Presented to Parliament by
the Secretary of State for Social Services
by Command of Her Majesty
August 1972

LONDON

HER MAJESTY’S STATIONERY OFFICE

68p net

Cmnd. 5055.

Contents

Foreword by the Secretary of State for Social Services

Section

THE REORGANISED SERVICE: THE MAIN FEATURES

I Unification …

II The Consultative Document

III Services within and outside the NHS

IV NHS authorities and their functions

V Area health authorities—functions

VI Area health authorities—collaboration with local government

VII Area health authorities collaboration with local government

VII Area health authorities—family practitioner services
VIII Regional health authorities
IX Central Department
X Membership of authorities
XI Professional advisory machinery
XII Community health councils
XIII Medical and dental teaching
XIV A sound management structure
XV The staff of the service
XVI Financial administration
THE REORGANISED SERVICE: OTHER ISSUES
XVII Voluntary services
XVIII The private sector
XIX Endowments
XX Handling complaints
XXI Special Hospitals
XXII Arrangements for London
XXIII RUNNING THE SERVICE UNTIL 1974
XXIV PREPARING FOR 1974
XXV CONCLUSION
APPENDICES (not reproduced)
I List and map of regions and areas
II Secretary of State for Social Services Parliamentary announcement on Health Service Commissioner .
III Management study

Foreword

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 wrong 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 careers 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.

Hence this White Paper. It is about administration, not about treatment and care. But the purpose behind the changes proposed is a better, more sensitive, service to the public. 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 both a clear duty to improve the service and the facilities for doing so.

Let me illustrate this. Everyone is aware of gaps in our health services. Even for acute illness, where we provide at least 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 they need—and all the more credit to the staff who have toiled so tirelessly for their patients despite the difficulties.

It is well understood 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 were better co­ordinated 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 health service that the 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 for the benefit of the public.

It is to enable 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 on ever-growing multitude of skills 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 to a programme of expenditure 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 ?—to improve the service for the benefit of all. The plans 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.

Furthermore they must include arrangements whereby the public can express their wishes and preferences, and know that notice will be taken of them. That is why I attach great importance to the establishment of strong community health councils, and to improved methods for enquiring into complaints, including the appointment of a health ombudsman.

The health services depend crucially on the humane planning and provision of the personal social services, and therefore on effective and understanding collaboration with local government. No doubt arguments will continue about the theoretical advantages of making both health and 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.

The doctor and other professional workers will gain too. The organisational changes 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.

We are issuing a White Paper, and promoting legislation about the adminis­tration of the National Health Service, solely in order to improve the health care of the public. Administrative reorganisation within a unified health service that is closely linked with parallel local government services will provide a sure foundation for better services for all.

KEITH JOSEPH

Secretary of State for Social Services.

The Reorganised Service: The Main Features

I Unification

  1. 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 unifica­tion 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 simultaneously proposed in local government, under the Local Government Bill now before Parliament. These will create new areas which, 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, previously shared with the Home Office, in the Department of Health and Social Security, which is also responsible for administering cash benefits, including those paid to the sick and disabled.
  7. All this has not been done just to get administrative 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 unsatisfactory service or even no service at all.
  8. There are very strong arguments for bringing health and social services under a single administration. This could be accomplished by putting the NHS within local government. But, for reasons accepted and fully explained by both the previous and the present Government, that is not attainable, at least in the forseeable 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 unifica­tion of its administration offer the prospects of real benefits, not only to the individual and the family, but to the public in general. They provide for a single administering body locally, which will draw its funds from one source, and will take a wide, unbiased and constructive view of the priorities across the whole range of needs served by the general practitioner and other community health services and by the hospitals. This is the hub of the Government’s proposals for NHS unification. “Unbiased” is important. There will be no question of the community health services swallowing up the hospitals, or, a more common suspicion, vice versa. “Constructive” is also important because the aim will be to keep the needs of the local people constantly under review, and to improve and adjust services in order to provide the best practicable health facilities for all.

  10. The NHS administering authorities will be entirely new bodies covering the whole field of health care, domiciliary and institutional. Their membership and administrative structure will be such that they are not dominated by people whose main interests lie in one or other service. They will have capable mem­bers, and will appoint skilled and appropriately trained staff. They will be armed with the most expert advice. They will have effective channels for the expression of local public opinion. These points are developed in later Sections of this White Paper.

  11. These features will enable the authorities, within the general framework of national policy, to provide a sensitive, constantly improving service in their areas, giving proper attention to care as well as cure, and a much needed impetus to the prevention of illness and the promotion of health.

II The Consultative Document

12.The previous Government had given much thought to unification, and had issued two Green Papers for public discussion. The present Govern­ment was not however satisfied that the proposals in the Green Papers would create the administrative structure needed for a fully effective NHS in England. A Consultative Document was therefore issued in May 1971.

13. This provided for a clear definition and allocation of responsibilities, with maximum delegation downwards, matched by accountability upwards. There would be regional authorities between the central Department and the area authorities. The aim would be to set objectives and standards and to measure performance against them. A sound management structure would be created at all levels. Authorities would be kept small and ability, drive and judgment would be the main criteria for the selection of members. The views of the public would be voiced, not by way of membership of the health authorities but more directly, through representative community health councils in each locality, to advise the area authority and keep it in close touch with local opinion

14.The consultative document also promised the early setting up of two special studies. The first was an expert study of the detailed management arrangements, at both member and officer level, in the regions, at the area head­quarters, in the districts within the areas and in the individual hospitals and other institutions. The second study was of the arrangements needed to secure close collaboration between the area health authorities (AHAs) and the local auth­orities; a working party, representative of the interests concerned, was to under­take this study. Both studies were started in the summer of 1971.

15. There were also to be consultations with the organisations concerned about the shaping of the general arrangements to meet the special conditions in Greater London. These consultations, too, began in the summer of 1971.

16.Comments on the Consultative Document were received from nearly 600 organisations and individuals, and discussions were held with a number of the principal bodies concerned. In the light of these, the Government has reached firm decisions on the future administration of the NHS. These decisions are set out in later Sections of this White Paper. Legislation is being prepared and will be introduced in time for the reorganised NHS to come into operation on the same date as the reorganisation of local government, ie 1 April 1974.

III SERVICES WITHIN AND OUTSIDE THE NHS

National Health Service

  1. The services that will be brought together under unified NHS administration are these:

  • the hospital and specialist services now administered by the Regioni Hospital Boards, Hospital Management Committees and Boards c Governors;
  • the family practitioner services now administered by the Executive Council
  • the personal health services now administered by the local authorities through their health committees (see the next paragraph);
  • and the school health service.

    18.The personal health services are those which now stand referred to the local authority’s health committee under the NHS Acts and the Local Authority Social Services Act 1970. They include:

  • ambulance services;
  • epidemiological work, including general surveillance of the health of th community ;
  • family planning;
  • health centres;
  • health visiting;
  • home nursing and midwifery;
  • maternity and child health care;
  • medical, nursing and supplementary arrangements for the prevention c illness, care and after care; and
  • vaccination and immunisation.

Nursing Homes

19.The registration of nursing homes 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 an children and with the education service. Local education authorities’ presen 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 specia 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.

  1. 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

22. 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 services departments); 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 emotional, learning or behavioural problems. Partnership is needed in ensuring co-ordination of the observation, assessment and treatment activities of the health authorities, the education service and the local authority social services for children in care.

Health education

23.As part of their responsibility for the prevention of illness, the health authorities will have comprehensive health education powers. But because they are responsible for environmental health services such as food safety and hygiene, local authorities will have complementary powers; local education authorities will retain their responsibility for health education within the school curriculum. The Health Education Council will continue to work with the various bodies concerned with health education, and to provide a national focus and centre of activity.

Personal social services

24.The personal social services will continue to be provided by the local authorities—the counties (other than the metropolitan counties), the metro­politan districts and the London boroughs—through their social services com­mittees. The future of hospital social work is under review.

Environmental health

25.Environmental health will also continue to be a function of local govern­ment. This term includes measures for preventing the spread of communicable disease (other than routine immunisation, some epidemiological investigation and treatment); powers relating to food safety and hygiene, port health, and the diseases of animals in so far as they affect human health; the public health aspects of environmental services; and the enforcement of requirements about environ­mental conditions at work places. These environmental hygiene responsibilities will be vested in the district local authorities. The local authorities will be encouraged to seek the advice, and indeed the services, of medical staff employed by the health authorities, though statutory responsibility will rest on the local authorities, not the health authorities.

Occupational health

26. The health authorities will be concerned with preventive health measures of many kinds and will provide treatment and care for people who suffer injury or ill health however caused. But, apart from the authorities’ concern with the health of their own staff, responsibility for the health of persons in relation to their employment lies with the Department of Employment. In matters affecting the health and safety of employed persons there must always be close working between those responsible for health and the environment both inside and outside the workplace. It is intended that there should be very close co-operation between the NHS and the Employment Medical Advisory Service in relation to both policy formulation and day to day operations. In addition arrangements are being made for EMAS to use NHS laboratories and other investigatory facilities.

IV NHS AUTHORITIES AND THEIR FUNCTIONS

  1. 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. Within the national framework, therefore, administration will be delegated to local bodies, which will set 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 administration 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 parallel 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 Minister’s 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 Security has central responsibility, are an example of this.

30. But the NHS is in a different position. Parliament has placed full statutory responsibility for the service on the Secretary of State and holds him accountable for the money spent on it—nearly all of which comes from central sources. Moreover, a great deal of planning and allocation of resources must take place on a basis wider than an area: for example, the services linked with University medical schools and those based on regional centres.

31.This means that the Secretary of State must satisfy himself that the service in England is being efficiently run. In Scotland and in Wales, with their rela­tively small populations, it will be practicable to do this by means of area health authorities in direct relationship with the central Departments in Edinburgh and Cardiff. Health services in those two countries could therefore be operated without interposing a regional organisation between the central Health Departments and the areas. But in England, a central Department operating from London could not hope to exercise effective and prompt general super­vision over area authorities whose numbers will be six times those of their counter­parts in Scotland and eleven times those in Wales.

Regional administrative tier

  1. In theory, the regional organisation necessary in England could take the form of regional offices of the central Department. In practice, they would be much less effective than separate regional authorities.
  2. To place the whole job on the central Department and its regional offices would result in over-centralisation and delay; it would draw the Department into many matters that should be resolved locally or regionally; and it would distract the Department’s attention from the policy tasks which must be done centrally and which are its proper concern.

  3. There is also a positive case for separate regional authorities rather than regional offices of the central Department. Each regional authority will be a body of local people knowledgeable about their region’s needs. They will have close relationships with the University, which has a key part to play in the region’s work through its teaching and research activities, and will be able to develop a continuing and constructive dialogue with their areas.

    35. These are the main reasons why the Government has decided in favour of a regional administrative tier for the NHS.

The job to be done: nationally, regionally, locally

36.Under these arrangements, there will be central strategic planning and monitoring by Department of Health and Social Security; regional planning and general supervision of operations (as well as some direct executive functions) by regional authorities; and area planning and operational control by area authorities co-ordinated with local authorities sharing common boundaries.

37. This means that the planning function in the NHS will be exercised at three levels: area, region and central Department. Each has its own distinctive role. The central Department will settle national health policies, objectives and priorities. The regional health authority (RHA) will have a regional planning responsibility which will include settling priorities when there are competing claims between areas. But the fundamental unit in the planning process will in the area. Area health authority plans for the communities within the area-the “districts”—will strongly influence the way in which local, regional any national priorities are carried into effect in the area, and how they are harmonise with local authority plans.

Management study

38. As mentioned in paragraph 14, the Consultative Document said that the Secretary of State would have a study made of the detailed arrangements for management at regional, area and district level and in the individual hospital and other institutions. The study is being supervised by a Steering Committee which includes members from the three branches of the present NHS and fro the Department, whose Permanent Secretary is its chairman. Detailed work and discussions with existing health service authorities are being undertaken I a study group acting on the Steering Committee’s behalf. These are the Steering Committee’s terms of reference:

“On the basis of the Government’s Consultative Document on NHS reorganisa­tion, and taking account of other relevant studies commissioned by the Secretary of State, to make recommendations on management systems for the services for which regional and area health authorities will be responsible and on the internal organisation of those authorities.”

  1. The method followed in the study has been to produce a range of hypo­thetical models of organisation at the various levels and to test them in discussion with a cross-section of health authorities throughout England.

  2. After the Secretary of State has received recommendations from the management study, he will consult the interests concerned. Decisions will not be taken on the recommendations until the views of those interests have been considered. Some of the ideas being developed in the management study are however described in the document at Appendix III to this White Paper. These ideas are provisional and subject to change in the light of further work in the management study.

V AREA HEALTH AUTHORITIES—FUNCTIONS

  1. 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 (AHA) 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 programmes of improvement 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 area authority’s performance.

Area operation of services

44. The AHA will be an operator of 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” (See paragraph 114),  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 “districts”

45. The day to day running of services will be based on localities (“districts”) within which it is possible to satisfy the greater part of the public’s health care needs. As such, the district will form the natural community for the planning and delivery of comprehensive health care. It will be small enough for profes­sional representative machinery to be effective within it, it will contain a district general hospital—or several hospitals together carrying out the functions of such a hospital—and will usually have a population of between 200,000 and 500,000. Because the boundaries of the health district will be related to health care needs, they will not necessarily correspond with the boundaries of a local government district, for which different criteria are appropriate. Many AHAs will be responsible for only one or two districts; a few will have up to five.

  1. The districts will not in any sense form a separate formal tier of authority below the areas. Within them, however, it will be possible for the services of doctors, nurses and others to be organised so as to answer community needs most effectively, and to fulfil the area authority’s obligation to ensure unification of health services. The organisation in a district will be designed to achieve integration of all health services available within it, so that the representatives of the medical profession and the professional 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.

  2. The document at Appendix III outlines the management study’s 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. They exist to serve the public. 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 AHAs 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 AHAs 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

  1. Some functions may best be performed by a joint health authority 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 joint health authority 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.

VI AREA HEALTH AUTHORITIES—COLLABORATION WITH LOCAL GOVERNMENT

Common boundaries for NHS and local government

  1. 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. But it cannot hope to do these things successfully on its own. 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. But in London the 32 London Boroughs and 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 outside London (38 corresponding with non-metropolitan counties, and 34 with metropolitan districts). These figures are related to the Local Government Bill as amended by Standing Committee D in the House of Commons. A list is given in Appendix I. 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. (See also the enclosed map).

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, environmental health, housing and other services where interests overlap. The position here is complicated by the fact that these 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 Inner London Education Authority is res­ponsible; environmental health and housing by the non-metropolitan districts, the metropolitan districts and the London boroughs.

55. 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

  1. The links are already being studied by the working party proposed in the consultative document, to which reference has been made in paragraph 14. 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.

  1. 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 Reorganisation 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 1 April 1974. But a number of important recommendations have already been made by the working party and, subject to the outcome of consultations 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 sure that the arrangements for working together are firmly established and comprehensive and that they involve mem­bers and senior staff of the authorities concerned. There will therefore be local joint consultative committees of members of the authorities to examine jointly the plans of the authorities and to advise on the planning and operation of services in spheres of common concern. One such joint consultative committee might be established in a metropolitan district to cover all the services of common concern; but in a non-metropolitan county two committees would be needed—one covering personal social services and school health, and representing on the local authority side the county council; and another for environmental health and housing, which would include representatives of all the local authority district councils. Special arrangements would be needed in some areas, eg London. Each joint consultative committee would be supported by a group of senior officers from the authorities concerned.

62. The joint consultative committee would make its views known to the constituent health and local authorities and these views might be published. It is expected that discussions on the joint committees would generally lead to agreement being reached between the authorities but there will be arrangements under which an authority can seek the help of Central Government on any matter where it has not been possible to reach agreement.

63.In addition to the joint consultative committees, each AHA will include in its membership members of the corresponding local authority (see Section X); and local authorities will be 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

64.In the last resort, the quality of collaboration will depend on the readiness of those concerned at all levels to communicate and co-operate 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; 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. Appropriate financial arrangements between health and local authorities to cover these different forms of collaboration will be recommended in the light of advice from the Working Party on Collaboration.

VII AREA HEALTH AUTHORITIES—FAMILY PRACTITIONER SERVICES

  1. 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.

  2. 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 (FPC). 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 one 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 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

70. 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 NHS 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

  1. The staff serving the FPC 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.

  2. These arrangements will give 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.

VIII REGIONAL HEALTH AUTHORITIES

74. The regional task will be in part strategic planning, in part co-ordination and supervision, in part executive.

Planning

75. The regional health authority (RHA) 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. The authority will need to develop, with professional advice, 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 work 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 policies, 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).

79. 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 building.

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 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.

Regional health authorities: numbers and boundaries

84. 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 of areas and regions in Appendix I. (See also the enclosed map).

 IX CENTRAL DEPARTMENT

86. The regional health authorities will be accountable to the Secretary of State for their own activities and for those of the area health authorities. The Secretary of State will continue to have responsibility to Parliament for the National Health Service as a whole and will determine national policy. The Department must assist him in these ways:

  1. Settling, within the framework laid down by the Act, the kind, scale and balance of services to be provided in the regions and areas. For this purpose it must develop, in consultation with the field authorities and the professions, appropriate long term objectives, priorities and standards of care as guidelines for effective area and regional planning.
  2. Guiding, supporting and (to the extent that this is desirable) controlling the RHAs. It must help the field authorities to understand the guide­lines and the reasoning behind them. And it must allocate to RHAs the resources for putting them into effect.
  3. Obtaining or developing resources which strongly influence the adequacy, efficiency and economy of the services. This requires specialist work on particular resources—personnel; finance; property and building; supply. The central Department will have a special responsibility in relation to staffing. The recruitment and training of the skilled man­power required in the NHS call for various measures at national level, eg to forecast staff requirements, to plan numbers of training places, where appropriate to monitor the quality of training, and to arrange publicity to attract entrants. The required qualifications, remuneration and conditions of service will continue to be settled at the centre. Also, all land and property will vest in the Secretary of State. And the central Department will continue to be responsible for overall budgeting and accounting of health expenditure.
  4. Carrying out other functions that are best organised centrally. Just as some things need to be done by the RHA rather than the AHA, so there are things best done centrally. Examples are some types of research and the standardisation and preparation of national statistics. Purchase of equipment or supplies centrally may be justifiable in economic terms or by reason of control of quality or distribution. The NHS superannuation scheme will also continue to be centrally admini­stered. A microbiological service related to communicable disease will continue to be administered centrally by the Public Health Labora­tory Service Board on behalf of the Secretary of State.
  5. Supporting the Secretary of State in his Parliamentary and public duties.

87. In addition, the central Department has responsibilities towards other services besides the NHS, particularly the personal social services and social security. And it discharges some central Government tasks such as the licensing of medicines (in association with the Medicines Commission), the control of food safety and hygiene, and acts as the production authority for the medical supply industry. These responsibilities have to be co-ordinated with the De­partment’s responsibilities towards the NHS.

88. As already announced, the organisation and operation of the Department has been reviewed, with the help of management consultants. Proposals have been formulated which are designed to enable the Department to carry out effectively the functions it will have after NHS reorganisation. The proposals are based closely upon the Department’s role as defined above. In particular,

  1. emphasis is placed on the development of a process of planning, in association with the field authorities, to help the Secretary of State to decide national objectives and priorities. One of the main sections of the Department will be organised to assist in this process. Special attention will be given to assessing the needs of particular groups of people—for example mothers and children, the old, the physically or mentally handicapped and the mentally sick—for health and social care and proposing how those needs can best be met from the full range of services that can be made available in the reorganised NHS, the personal social services, and other relevant services;
  2. great importance is attached to a close and continuing relationship with RHAs. For this purpose, another main Departmental group will be organised as the focal point for action in partnership with the RHAs. Its Divisions will be responsible for assisting RHAs to produce and implement plans which will give effect to national policies and priorities while taking full account of local circumstances, priorities and policies. They will also ensure that the RHAs receive any help from the Depart­ment that they need. And they will be responsible for surveillance over the quality and effectiveness of health service management. When appropriate, RHAs will communicate direct with other, more specialist parts of the Department, but these Divisions will be created specifically to support and guide them across the full range of their business;
  3. the Department’s staff concerned with personnel policies in the NHS will also be increased, and will be organised in a third main group.

89. Thus the central Department will be organised on an inter-professional basis to carry out three main groups of tasks in connection with the NHS: planning the kind, scale and balance of services in association with the field authorities and the professions; working in partnership with the RHAs and providing them with support and guidance; and carrying out central NHS personnel functions. The Department is also planning to increase the number of NHS staff seconded to it, and of its own staff who spend training spells in the reorganised service.

X MEMBERSHIP OF AUTHORITIES

90.The strength of the new administrative structure will in the Government’s view largely depend on three factors: small and capable membership of autho­rities to approve and monitor policies; effective machinery for getting expert advice to the members from the medical and other health professions, and for gathering, appraising and handling intelligence; and channels by which, in every health district, the users of services can represent their views vigorously to management. This Section examines the first of these factors; the following two Sections discuss professional advisory machinery and the community health councils.

Volunteer members remuneration for chairmen

91.The Government believes that, as in the past, the NHS should be admini­stered by trained staff, under the general direction of authorities composed of part-time members who give their services voluntarily. Members of the area and regional health authorities will serve in an unpaid capacity though they will be entitled to travelling and other allowances. The chairmen will however have a specially heavy and time-consuming job and it is desirable that there should be no financial barrier that would prevent those with other commitments from giving adequate time to the health service. The legislation will include a provision to make it possible for the chairmen of health authorities to be remunerated on a part-time basis.

Scope of the authorities’ work

92.The new authorities will have important work to do. The area autho­rities for example will employ thousands of staff, professional and others, they will be responsible for the health care of up to a million people or even more, they will administer annual budgets running into millions (in some cases many millions) of pounds and will be responsible for buildings and plant worth many millions.

93. In general terms, members will have two interacting sets of respon­sibilities: the supervision of the creation and development by their chief officers of policies in response to changing needs; and the overseeing of standards of performance, both in quantity and quality. They will need ability to give guidance and direction on policies to their chief officers charged with the management of the service.

Basis for membership of authorities

94.To do this work effectively, the authorities must be small. The area authority will normally have about fifteen members. The regional authority will be about the same size depending on the number of areas in the region and other variable factors such as the number of Universities providing medical and dental education. The authority will be free to co-opt to committees where they think the committees would benefit from the help and advice of people who are not members of the authority.

95.An important part of the area health authorities members’ work will be to visit the hospitals and other units for the management of which they will be responsible. A planned programme of visiting will be one means by which members will be able to enlarge their understanding of problems requiring their attention and check progress made in dealing with them. But authorities will not need to rely only on their own members for visiting. They will be able to co-opt suitable people to help them.

96.The work to be done by the members calls for general ability and personality. They will need to be interested in the NHS; to have an unbiased, questioning yet constructive approach and good judgment; to set high standards and provide vigorous leadership. A diversity and a proper balance of relevant ability and experience are also called for. These needs can best be met if, in the main, members are chosen for their personal qualities after appropriate con­sultations, not elected as representatives reflecting the views of particular interests.

Membership of regional health authorities

97.The RHAs will form part of the chain of responsibility running from the Secretary of State to the areas. Their authority will derive from the selection and appointment of their chairmen and members by the Secretary of State, who will be required before making his choice to consult with the appropriate in­terested organisations including the Universities, the main local authorities and the main health professions.

Membership of area health authorities

98.The Chairman will be appointed by the Secretary of State, after consul­tation with the Chairman of the RHA. Because of the need for close decision-making links with the local authority services, local authority members who are active in the management of the personal social services, education and other relevant services, should have places on the AHA and four members of it will therefore be appointed by the corresponding local authority. Because of the need for a close link with the University providing medical and dental teaching facilities, one place on the AHA will be filled on its nomination: there will be a second place if the area includes substantial teaching facilities.

99.The remaining members of the AHA will be chosen and appointed by the RHA. The RHA will be required, before making its choice, to consult with appropriate organisations. These organisations will include those represen­tative of the main health professions, as it is intended that AHAs should include in their membership people of authority and experience who themselves are members of the healing professions. Ths is in addition to the AHAs pro­fessional advisory machinery and to its chief professional officers. The pro­portion of professional members will not be prescribed, and will differ from area to area and change from time to time according to circumstances, but an AHA will always include doctors and at least one nurse or, midwife—but not drawn from staff who are accountable to the authority’s chief professional officers.

XI PROFESSIONAL ADVISORY MACHINERY

100. Strong professional advisory machinery will be built into the new structure. The Act will include provision for this. It will function at each level of management, 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 1974. Though the detailed arrangements will vary according to the circumstances of the individual professions, it is clear that

at least the following professions must be covered: doctors, dentists, opticians, pharmacists, and nurses and midwives;

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;

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 Hospital Management Committee and individual hospital level, and the advisory systems on professional matters built up by the Regional Hospital Boards); and should take account of the interests of medical, dental and nursing education.

Professional advice for the Department

102. At the national level, the Department of Health and Social 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 appointed as occasion requires.

103. The main standing advisory body is the Central Health Services Council, created in 1948 to advise the Secretary of State on general matters bearing on the service. Standing Advisory Committees have been appointed to advise the Central Health Services Council and the Secretary of State on specific aspects. The constitutions and terms of reference of the Council and of the Advisory Committees will be adjusted as necessary to meet the needs of the reorganised and unified service. In 1946 the elements in the composition of the Central Health Services Council were specified in the Act, but it is now proposed to use subordinate legislation for this purpose—as has always been the case with the Standing Committees—so that the composition can be readily adjusted to meet changing circumstances. As well as members appointed by virtue of their official positions at the heads of certain professional bodies, the list of which is under review, and members with other health service experience, it is intended to include on the new Council some people specifically appointed to advise from the patient’s viewpoint.

There will also be cross-representation with the Personal Social Services Council, so as to secure representation of social work interests on the Central Health Services Council and of health service interests on the Personal Social Services Council. The new—like the present—advisory bodies will be free to offer advice on their own initiative as well as on request.

Advice on staff training

104. Arrangements are also being made for giving expert advice to the Secretary of State on the training of NHS staff: details are given in Section 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 membership 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 areas’ health districts. It is at the district, rather than at the (often large) area, where there is real local interest. Special arrangements will be made where the people living within a health district look for a large part of their services to a neighbouring district (which might be administered by a different area health a u thority).

108. Each council will be made up of people with particular interest in the health services. Half its members will be appointed by the local government district council(s), and the rest by the AHA, mainly on the nomination of voluntary bodies concerned locally with the NHS and some after consultation with other organisations. No upper or lower limit of membership will be set, but a total of between 20 and 30 members would normally be about right for ensuring a proper spread of local interests within an effective and coherent working unit. Councils will appoint their chairmen from among their own members.

Functions

109.The council’s basic job will be to represent to the AHA the interests of the public in the health service in its district. It will be for each council to decide how best to go about this, but they will be expected to influence area policy by contributing their own ideas on how services should be operated and developed. To help them do this effectively, councils will have powers to secure information, will have the right to visit hospitals and other institutions, and will have access to the area authority and in particular to its senior officers admini­stering district services. Some council members may want to take a special interest in particular institutions or services or parts of their district, especially where the districts are large.

110.Councils will be well placed to bring to the notice of the AHA and its district staff potential causes of local complaint, especially those of a general nature, but their function will be distinct from that of the AHA’s complaints machinery and of the Health Service Commissioner (see Section XX). There will be well understood procedures for the investigation of individual com­plaints in the reorganised service but a community health council 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 councils 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, less formal meetings which will take place between the authority’s members and officers and council 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.

Council’s expenses

112.The AHA will meet the council’s reasonable expenditure, including expenses incurred by their members, and will provide accommodation for meetings and secretarial staff.

XIII MEDICAL AND DENTAL TEACHING

113.The NHS has always given high priority to providing facilities in support of 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 AHA’s which administer them will be called AHA(T)s.

Integration within the regions

115.Administrative unification is essential if 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.

Special provisions for teaching hospitals

117.But integration of teaching hospitals within the unified NHS must take account of the special character of undergraduate teaching and of University sponsored research, and of the fact that the hospitals where they take place also provide specialised services for many people living outside their area . The hospitals’ individual identity and historic traditions are valuable assets which must and will be preserved when the new organisation is set up. The rest of this Section describes the arrangements to achieve these important objects.

118. The teaching hospital will obviously have a central role in the health services for the district in which it is situated. The administrative arrangements at hospital and district level have still to be worked out in detail in the light of the recommendations of the management study. But it is clear that there will be intimate links between the AHA(T) and those responsible for the administration of the teaching hospital. It is clear also that the management at the district level, acting for the AHA(T), will have the main responsibility for all operational matters and will play a leading part in planning the development and improve­ment of services. It is expected that AHA(T)s will wish to nominate one or more of their members to take a special interest in the services of a district where there is a teaching hospital. They will be free to co-opt people to give them support in this, and to assist in planned programmes of visiting.

  1. It is important to maintain the present close working relationships between teaching hospitals and their associated medical and dental schools, and to extend those relationships to all the health services in the districts. The responsibility for securing this, day in and day out, must rest at the local level. A joint committee between the AHA(T) and the medical or dental school may also be found useful. Where, in London, statutory arrangements exist for Board of Governors representation on school Councils, similar arrange­ments will be made for AHA(T) representation.
  2. The AHA(T) itself will have teaching and research interests prominently in mind in its operational responsibility for the area and in the work it does on planning the improvement and development of the NHS. The AHA(T)’s membership will demonstrate this. The AHA without substantial teaching and research facilities will have one member nominated by the University, but the AHA(T) will have two. The AHA(T) will also have at least two additional members with teaching hospital experience—more if the area includes more than one teaching hospital (or group of hospitals of a kind that has hitherto been designated as a single teaching hospital).
  3. The AHA(T)s will exert a strong influence at the regional level, where the regional health authority’s responsibilities will be much wider than those of the existing Regional Hospital Board and, will include provision of support for teaching and research. The RHA will include a member appointed by the Secretary of State after consultation with the University (more than one member if there is more tha one University concerned).
  4. The Department’s review of regional plans and estimates to ensure consistency with national policies and priorities, will pay particular attention to the balance between teaching and non-teaching areas. The RHA will receive in its financial allocation a specific identified allowance for teaching and research. It will also be required to set up a committee to advise it on its responsibilities in relation to medical and dental undergraduate education and research; this committee will contain members co-opted from the University (or Universities) and the AHA(T)s.
  5. Regional health authorities will have important responsibilities for helping to ensure that there are satisfactory arrangements within the new service for postgraduate medical and dental education and training. It is 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.
  6. 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 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 relation­ships. There is therefore a need for additional safeguards during these 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.

126.The scope of the safeguards needed is still being discussed, but two have already been decided upon. On the first appointment of the 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 Boards of Governors of teaching hospitals and University Hospital Management Committees. Similarly, on its first appointment, the RHA’s teaching and research committee will include members drawn from the present Boards of Governors and Uni­versity Hospital Management Committees.

XIV A SOUND MANAGEMENT STRUCTURE

127.The Government considers that these arrangements—for area, regional and central administration, for strong advisory machinery, and for the expression of local opinion—provide a sound structure within which the health professions can provide the public with an efficient and humane service.

Administration: statutory provisions

128. At present, statutory responsibility for administering the NHS is divided between the Secretary of State (acting through regional and local bodies) for the hospital services, the Executive Councils for the family practitioner services and local authorities for the other community personal health services. In future, there will be a clear line of responsibility for the whole NHS from the Secretary of State to the RHAs and through them to the AHAs, with corres­ponding accountability from area to region to centre. The overall responsibility which will rest on the Secretary of State makes it necessary that, in addition to making statutory regulations and issuing guidance, he should be able to give formal directions to RHAs and AHAs; RHAs will have the same power of formal direction in relation to the AHAs. These directions may be general, covering all authorities, or they may bind only one authority, in relation to either a general or a particular matter. The power of formal direction should however be needed only in the most exceptional circumstances.

129. This framework will be flexible so that practices may be changed in the light of experience and altered circumstances.

Administration: delegation, clinical freedom

130. National and regional planning is essential. But it is far from the Government’s intention that the National Health Service should continually be administered or supervised on the basis of regulations and directions from centre or region. Objectives and priorities will be approved and performance monitored, but the authority doing the job itself will be left to get on with it, with a minimum of interference. This will apply as between the central Department and the RHA and as between the RHA and the AHA.

Financial administration

131. The Secretary of State will be responsible to Parliament for the ex­penditure by regional and area health authorities of the funds needed for their services. But subject to such directions, regulations and guidance as may be necessary, he will delegate financial responsibility to RHAs, and RHAs will similarly delegate it to AHAs. More detail is given in Section XVI.

Supervision of delegated authority

132.The first requirement for effective supervision is good planning, so that comprehensive plans, which take account of available resources, are prepared within the AHAs and are reviewed and approved by RHAs and in more summary form by the Department. If omissions can be spotted and put right at the planning stage, then there can be the maximum delegation of authority in the actual conduct of the job, and the need for much more detailed intervention later on can be avoided. Secondly, supervision entails the monitoring of performance to ensure that planned standards of service and efficiency are being achieved. Performance can be monitored in various ways: by the collection and analysis of regular statistical information, by specially commissioned reports and enquiries, by visiting and contacts between the staff of the Depart­ment and field authorities, by systematic visiting, inspection and advice such as are carried out by the Department’s auditors or by the Hospital Advisory Service, and by the self-critical observation and analysis of practice by which the professions monitor their own work. Finally, supervision requires follow-up of plans to ensure that agreed actions are being taken and to consider their effect.

133. In the reorganised service, there will be a more systematic and compre­hensive planning process than now exists. The Department will annually prepare guidance on national policy objectives for AHAs and RHAs who will then draw up their plans for the development of their services to meet these objectives together with their own local priorities. It is intended to seek methods of obtaining improved information and more effective measurement of needs and of performance. Such measurement is exceptionally difficult in health care and better statistical indicators have to be devised. All authorities will need to seek ways of using this information more effectively to assess the real progress of the service in achieving its objectives and to identify opportunities and problems. The reorganisation of the Department will, as has been explained, provide for it to have closer and more regular contact than in the past with the health authorities, which should lead to a better mutual understanding of problems and objectives. The Department’s function of general supervision will be mainly directed towards the activities of the regional health authorities, who will be expected to supervise the activities of the area health authorities in the same way.

The member/officer relationship

134. RHA 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. Not 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 specialities and in association with general practitioners along lines recommended in the “Cogwheel Report”*— with the aim of 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 nursing services also are being reorganised, under Chief Nursing Officers, for hospital groups, on the lines of the recommendations of the Salmon Reportt. Similar principles are being applied to nursing staff of local authorities. Hospital pharmaceutical services are being reorganised in accordance with the Noel Hall Report.

140. The intention is to develop these principles of organisation and adapt them to the unified National Health Service. 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 of those and other services.

143.The Working Party on Medical Administrators, under Dr R B Hunter’s chairmanship, has 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 promoting 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.

XV THE STAFF OF THE SERVICE

145. 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 National Health Service 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 70 % 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 personnel management 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 and elsewhere. The managers of the reorganised NHS at all levels will be encouraged to give closer attention to this subject and will have better resources to handle it than their predecessors have had.

Staffing studies

147.The development of the service will be assisted by the results of studies—to some of which reference was made in Section XIV—already completed or currently in progress, of the role and functions of staff engaged in the scientific and technical services, building maintenance, pharmaceutical services in hos­pitals, and in the nursing and midwifery services in hospitals and the community.

148.These studies will help in adapting professional and occupational training to the needs of a modern intergrated health service. In particular, the content and the organisation of the training and education of nurses and midwives will be reviewed in the light of the recommendations of the Briggs Committee on Nursing.

Management training

149. Professional and occupational training will be complemented by manage­ment training that is, training to equip all the decision-makers with an under­standing of the needs of the service as a whole and of its staff, and with the skills enabling them to make the best use of the available resources. Most manage­ment training will need to be multi-professional. It will need also to take account of the close relationship between the objectives of the National Health Service and those of the local authority social services. This will accordingly form a part of management training at all levels. In addition, it is intended to arrange a regular series of seminars for senior people over the whole range of services for which the Secretary of State is responsible.

Advisory machinery

150. Various Committees have already provided valuable advice about staff training. In particular the National Staff Committee for hospital administra­tive 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 function, including training, must now be developed. The Department’s own resources are being strengthened for this purpose. The work done by the National Staff Committee and the National Nursing Staff Committee 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 a National Health Service 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 is 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 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. The measures outlined above are all intended to contribute to the devel­opment of clear and comprehensive employment policies for the reconstructed National Health Service, 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.

VI FINANCIAL ADMINISTRATION

156. The change in administrative structure will not mean a change in the methods of financing the National Health Service except in the case of services transferred from local authorities. The cost of those services, and of the health authorities’ other expenditure, will be financed mainly by taxation and met from moneys voted by Parliament. The general arrangements for charging for certain NHS services will not be affected.

157. The Department will make capital and revenue allocations to regional health authorities. From these, the RHAs will meet the cost of their own ser­vices and will allocate money to AHAs to meet the cost of area services in­cluding the cost of the community health councils. Payments made to prac­titioners under the terms of their contracts will be separately funded by the Department.

158. Regional and area health authorities will be required to prepare and maintain a medium term “roll-forward” plan covering a four-year period together with indications of likely targets for the main capital developments over a longer period. Authorities will be notified of provisional financial ceilings for each of the succeeding four years so that plans may be expressed in the form of financial estimates, covering both revenue and capital expenditure. The allocation of funds by the regional authorities will be closely integrated with the planning processes so that the plans are based realistically on the levels of funds likely to be made available. To encourage the most efficient use of resources and flexibility in the execution of planned developments, authorities will have freedom, within limits, to use funds allocated for capital expenditure to meet revenue 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 systems are being devised. The 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 and 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 REORGANISED SERVICE: OTHER ISSUES
XVII VOLUNTARY SERVICES

162. 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, as 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 be scope for AHAs and local authorities to make joint appointments 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.

164. Good working relationships must also be preserved and strengthened in each community. Individual hospitals will still provide a focus for a wide range of voluntary service. Of particular value is service directed to needs of long-stay patients—visiting and befriending, helping relatives to visit, occupying the patients’ day and keeping them in contact with the everyday life of the community. Outside the hospitals, there are many other needs for voluntary help. Examples are visiting the elderly and the disabled in their own homes and hostels; and, to a growing extent, providing car services for those who need help to travel to doctors’ surgeries, health centres or hospital out-patient departments, to visit friends and relatives in hospital or to attend social clubs.

165. The RHAs and AHAs will be able to make grants in support of voluntary bodies which provide and promote services within the general scope of the authorities’ responsibilities. Financial help for national activities will continue to come from the central Department.

XVIII THE PRIVATE SECTOR
Role of private sector

  1. The Government 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 National Health Service 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.

  2. 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 can 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.

Denominational Hospitals

169. 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 tranferred to the National Health Service in 1948.

XIX ENDOWMENTS

  1. The hospital authorities are trustees of substantial sums given to them by the public. Much of this money was given for local and special purposes. In transferring these trusts to the new authorities, it is right and necessary to preserve both the local administration and the purposes of these gifts as far as it is possible to do so.
  2. The funds now held and administered by Hospital Management Committees will be transferred to the appropriate area health authority. To preserve the advantages of local administration, the AHA will be able to establish committees, of those in the locality who are concerned, to advise it on the spending of the funds. The future administration of funds held by Boards of Governors of teaching hospitals—some of which are very sub­stantial—is still under discussion. The Boards of Governors of the London postgraduate teaching hospitals will retain their endowments as long as the Boards remain in existence (see Section XXII).
  3. In spending endowment moneys, the authorities will be required to respect the special and local purposes for which the funds were originally given. Thus endowments held for special purposes will continue to be used only for purposes within the scope of the trust; and those held for the general purposes of a particular hospital only for the purposes of that hospital. Endowments at present held for the general purposes of a hospital authority (as distinct from those of a particular hospital) will be used only for the hospitals at present controlled and managed by the hospital authority con­cerned and for health services associated with them (for example, research and local health centres).
  4. The Hospital Endowments Fund will be available to health authorities for use for hospital and associated purposes.
  5. The new authorities will have powers to accept fresh gifts to help them in any part of their work. Financial help from voluntary sources has an important part to play in the National Health Service, and every encouragement wil be given to locally organised fund-raising by voluntary organisations. When it is directed to specific local objects approved by the health authorities, it is a useful means of speeding up progress. It also encourages local innovation and pioneering. Independent funds are badly needed, not only by the acute, children’s and other hospitals which at present tend to attract most of the public’s gifts, but also for the geriatric and psychiatric services. They are needed, not for patients’ basic requirements, but for raising standards and to encourage the inventiveness and imagination that are important in the services provided.

XX HANDLING COMPLAINTS

  1. For the investigation of complaints, each health authority should have arrangements which work well and which command the confidence of the public. Arrangements already exist in most local authorities. In Executive Councils, there are long-established statutory procedures for investigating complaints against contractor practitioners. As to the hospitals, the Secretary of State for Social Services and the Secretary of State for Wales set up an independent committee in February 1971 with Mr Michael Davies QC, as its Chairman, to undertake a thorough review of their arrangements for handling complaints, to provide the hospital service with practical guidance, and to make recommendations. The Committee is expected to report later this year.
  2. But however good the arrangements, some complainants will remain dissatisfied, and it is important that they should feel that they can seek the help of an independent third party. As already announced, the Government has therefore decided that a Health Service Commissioner should be estab­lished to investigate complaints against National Health Service authorities. The full text of the statement which the Secretary of State for Social Services made in the House of Commons on 22 February 1972 is reproduced in Appendix II.

  3. The appointment of a Health Service Commissioner is an important extension of the ombudsman principle in the public service. The Parliamen­tary Commissioner for Administration was appointed in 1967 with a remit covering Government Departments (including what is now the Department of Health and Social Security, and the Special Hospitals, but not the National Health Service), and the Government has also announced its intention of introducing a complaints machinery for local government.

  4. The legislation necessary to establish the Health Service Commissioner will form part of the NHS Reorganisation Bill, but the Commissioner will be able to start work before the unified service comes into operation on 1 April 1974, though until that date his jurisdiction will not extend to health services provided at present by local authorities. After unification, his terms of reference will cover the whole of the NHS, but he will not investigate com­plaints that in his opinion relate to the exercise of clinical judgment by doctors and other staff, and he will not deal with complaints for which statutory procedures already exist (eg those about general medical and dental practi­tioners, pharmacists and opticians, which will continue to be dealt with under the service committee procedure), or which he thinks the complainant could reasonably pursue through the courts or before some tribunal.

  5. The complainant will have direct access to the Health Service Com­missioner. The Commisisoner will not however investigate a complaint until he is satisfied that the health authority concerned has had a reasonable oppor­tunity to investigate it and reply to the complainant who, despite this, is still dissatisfied. It is plainly important that the health authority should itself have the opportunity to investigate a complaint about a service for which it is responsible, and in the great majority of cases the internal procedures can be expected to satisfy the complainant. It is only when the complainant remains dissatisfied that there may be scope for an investigation by the Health Service Commissioner.

180. Complaints to the Health Service Commissioner will not have to be made by the patient himself, although no doubt most of them will be. There will be cases where the patient is unable to act for himself, and when that happens, the complaint may be made for him. This is an important safeguard for those who, because of the nature of their infirmity, are unable to speak for themselves; it will enable a wrong suffered, for example, by a mentally handicapped person to be brought to light. In such cases, the complaint can be made by a relative or friend of the patient or by a member of the hospital staff.

XXI SPECIAL HOSPITALS
181. The Secretary of State is directly responsible for the control and management of the Special Hospitals which are provided under the Mental Health Act 1959 for patients detained under that Act who, in his opinion, require treatment under conditions of special security because of their dangerous, violent or criminal propensities. These hospitals receive patients from all parts of England and Wales. In addition to their therapeutic functions, the maintenance of security for the protection of the public is an essential feature of their work. It is intended that the Secretary of State shall retain direct responsibility for their control and management, but with power to delegate such responsibility to a regional or area health authority or a specially constituted joint health authority if future developments should make this desirable at any time. The Secretary of State has no present intention of changing the arrangements for direct control by the Department.

XXII ARRANGEMENTS FOR LONDON

182. The Londoner needs integrated health services, closely associated with the personal social and other local authority services, no less than people living elsewhere. The arrangements in Greater London will therefore be based on the general regional and area structure adopted for the rest of the country.

Special features of London area

183. There are however exceptional features in the health and related services in London which call for adjustments to the structure. Among these features are the already established pattern of local government boundaries and services, the way in which hospitals—including the very large number of undergraduate and postgraduate teaching hospitals—are distributed, and the fact that’ xecutive Councils administer family practitioner services over much wider areas than those of the individual London boroughs. In recognition of these features, and taking account of the consultations referred to in para­graph 15—which are continuing—certain special arrangements will be made in the London area.

184. These special arrangements take account of three important aspects of the situation in London:

  1. London borough boundaries must be used in forming area health authorities so that there can be collaboration between the NHS and borough services;

  2. these boundaries are in the main unrelated to many of the existing health services, and the natural health districts overlap them;

  3. some important health services—notably the family practitioner and ambulance services—need units of administration larger than either the borough or the health district.

Special arrangements

185. The special arrangements are these

  1. There will be four regional health authorities which, like such authorities elsewhere, will include teaching areas. Each regional authority is likely to contain territory inside and outside Greater London, and territory in inner and in outer London;

  2. an advisory co-ordinating working group will be set up on lines similar to the Joint Working Group which now exists to advise on hospital services in London. The group will secure co-ordinated planning of facilities for medical and dental teaching and research and the location of regional and sub-regional specialities;

  3. health areas will be formed out of single London boroughs or groups of boroughs. The boundaries have not yet been settled. The local authority places on the AHA (which, in order to give each of the grouped boroughs appropriate representation, may be more than the four mentioned in paragraph 98) will be shared between the boroughs on an equitable basis;

  4. the health districts, each of which will have a community health council, will have boundaries which will not always follow the borough boundaries within the health area;

  5. the Greater London Ambulance Service will not be split up between the RHAs or AHAs but will continue to be administered as a single unit;

  6. it is an accepted aim that each postgraduate teaching hospital should become closely associated with other hospitals and health services in its vicinity. But until this association is close enough to make it desirable for the postgraduate hospital to be administered by the AHA(T), the Secretary of State will, after consultation with London University, continue its Board of Governors in being for an appro­priate transitional period. During this transitional period the Board will continue to be appointed as at present, except that the members now nominated by the Regional Hospital Board will be nominated by the regional health authority. The Board will have a direct relationship with and will get its money from the central Department.

Family Practitioner Committees

  1. Area health authorities and Family Practitioner Committees must correspond on a one-to-one basis in order to get maximum benefit from integration of the health services. This applies as much in Greater London as in the rest of the country. The replacement of the five Executive Councils which cover Greater London and parts of the surrounding areas by a different number of Family Practitioner Committees will give rise to certain practical problems, and the central Department will give all the help it can in over­coming them, in consultation with the interests concerned.

Boundaries and patients

187. No part of these special arrangements will prevent Londoners crossing boundaries to their family doctor or to a hospital outside the health area in which they live. In London, as in the rest of the country, administrative boundaries will not be barriers to the movement of patients.

XXIII RUNNING THE SERVICE UNTIL 1974

188. It is important that the National Health Service should continue to develop without any loss of momentum, and that the administrative changes on 1 April 1974 should not cause interruption or delay. This means that all the existing health authorities should see their work as going on beyond that date, even though they will not themselves continue to exist in their present form.

Local authority health services

189. The local authority health services have been impressively developed in recent years. The new health authorities will be able to take over a flourishing range of community-based services if the pace of development does not falter in the period before unification. The Government has made pro­vision for increasing public expenditure on the community health and personal social services. In the case of family planning, financial support was given for a trebling of expenditure in the years 1971/2 and 1972/3. Financial terms more favourable to authorities than in the past for renting health centre premises to general practitioners have been announced.

190. The work of existing staffs of local health authorities—whether operational or administrative and whether or not professionally qualified—will increase in importance and scope. Medical Officers of Health can look forward to greater opportunities in medical administration in the widest sense, and training is being provided (see Section XXIV) to equip them and other medical administrators to take advantage of these opportunities. Nursing staff in the community will also have a wider span of work, both in preventive health work and in clinical care of patients.

191. Members and senior officers of most local health authorities attended the regional conferences held in late 1971 and early 1972 by the Secretary of State for Social Services and his Ministerial colleagues on the need to ensure that standards of local health services and morale, and the interest of staff, are maintained and strengthened in the interim period. In February 1972 (Circular 13 / 72), the Secretary of State made a number of recommendations for improving the effectiveness of the local health services with particular emphasis on deployment of nursing staffs. Local health authorities were urged, for example, to continue to encourage schemes for the association of nursing staff with group general practices and to put into effect the recent recom­mendations about management structure and management training of nursing staff in parallel with what has been in progress for some time on the hospital side following the Salmon Report. They were also asked to make wider use of ancillary help and of the skill of state enrolled nurses so as to enable health visitors and home nurses to be deployed more effectively. It is hoped, too, that local health authorities will maintain the impetus already given to the improvement in the standard of equipment and training of the ambulance service.

XXIV PREPARING FOR 1974

Joint liaison committees

  1. There is a great deal of preparatory work to be done if National Health Service reorganisation is to be carried through smoothly, and without interrupting, continuity in the provision and development of services for patients.
  2. 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.

  3. 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.

  4. 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 one 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 new health region, composed of representatives of each area joint liaison committee and of the Regional Hospital Board.

  5. These joint liaison committees will work in consultation with similar committees that are being set up for local government reorganisation. They will have a special responsibility for ensuring that NHS staff are fully consulted, and are kept fully informed about NHS reorganisation by their existing employing authorities.

    Training for reorganisation

  6. Arrangements have been made and announced for the holding of integrated training courses lasting about four weeks, at Universities and other centres, to prepare senior staff for their new responsibilities and opportunities.These courses, and other special courses designed to complement the inter-professional courses, have already started. In addition, it is proposed soon to arrange a series of short conferences or seminars for the most senior staff in each region, following publication of this White Paper; and local arrange­ments for training will be made by the joint liaison committees.National Health Service Staff Commission
  7. NHS reorganisation will bring together under a single management staff previously employed by a variety of bodies. For many, their work will change little or not at all, except that they will have a new employing authority. But there will all the same be problems of redeployment; and there must be arrangements for filling particular posts under the new authorities. It is of the first importance that these matters should be handled—and felt by all concerned to be handled—with the greatest possible fairness for the staff concerned. The Government has already made clear its intention to set up a National Health Service Staff Commission responsible for advising on the procedures to be followed for filling posts and on the arrangements for the transfer of staff, and for safeguarding their interests during the period of reorganisation. The Commission would also have the duty of considering arrangements for appeals. As explained in a Parliamentary announcement on 29 November 1971, the Commission cannot be set up formally until legislation has been passed. Meanwhile, an Advisory Committee—as foreshadowed in that announcement—has been appointed and has started work.
  8. As stated in the White Paper on the Reform of Local Government, the Government is examining the present arrangements for compensation for loss of office with regard to their implications for the whole of public employment.Other matters
  9. Many statutory instruments will need revision, and some new ones will have to be made. There will be consultations about them with the interested bodies.
  10. In addition to the arrangements for the transfer of staff, it will be necessary to transfer the ownership of property, fixed and moveable, from the local health and education authorities and the Executive Councils to the Secretary of State. Property used for hospital purposes already vests in him. Rights and liabilities (including outstanding local authority loan debt) will similarly be transferred. There will be doubtful cases to settle, apportionments to be made, and transitional arrangements to be negotiated. Finally, it will be necessary to allocate the property (and where appropriate the rights and liabilities) to the new authorities for use in the exercise of their functions.XXV CONCLUSION
  11. In the final analysis, health care depends on the effective delivery at the right time and place of the skills and devotion of those providing the services required. We are indeed fortunate in this country in the quality of the staff of our health teams, and we have good reason to be proud of the achievement of the National Health Service.
  12. Nevertheless, no one would claim that it is perfect. The proposed reorganisation offers the chance to establish a framework within which a more integrated and improved service can be offered to the public. The purpose of this White Paper and of the Bill that will follow is to provide a better health service for all.
  13. How in fact will the public benefit from reorganisation? A more informed judgment of priorities will concentrate more of the available resources where they are most needed. There will be better co-ordinated provision for their health and social needs. Professional skills will be grouped into teams to meet the needs of particular categories of patients—the old, the handicapped, the acutely ill, mothers and children, the mentally sick. Strong community health councils will ensure that the public’s views are known and that the service is run with full regard to them. Improved arrangements will be made for enquiring into complaints, and an ombudsman for the health service will be appointed.
  14. Reorganisation will be of equal benefit in helping those who provide or manage health services to improve the quality of care given to the public. The health professions will have the support of a well organised NHS for the exercise of their professional skills and will be freed from some of the frustrations which the lack of this in the past has caused. Furthermore, they will make an important contribution to the management of the service : the governing authorities will include members of the main health professions and will reach their decisions on the basis of advice from strong professional advisory committees and from their chief professional officers. Those of the professions who are independent contractors will be strongly represented on special committees for administering their contractual relationship with the service.
  15. The staff of the NHS, including the professional staff, will in a unified service have wider scope and opportunities than is now the case. They will be fully consulted about the changes, and care will be taken, by the establish­ment of a Staff Commission and in other ways, to safeguard their interests when the changes are being made.
  16. The members of the new health authorities, and their administrative staff, will be able to develop comprehensive services without running into the artificial administrative barriers which now divide the sectors of what should be a single service. The administrator will have full scope for personal initiative within clearly allocated responsibilities. This will give him the satisfaction of being able to do a worthwhile job well, of securing value for money and providing a framework and the necessary support for an efficient and sensitive health service.

208. This White Paper proposes a framework which will co-ordinate the many and varied skills of all those who work in the National Health Service and will focus them on the needs of the individual citizen of this country. Its purpose is to enable an improved health service for all to be provided.

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