presented to the MINISTER RT. HON. R.H. CROSSMAN, O.B.E., M.P. SECRETARY OF STATE FOR THE SOCIAL SERVICES
by the CAMPAIGN FOR A DEMOCRATIC HEALTH SERVICE
- President- Sir Frederick Messer
- Chairman Mr. Marsh Dickson
- Hon. Treasurer- Mr. E. Messer
- Hon. Secretary: Miss Hilary Hodge, 16, Gowlett Road, Peckham, London, S.E.15.
January, 1969.
THE CAMPAIGN FOR A DEMOCRATIC HEALTH SERVICE
This memorandum is prepared as a set of principles for National Health Service Reform. They suggest improvements to those outlined in the Green Paper issued by the former Minister of Health, Mr. Kenneth Robinson, M.P.
Our Campaign Committee respectfully presents it to the new Secretary of State for the Departments of Health and Social Security, the Rt. Hon. Richard Crossman, M.P. with the sincere hope that he will find our proposals helpful in reforming a wonderful Service in order to make it dynamic, more responsive to our needs, and, in a word, more democratic. Democracy is by what it does. The National Health Service will flourish the more we are all able to become involved with it.
The Campaign for a Democratic Health Service was founded as a result of pressure from all sides of the Labour, Trade Union, and Co-operative Movements. We wish to effect alteration in the National Health Service to make it free, democratic and integrated. Whatever changes are carried out will probably reveal difficulties in practice but at least we can make a start to get major reforms carried through during the lifetime of our present Labour Government.
We have set up Working Parties to examine and report upon every facet of the Service and we shall publish our findings and proposals with a view to quick action, We welcome help and correspondence from everyone who has the interest of the Patient and Service at heart. Our proposals for reform are not yet complete but this Memorandum, concentrating for the most part on the Green Paper, has to be in the Minister’s hands by 31st January. 1969.
REFORM COMES BETTER FROM THOSE WHO BELIEVE IN THE SERVICE THAN FROM THOSE WHO GRUDGINGLY ACCEPT ITS VERY EXISTENCE,
The Trades Union Congress, the Co,-operative Party in Conference 1967, the Labour Party in Conference 1968, have all passed resolutions in favour of the establishment of a unified, comprehensive and democratic National Health Service (see Appendix),
The Campaign for a Democratic Health Service holds that a free integrated and comprehensive service should be one which provides equally for all members of the community without charge at a time of need, This will include all forms of medical care and treatment whether in the home, hospital, convalescent home or other institution. The term “medical treatment” is taken to include the provision of surgical appliances, dentures, spectacles, drugs and dressings with the exception of anything which has been officially placed on a proscribed list.
DEFECTS AND FAULTS IN THE NATIONAL HEALTH SERVICE
National Health Administration is carried on by three sets of bodies under the general direction of the Secretary of State for the Social Services. These are:-
- A. Hospitals, including (1) Regional Hospital Boards, Boards of Governors of Teaching Hospitals and Hospital Management Committees.
- B. Executive Councils which control general medical, dental and opthalmic services.
- C. Local Health Authorities which provide services auxiliary to ordinary institutional and non-institutional medical practice.
On a national level a number of other bodies exist to perform certain special functions, e.g. the Dental Estimates Board. Professional advisory committees exist to help at all levels other than local authority.
The National Health Service as introduced differed much from the original conception. Originally the Minister of Health, Mr.Aneurin Bevan, envisaged a unified service of salaried Doctors working from Health Centres jointly administered and controlled by local Councils and linked to hospitals. Doctors, however, at that time would not accept this interference with their independence, and instead insisted upon individual status as Family Doctors operating their own practices subject to some slight control of their own devising. Mr. Bevan was concerned to get the Service working and accordingly had to make compromises right fromth e start.
Family Doctors were kept quite separate from the Local Authority Health Services.
The Hospitals are the third section of the tripartite structure separate from both Family Doctors and Local Authority Health Services.
Welfare Services as now run by Local Authorities were established in 1948 under a separate Act of Parliament. Overlapping of facilities exists. The administration is too fragmented.
The compromises which had to be made to get the Service working and the experience of 20 years are now shown in the various criticisms and proposals for reforming a Service which in spite of defects has received world wide acclaim from impartial observers. (And this is why our Campaign has arisen).
Pay-beds
For a long time there has been criticism of the pay and amenity beds system. Patients are kept on hospital waiting lists whilst those who can afford to pay are admitted out of turn. In future the Minister should appoint only full-time Consultants. The Chancellor of the Exchequer should arrange that tax concessions favour ful1-time practice. Payment of tax-free private insurances should not be permitted as a ‘fringe benefit’. The general public must bring pressure to bear against any unfair practice. All urgent cases should be admitted ‘urgently regardless of pay’. In many hospitals paybeds are not full and legally should not be reserved if urgent cases are waiting. (Complaints made by individuals should be made at all levels, i.e. Hospital Secretaries, Regional Hospital Boards, Members of Parliament, or the Minister of Health.)
Ill-treatment
Hospital board enquiries into allegations of Ill-treatment in mental hospitals are felt by some not to be sufficiently independent. It is pertinent here to point out that had the Service been democratic such criticisms might never have arisen. We ourselves favour the proposal that the Ombudsman be given power to investigate complaints, no matter what: reforms are eventually made law.
Training of Doctors and Dentists
The Royal Commission on Medical Education has argued that the aim of the undergraduate training course, inter alia, should be to provide “a broadly educated man”,
Medicine is a vocation as well as a job, The better a Doctor is trained the greater his personal satisfaction from his work. The patient wishes to feel, that he is in the best possible hands. And the Doctor must be well paid. We do not yet live in a society where the satisfaction derived from a good job well done is allowed to be sufficient reward in itself!
Material rewards are important. And those rewards must take into consideration the temptations qualified Doctors and Dentists receive to leave our shores. At: the same time students must always be made aware as part of their training that their training itself causes them to incur a debt to the community which is giving it. Many teaching hospitals do not place enough emphasis on this nor on the need for the trained Doctor or Dentist always to put the interest of the patient and the community above all else.
We believe that the Doctor or Dentist who qualities in this country should give a definite undertaking to serve a minimum number of years here or, if he wishes to go abroad, in such territories as specified by the Minister.
Pay of Doctors and Dentists
The present arrangements should be changed. In the Hospital Service young Doctors are overworked and underpaid. We maintain that the whole structure of present payment is wrong. Many Dentists for example are working themselves to death before they are forty – because the quicker they work the more they get. Dentists should be paid more on quality than on speed. School Dentists are inadequately rewarded. The position of Dental Technicians should be reviewed and their salaries should be paid directly by the Ministry-.
As recently as 24th October, 1968, Lord Todd said in the opening address to the British Medical Association’s annual clinical meeting at Cheltenham that:
“Under a fully-developed National Health Service it seems that the practitioner should logically be paid on a salary basis just as his counterpart in the hospital service today. If working on a salaried basis has not proved disastrous for the consultant, I find it difficult to believe that it would be so for the general practitioner.”
Position of General Practitioners
During the first 18 years of the NHS the GP came to feel more and more dissatisfied. The family doctor came to feel isolated – the more obvious causes of frustration were the shortages of medical staff, overwork on the man trying to give a 24 hour service, out of date conditions of work and the “pool” system of payment, (It can of course be reasonably argued that the Doctors’ own opposition to the introduction of the NHS was mostly to blame for their troubles.)
But there was a real feeling of a loss of status at a time when the old and the very young, increasing in numbers in proportion to the rest of the population, were throwing more work on him. The negotiation of a new contract in 1966 has admittedly eased the situation.
A Survey has suggested that a third of all hospital patients would like their GPs to visit them regularly whilst they are in hospital and most of these think it would be helpful to them if they were able to discuss their illness with him. This lack of co-ordination between the GP, the hospital and the patient is inevitable under the present set-up.
So becomes evident another reason for the GP to feel intellectually stultified. His task has often become that of distributing those of his patients in need of medically advanced treatment to the hospital Consultant.
Most of us would evidently prefer a “personal” family doctor who knows us and our family, But as more health centres come into operation, our “personal” doctor will have on the spot a choice of perhaps as many as ten colleagues,GPs, but nevertheless interested each in his special field, whom he might be able to consult as the need arises.
Some doctors, because of their own family backgrounds and inadequate public school training, are quite unable to put themselves across to some of their patients. How often all the patient really wants is to unburden his problems. Better group practice Organisation, based on health centres, will be a great help. Again, working from health centres will also mean closer co-operation with local authority and domiciliary staffs.
By the end of 1964 only 21 health centres had been built. Now 220 are either built or in the pipe line. We ask for at least 500 within the next 10 years. We suggest that this will help towards the conception of prevention of illness being better than curing.
The Green Paper
The Green Paper proposes abolishing the tripartite structure governing the administration of Family Doctor, Hospital and Council Health Services. Instead is substituted a unified system. The Civil Servants of the Ministry have prepared proposals both neat and tidy. They will facilitate neat and tidy administration of the Service from Whitehall.
There is inadequate provision for public participation. The needs of the patient are not given sufficient consideration. The interests of Nurses and auxiliary staff are not sufficiently considered nor is that of the Family Doctor in the running of his or her local Health Centre. And elected Councillors and the public are largely forgotten in the proposed Green Paper Structure.
The new proposals for an altered structure of administration as set out involve:
1. The scrapping of the existing 15 Regional Hospital Boards in England and Wales. In place of these would be 40-50 Health Service areas with boundaries similar to those of the large Regional Local Authorities. The new Regional Local Authority Boundaries are likely to be recommended by the Royal Commission on Local Government. However, London is excluded from this review having already been reorganised into the Greater London Council and 32 new London Boroughs. So for the Greater London area the Green Paper proposes 5 or 6 Area Boards covering populations of 1 1/2 – 1 3/4 million covering groups of the London Boroughs.
2. The new Health Service Areas would be controlled by “Health Area Boards”. The Local Authority Health Services, the Hospital Services (including Teaching Hospitals), and the Family Doctor Service (General Practitioners, Dentists, Etc.) would all become part of a unified integrated Health Service.
3. These Area Health Boards would take over. the duties of Hospital Management Committees, Executive Councils and the Health Services of Local Authorities, the Ambulance and other transport services previously run by local authorities would be run by, Area Health Boards.
4. Any Committee set up under the Area Boards would cover all parts of the Health Service so as to encourage operation as a comprehensive and unified service. (This represents a clean break from the present divisions in that Committees would not be set up to deal with particular services in the area such as ‘Hospital Services” or “General Practitioner Services”.)
5. The Senior Officers of the Area Boards appointed as “directors” of the 4 or 5 functional departments would together, make up a small Executive. This Executive would meet frequently and be collectively responsible to the Board for advising it on its objectives and policies and for executing the Board’s policies and maintaining the standard of services.
The Green Paper Proposals which appear right
The creation of a system of Area Health Boards is a sound idea, The present system of Local Council health services all operating in virtual isolation is inefficient and leads to duplication. of effort and misunderstandings.
The Green Paper proposals which appear wrong
There are a number of serious disadvantages in the Green Paper proposals:
1. The Green Paper does not state how the Area Boards would be formed, but presumably the members would be appointed by the Secretary of State. The idea of Area Boards appointed by the Secretary of State is contrary to the growing public demand for greater involvement in Democracy. (the words of Aneurin Bevan are worth quoting here “Liberty and responsibility march together”)
2. Local Authorities are likely to become larger and to be reconstituted in a manner designed to make them more suited to present-day administrative demands. Local Authorities are run by Councillors directly elected by the public and are, therefore, supposed to represent public needs. Many Local Authorities used to run hospitals before the National Health Service, The larger authorities now run, and have great experience in a wide range of Health and Welfare Services administered under the direction of their Medical Officers of Health. The transfer of all these functions to a non-elective Area Health Board perhaps two or three times the size of the Council will make for remoteness in administration and extinguish any form of democratic control at present existing. This proposal should be scrapped entirely.
3. The proposed abolition of Hospital Committees will mean that patients will be separated still further from those responsible for their treatment. There have been serious accusations concerning the method of choice of members of Regional Hospital Boards and Hospital Management Committees. For instance, an investigation reported in the Fabian pamphlet: “Unpaid Public Service” referring to Regional Hospital Boards stated, “We did not in fact find one Labour supporter among the 15 Chairmen.” This seems somewhat surprising bearing in mind that the National Health Service is a Socialist service – to each according to his or her need for medical care, Yet those most likely to support the principles of the service are evidently, excluded in place of mainly retired members of “The Establishment”. Even with these defects, the choice of elected local people to serve on hospital committees is to be preferred to the proposed alternative of having no hospital committees and no local representation, not even of nominated persons,
4. The Green Paper proposals will mean that the lay influence in administration will be taken away from those places where it is needed most. The disappearance of hospital management committees will leave the running of the hospitals in the hands of the officials. It may be that committees are sometimes a nuisance, it may be that a streamlined mechanical, efficiency is economical, but a health service is not a business, it is a human service of such an intimate character that those charged with the responsibility of its management should not merely secure efficient day to day organisation, but. also safeguard the care and comfort of the patient. It is not only what is done that matters but the way in which. it is done.
5. The proposed Area Boards would be empowered to set up certain Committees; it is suggested that there should be five, They would be lateral in form not vertical. In other words the committees world not be sectional; there world not be a “hospitals committee, a “general practices committee” and so on, but a Planning Committee, Staff Committee, etc., and these committees would deal with all sections of the service and not any special aspect,
The Green Paper plan as it stands cannot commend itself to those who are more interested in the patient than in the mechanics of administration. The implication here is clearly that the country consists of the governors and the governed.
What Should Be Done
1. Establish Area Health Boards. At least 20 of their members should be directly elected, possibly with powers to co-opt another 10.
2. Abolish the present Regional Hospital Boards.
3. Transfer the functions of Local Authority Health departments, the General Practitioner Executive Councils and Regional Hospital Boards to the Area Health Boards.
4. Authorise the Area Health Boards to set up Committees for the management of certain parts of the service, such as hospital service, general practice, health centres etc.
5. The creation of the Area Boards should be done now, legislation presented and passed in the shortest possible time, so that reform does not have to wait upon Local Government Reorganisation.
6. Serious consideration should be given to the payment of the Chairmen of the new Area Boards.
Elections
There are alternative methods which can be adopted to ensure that the service is made democratic. From a Local Government point of view should the new Regional Bodies have powers to administer a health service then the whole of the National Health Service administration could perhaps be transferred to them. If this should not be the case, then there could be direct election of members of Area Boards. These elections could take place at the same time as the election of members of the new Regional Authority. In either event the public will be in contact with those who manage the service even though the administrative body is responsible to the Minister.
A hospital is a living entity with its own traditions and staff and way of life. Accordingly, Hospital Management Committees should be retained under the new set up and improved considerably by the introduction of a democratic element. And here it is relevant to draw attention to the fine work done by local “Friends of Hospitals”.
It is suggested that lay people who would come forward from the community to offer themselves for election to the Area Health Boards would be serious intelligent people, They are likely to be more sensitive and responsive to criticism of the quality of Health services in their locality and more anxious to eliminate defects than the remote “Establishment” non-elective Regional Board. and Hospital Management Committee members as constituted at present.
The tendency towards Group Family Doctor Practices working from Health Centres in the future will mean better service more quickly for the patients. The original intention of the Labour Government was for doctors to work from Local Authority Health Centres. Under successive Conservative governments little real progress was made in this direction.
We all have a vested interest in ensuring that the Health Service upon which we rely is the best possible for our welfare and convenience. Democratic elections would give us a degree of control over the provision of Health Services in our locality. The more the public is involved in the running of the Service the more it will become aware of its needs,
The time has now come to remedy the defects revealed over 20 years so that every single resident of Britain is able to feel that. the utmost is being done to give a Service which is COMPREHENSIVE, UNIFIED AND DEMOCRATIC. That way we shall continue to lead the World in the sphere of Health.
APPENDIX – THE RECORD
“National Service for Health” Policy Document published by the Labour Party and accepted by its Annual Conference 1943,
“Labour’s Plan for the reform of Local Government (see the Labour Party’s pamphlet, ‘The Future of Local Government’) recommends that the country should be divided into Regions, each having a Regional Authority for certain purposes of Local Government; and that these Authorities (unlike the regional Organisation during the war) should be democratically elected. The party also proposes that, for health purposes, each of these elected Regional Authorities should appoint a Health Committee for its Region. Under these Regional Health Committees there should be appropriate sub-committees.”
Rt. Hon. Aneurin Bevan, M.P. – Quotation – “In Place of Fear’‘:-
“Election is a better principle than selection. No Minister can feel satisfied that he is making the right selection over so wide a field.”
Resolution of Co-operative Party Annual Conference, Easter 1967,.-
“This Conference considers the present method of selecting representatives to serve on Regional Hospital Boards and Hospital Management Committees is undemocratic and urges the Government to abolish this method of selection at the earliest opportunity and establish the system of democratic election”.
Resolution of U.S.D.A.W. Annual Delegate Meeting, 1967:-
“This Annual Delegate Meeting is of the opinion that members of Regional Hospital Boards and Management Committees should be elected and calls upon the Executive Council to pursue the matter through the appropriate bodies”.
Resolution of Labour Party Annual Conference, 1968:-
“This Conference reaffirms that the right to health was one of the basic principles on which the Labour Party was founded and calls on the National Executive Committee to restore it as the first priority of any government. The Labour Party created the first comprehensive health service, free at the time of use, planned by a democracy and Conference reiterates its support for such a service both in principle and practice. It calls on the Government to remove the charges on prescriptions and to phase out other National Health charges such as optical expenses and dental charges and to press on with the production of a unified service with the establishment of area health boards having an elected membership with powers to co-opt and receiving an adequate proportion of the national income to enable it to expand to meet modern needs”.
Resolution of Labour Party Annual Conference, 1960:-
“This Conference re-affirms that the policy of the Labour Party to be pursued nationally and in Parliament on questions of principle shall be determined by Annual Conference. While acknowledging that the day to day tactics in Parliament must be the job of the Parliamentary Labour Party, this Conference declares that Labour policy is decided by the Party Conference which is the final authority.