Local Government Management of the Hospitals, 12 March 1954

An old problem of local government is how to marry function to area. The technical requirements of the function are apt to exceed either the size of population within a given local authority or its extent in terms of square miles, or both. When the marriage is convenienced by enlarging the local authority, or by singling out the larger local authorities to perform the function in question then it is true the marriage is consummated, but it is often divorced from local government in any acceptable meaning of the term.

I was faced by this difficulty when framing the National Health Service. Not even the larger local authorities provided a gathering ground extensive enough for certain medical specialities. An extreme instance is leprosy, a notifiable disease, but one, fortunately, so rare in this country in its more serious and infectious forms that no unit smaller than the whole country sufficed.

The principle of national financial responsibility also conflicted with local government responsibility for the service. Uniformity of treatment could not be achieved by making the nation the unit of the service, nor, indeed, should it be attempted. But, equality should be the aim and this could not be guaranteed if facilities varied with local finances.

Then again there was the old problem of passing patients from the care of one health authority to another, a transference often necessary for clinical reasons, but one fraught with financial complexities for the authorities concerned.

All these considerations had to be kept in mind when shaping the service and any modification of the existing structure should be able to accommodate them, otherwise we shall not retain the enjoyment of a truly free National Health Service.

Nevertheless, it remains a defect that the principle of election had to give way to that of selection, by the Minister, in the administrative agencies of the service. I found this hard because I am by experience and conviction a local government man. In my book, In Place of Fear, written in 1952, I wrote the following on this subject:

“…Although it is essential to retain Parliamentary accountability for the service, the appointment of members of the various administrative bodies should not involve the Minister of Health. No danger of nepotism arises, as no salaries are attached to the appointments, but election is a better principle than selection. No Minister can feel satisfied that he is making the right selection over so wide a field. The difficulty of applying the principle of election rather than selection arises from the fact that no electoral constituency corresponds with the functional requirements of the service. This is particularly so in the case of hospitals. These are grouped in such a way that most, if not all, the different medical specialities are to be found within a given area.

A solution might be found if the reorganisation of local government is sufficiently fundamental to allow the administration of the hospitals to be entrusted to the revised units of local government. But no local finances should be levied, for this would once more give rise to frontier problems, and the essential unity of the service would be destroyed.”

The idea is for the local authority to act for the Minister on an agency basis, on financial terms which should not present too much difficulty in working out. All staff appointments should be in the control of the local authority, with the exception of the specialists. These could be appointed on the recommendation of a regional advisory body, with adequate representation from the medical and other allied professions. By this means a considerable measure of local responsibility would be restored.

But one qualification must be made. The local authorities should avail themselves of the immense reservoir of voluntary workers in this field; otherwise there would be a danger of merely making a transfer of power from the officials in Whitehall to those in the town hall.

This is not the place to work out all the details of the change. These are many and varied, but we now have a wide experience to draw on; and, I hope, a more co-operative mood in the medical profession. Now that the fears of the doctors have been largely assuaged there should be a readier disposition to set aside the traditional antagonism between the clinicians and the medical officers of health.

But, in my opinion, success is dependent on a radical reorganisation of the structure of local government. As we all know this is long overdue. The example of the National Health Service is only a special instance of a general case. Unless it can be brought about Ministers, in framing their legislation, will feel compelled, as I was, to improvise other forms of administration. Ardent supporters of local government have no answer if they continue to resist changes which are necessary to meet the requirements of a changing society.

In the proposals which I outline from now on, I must make it clear that I am speaking for myself alone and not for any particular section of political opinion. Arguments about the reform of local government cut across political parties, because it cannot be said that any one party would stand to gain by a change. It is this fact, as much as anything else, which has postponed action where, for so long, it has been so badly needed.

In reforming local government what should be our general aim? We should wish to revive and maintain local government as a form of government which is truly local, and which is so near to the people as to ignite and keep their interest.

This interest by the public is important as a spur and refreshment to the governing bodies themselves and for the creation of an intelligent and educated democracy inspired with civic spirit. Quite apart from its value to the well-being of society and to the individual citizen, it is of incalculable value to the community in any kind of crisis. Because of all these central objectives we must have local bodies which are near enough to the electorate to command interest, which have functions of sufficient importance to attract the best type of councillor and which are strong enough to carry the services they administer.

How do we apply these principles to the actual facts of the present complex of local government? There are two extremes operating in the district councils and the county councils. Within each group there are considerable variations in size, but taking the average unit in each, there seems little doubt that the present boroughs and district councils are too small for efficiency, whereas the administrative counties are too large for democratic principles to flourish; in my view county administration is a practical example of the way excess of size can turn the administration of an elected body into largely a bureaucratic form. There is little or no spiritual identification by the citizen with the administrative county. The latter is a machine with no organic thrust from the accretions of community living. Its disappearance would involve the dispersal of sometimes highly efficient teams of officials but no emotional disturbance among the electorate embraced by it.

Machines are important but democracy is a way of life as well as a means of living. Efficient machinery can guarantee the performance of material functions but it cannot by this means alone provide the full life; for if efficiency were to be accepted as the sole test the mechanised feeder would replace the domestic table.

This is not to say that I award the palm, even for efficiency, to the majority of county councils. Far from it. But it must be admitted that the abolition of the county as an administrative unit, for local government purposes, would involve the dissolution of a number of devoted and efficient teams.

The second aim we set for our reform was that it must ensure functions important enough to attract the best kind of councillor. This points directly at the all-purpose authority. No one acquainted with local government would seriously contest the proposition that a two tier local authority system leaves neither with enough functions to achieve viability. The delegation of powers from county to district causes endless friction between the two. The problems of overspill, boundary extensions and the promotion of non-county borough to county borough status; all these, which sorely vex and perplex us at present, would either disappear, be easier of settlement or partly resolved by the change.

In particular, except for the great conurbations, most local government units would embrace both rural and urban areas to their mutual advantage. There can be no doubt that one unit of local government, discharging all the functions now shared between county and district, would attract and keep the very best type of councillor, and give local government in Britain a much-needed fillip.

The third aim we mentioned was the necessity for strong administration. The all-purpose authority, enjoying diversity of function and based on a large enough population, would be able to command efficient teams of officials, provide them with status and pay them rates of remuneration which would serve to protect them from constant erosion by other forms of employment.

I believe it can be shown that the practical application of these principles would result in the creation of between 235 to 240 all purpose authorities. With a little patience and industry and a good map anyone can make a rough outline of the scheme. If you take an existing township of substantial size and attach to it an area so that both taken together would comprise a population of more than 50,000 the result is surprising and in the main gratifying. The bulk of the population would be within ten miles of the civic centre. In these days of easy transport this would give an accessibility far in excess of what was deemed tolerable a short while ago.

The rest would be under 20 miles. Less than ten would possess populations of less than 50,000. As one should expect, these occur in sparsely populated districts of Wales and near the border. More than 75 per cent. would have populations exceeding 75,000. I have deliberately not chosen to show how this would work out in particular places because it is not desirable to provoke local argument at this stage.

There would be a substantial increase in the number of education authorities but on the other hand the excepted authorities and divisional executives would disappear. As we all know, there is constant bickering between these executives and the county councils.

The important fact to keep in mind is that the exercise produces local authorities which satisfy the three conditions I mentioned: strength, viability and accessibility.

Of course it is not proposed to split places like Cardiff, Bristol, Manchester, Birmingham and the like, except in some instances to provide rural belts.

In considering proposals of this sort, which are so fundamental and far-reaching It is necessary to avoid too violent a disturbance with local bodies, such as the Charter boroughs, for example. Many of these are much too small to entrust with the full range of local functions. Nevertheless, they are repositories of historical interest and command strong local sentiment. Arrangements could be made for them to discharge certain services of a strictly local and immediate character, and also retain the pageantry and ceremony so long associated with them. For these purposes they could spend money provided by the all-purpose authority. In addition there seems no reason why they should not be allowed to require that body to raise from their own citizens a rate to be spent on such matters as they think fit. The parish is the oldest form of local government. There is no reason why it should not find its place in the new arrangement. Indeed, it might get fresh vigour.

Obviously it is not possible to deal with the details of these proposals in one article, nor to answer all the objections that might be brought against them. There are exceptional circumstances, like Greater London, for example, where special provision would have to be made in any scheme for the reorganisation of local government.

The London County Council is not London. But Greater London is clearly too big to be one unit. Even the LCC is considered by many to be too big and remote. It is incontestable that there should be a body which is recognisable as the authority for London. What its functions should be is a subject for argument, but they should not be so extensive as to deprive the rest of local government in the area of viability and status.

Where so many deeply rooted vested interests are concerned it is hopeless to expect the argument to be conducted without prejudice and even passion. Nor are there subjects too extraneous to be mobilised in the service of the controversy. I have been told, for instance, that the end of the county as an administrative unit of local government would mean the end of the county cricket team. What possible connection there is between the two passes comprehension. The county, as an historical entity, existed before the creation of county administration and it would continue to exist after the latter ceased. Yorkshire would still enjoy its centuries-old friendly rivalry with Lancashire.

The issue here is the restoration and preservation of local government as a vital part of our constitutional apparatus and as an Indispensable element In the British way of life.

Those of us who have had experience of county and district administration can be in no doubt as to which is local government in all the essential meanings we attach to the term.

Source: The Municipal Joumal, 12 March 1954, pp. 544-5.