a p i t a l schemes f o r whose e x e c u t i o n i t w i l l be
r e s p o n s i b l e and a l s o f o r t h e c o s t o f common s e r v i c e s , e g from t h e c e n t r a l
s u p p l y u n i t and t h e computer u n i t , p r o v i d e d e q u a l l y t o a l l AHAs.
p a r t i c u l a r c a l l s on i t s s e r v i c e s t h e r e w i l l be p r o v i s i o n f o r
For
individual
AHAs t o b e a r a charge i n a p p r o p r i a t e c a s e s .
kk
Though t h e S e c r e t a r y o f S t a t e w i l l w i s h t o be s a t i s f i e d ,
through
t h e e x a m i n a t i o n o f p l a n s and e s t i m a t e s , t h a t t h e g e n e r a l b a l a n c e o f
p r o v i s i o n between p a r t i c u l a r p a t i e n t and community groups and between
t h e r a p e u t i c and p r e v e n t i v e s e r v i c e s f a i r l y r e f l e c t s t h e b a l a n c e o f n e e d s
and i s c o n s i s t e n t w i t h approved s t r a t e g i c p o l i c i e s , t h e aim w i l l be t o
l e a v e AHAs a s much d i s c r e t i o n a s p o s s i b l e i n t h e d i s t r i b u t i o n o f
resources.
their
As p r e v i o u s l y i n d i c a t e d (paragraph 3 3 ) improved f i n a n c i a l
systems are being developed t o a s s i s t i n budgeting, f i n a n c i a l
and o v e r a l l management c o n t r o l .
21 monitoring
PART IV THE STAFF OF THE SERVICE The new opportunities k$
The health service works through its staff and to them must go the
main credit for its very real achievements over the years since 1 9 ^ 8 . The
administrative changes which this White Paper foreshadows are designed to
provide a more effective framework for the release of their skills and
energies. There will be new opportunities to take a wider and more
coherent view of health care. For example medical administrators, as
specialists in community medicine with a vital role in planning and
managing the unified service, will be concerned not only with developing
preventive and domiciliary health services and with the provision of
medical advice and help to local authorities, but also with the overall
assessment of health needs and the most effective ways of meeting them,
and with promoting functional integration within the service and close
planning and working links with related services. For them and for
nursing and other administrators the changes will open new horizons. For
those in clinical work the removal of administrative barriers will mean
greater ease in fitting together complementary services: for example more
effective mechanisms will be possible to co-ordinate services for
vulnerable groups like the mentally ill, the handicapped and the elderly,
whether given at home or in hospital.
Training ^6
The new perspectives will call for retraining. A series of special courses for senior staff has already begun and there will be local arrangements for helping other staff to understand the purpose of the forthcoming reorganisation and its meaning in their everyday work. Within the unified service, management training at all levels will complement professional and occupational training as part of the very important function of personnel management. It is proposed, in consultation with the interested bodies, to create a number of linked staff advisory committees to build on and extend to other groups of staff the work which the National Staff Committee has done for administrative and clerical staff and the National Nursing Staff Committee has done for nurses and 22
midwives. It is also proposed to establish an NHS Training Council to work with them. All these bodies will cover both England and Wales. The Welsh Office, as part of its responsibility for promoting consistent personnel policies throughout V/ales, will co-ordinate the training activities of Area Health Authorities and relate the work of the national advisory machinery to the training programme in the Principality. Staff will be encouraged over the years to take advantage of the greater flexibility which will be possible within Area Health Authorities so as to gain varied experience. Arrangements for staff interchange betv/een AHAs, the Welsh Health Technical Service Organisation and the Welsh Office, as part of the career training process and to help to knit closer links betvreen them all, will be studied in consultation with staff interests. Such arrangements will be particularly desirable for the provision of the medical and nursing advice which the WHTSO will require in relation to its building and other functions. Doctors and nurses employed by the particular AHA which will have the responsibility of operating a new hospital or other building will be associated with WHTSO architects and other specialists in the team which designs it. But while their experience as users of the facilities will be important they will not necessarily have the wider comparative experience of design problems and developments which comes from regular involvement in a major building programme and which is also important in producing effective and economical solutions. The central WHTSO organisation will therefore need to include doctors and nurses with this experience and since a career in a primarily technical organisation may not seem attractive to members of these professions it is proposed that the necessary advice shall be provided by officers of Welsh Office and of AHAs, probably on medium-term or part-time secondment.
/
The NHS Staff Commission for Wales k8
Reorganisation of the service will not affect the clinical
responsibilities or working circumstances of doctors, nurses and members
of other healing professions who are engaged in the care of patients.
Their contract for employment, or for services, will normally pass over
23 to the new authority for the place where they work. This too will be the only immediate change for most other staff: they will carry on working at the same hospital, ambulance station, health centre etc on the same kind of duties as before. But for some, particularly among those who are engaged on administrative work, there will have to be changes in duties and places of employment,, There will be problems of redeployment and of the selection of people for senior posts. An NHS Staff Commission for Wales has already been appointed - in the form of an Advisory Committee pending the passing of the legislation - to advise on procedures to ensure the utmost fairness and to safeguard fully the interests of staff. PART V OTHER MATTERS Voluntary help for the Service ^9
There has always been generous voluntary support of the service to
supplement its staffing and financial resources. Members of the health
authorities are themselves unpaid volunteers and the service owes them a
very great debt. But, besides this, many voluntary organisations and
good-hearted individuals bring help, friendship, comforts and extra
amenities to patients at home and in hospital, making life better for
them in more ways than can be mentioned here. The Government sets the
greatest possible store by this help and will seek actively to encourage
it. Unification of the service and close co-operative working between
Area Health Authorities and matching local authorities will make it
easier for voluntary organisations to see how they can best develop their
services to help families, individuals and groups over the whole range of
their needs and membership of Community Health Councils will deepen their
understanding of the service as well as influencing the way it works.
For their part Area Health Authorities will support the voluntary
organisations in their efforts to co-ordinate and increase their
activities.
Gifts and endowments
50
Voluntary organisations also help by local fund-raising efforts and
these too will be encouraged. The new authorities, like the present
24
hospital authorities, will also have power to accept gifts and bequests,
which have been so valuable both in enabling extra amenities to be
provided and in supporting research into new forms of care. Endowments
nov; held and administered by hospital authorities will be transferred to
the new authorities, with arrangements to safeguard local and special
purposes of bequests: for example a bequest to a Hospital Management
Committee for general use in its services will be used for the same group
of hospitals as before and for health services associated with them and a
bequest relating to a particular hospital will be used only for that
hospital. An appropriate share of the Hospital Endowments Fund, to which
many endowments given in England and Wales before the passing of the
National Health Service Act of 19^6 were transferred, will be available
to Area Health Authorities in Wales for hospital and associated purposes.
Patients Complaints: the Health Service Commissioner 51
Like existing authorities, Area Health Authorities will be expected
to maintain satisfactory arrangements for investigating complaints from
individual patients. Arrangements for complaints concerning hospitals
will be reviewed in the light of the recommendations of an independent
committee currently sitting under the chairmanship of Mr Michael Davies QC.
To enable complainants to seek independent help where they remain
dissatisfied with the results of investigations by the AHA, the
legislation will (as already announced) provide for the appointment of a
Health Service Commissioner for Wales. The Commissioner will not be
concerned with complaints which relate only to the way clinical judgement
has been exercised, nor with complaints against family practitioners where
existing Statutory investigation procedures will continue and he would
not normally pursue a complaint which could be taken to a tribunal or to
the courts. Subject to this, any complaint by a patient of injustice or
hardship through maladministration or through failure to provide
necessary treatment or care may be taken to the Commissioner if recourse
to the AHA does not resolve it. Complainants will have direct access
1
to this "ombudsman' , or their case may be taken up by someone else on
their behalf.
25
52
In addition to preparatory training and the preparation of guidance
on management organisation and processes in the new health authorities
much preparatory work must be done before April 197^ to ensure a smooth
changeovero
The new authorities in "shadow" form, together with their
prospective chief officers, will be appointed as soon as possible after
the necessary legislation has been passed and it will be for them to
prepare definitive proposals on the development of their services, on the
pattern of organisation each wishes to adopt and on its staffing and
accommodation implications. Time will be short and their task will be
greatly eased if as much preliminary work as possible is done beforehand
by existing authorities working in co-ordination, for example preparation
of statements about existing staff and services and developments in
progress or currently planned; and about endowments, rights, property
and liabilities (including local authority loan debt) which may need to
be included in arrangements for transfer to the new authorities. Informal
joint liaison committees of existing authorities are being set up in the
new areas for these purposes. Their work will be guided and co-ordinated
by a similar committee for the whole of Wales in which the Welsh Office
and the Welsh Hospital Board will join.
PART VI CONCLUSION 53
Administrative reorganisation is designed to benefit all who use the
National Health Service by enabling it to use those resources more
effectively. The Government believe that the changes outlined in this
White Paper will secure this objective. Through bringing all personal
health services together under Area Health Authorities they will provide
the framework in which fully integrated services can be developed in the
right balance with each other; no one form of service will dominate
another and the Government hope that between now and April 197^ local
authorities will continue the present development of the health services
for which they are now responsible in the assurance that their importance
will increase in the unified service. The matching of AHAs with the new
counties and the forging of planning and working links between AHAs and
local authorities will help to promote the complementary development of
26
health and related social services. The direct and close relationship
between the Secretary of State and the 8 AHAs will allow the fullest
possible delegation of responsibility to them for the planning and
operation of their services.and ;riLll provide for their effective
participation in central decision making; this, matched by clear
accountability for their stewardship, will fit them better to serve
their communities. Particular supporting functions will be provided
by the Welsh Health Technical Services Organisation. The Community
Health Councils will ensure that Area Health Authorities are responsive
to the local needs and professional advisory machinery will bring them
the strength of expert knowledge. The Secretary of State, acting through
the Welsh Office and with the advice of professional and expert committees
and of the Welsh Council, will guide and co-ordinate the work of the
health authorities, leading them in the search for a better and more
efficient service.
5^
In these ways the reformed administrative structure will help the
service to respond to the challenges of the coming decades.
27