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Reconstruction

HOSPITAL MANAGEMENT COMMITTEES

FROM A CORRESPONDENT

THE National Health Service Bill has now finishedits course through standing committee and is awaitingfurther discussion on report stage in the House ofCommons. So far as the actual clauses of the Bill areconcerned the position of hospital management com-mittees has been little changed in committee. Sincethis Bill institutes a long-term programme of development,and in days to come it is only the statutory positionwhich the executive will be bound to consider, it is

profitable to look first at the position of hospital manage-ment committees as it appears from the clauses of theBill, without regard for the moment to the declarationsof.the Minister of Health as to what he thinks andintends that these committees should be.

(a) A hospital management committee is to be appointedby the regional hospital board.

(b) Subject to regulations and directions given by theMinister or the regional board, it shall exercise on behalf ofthe regional board such of the functions of the board relatingto the control and management of its hospital or group ofhospitals as may be prescribed by regulation.

(c) All its officers-medical, nursing, administrative,domestic, and others-are the officers of the regional boards.

(d) All the expenditure of the committee shall be defrayedby the regional board.

(e) The committee will not be a body corporate-as theregional hospital board and the board of governors of teachinghospitals are to be.

(f) All proceedings for the enforcement of rights acquiredor liabilities incurred by the committee in the exercise of itsfunctions are to be brought by or against the regional hospitalsboard.

The Minister has said that before the report stage ofthe Bill he will consider an amendment to enable hos-

pital management committees to accept gifts on trust.This is the statutory position of a body on which

more than on any other body or person-the Ministerincluded-will depend whether a hospital functions inan efficient and humane manner. As the body respon-sible for the day-to-day administration it is the arbiterof the- interests of the patients and the needs of thepublic served by the hospitals group. The committeewill be concerned with the internal management of oneor more institutions with a total bed capacity in theregion of 1000. What does this mean It means thatin these institutions there should be a staff equivalentto, say, 40 full-time medical officers, and nursing anddomestic staff numbering 600-700. The annual expendi-ture may be of the order of 250,000, probably more.As many as 16,000-17,000 patients may pass through thewards in the course of a year and if outpatientdepartments are part of the work the number of patientsattending, if the institutions are in a populous area, maybe 90,000. Clearly the burden of responsibility which isto be placed upon a hospital management committeewill be a heavy one. Yet of all the bodies providedfor in the Bill for the administration of the various partsof the health service, the hospital management committeeis the only one which is to -be denied statutory rightsof any kind. And this denial is deliberate.

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RESPONSIBILITY WITHOUT RIGHTS

During the tenth day’s proceedings of the standingcommittee an amendment was moved by Mr. Lipson tothe effect that the duty of managing and controlling ahospital or group of hospitals should devolve upon thehospital management committee on behalf of the regionalboard in accordance with regulations and such directionsas may be given by the Minister, and that, in particular,it should appoint hospital officers, except specialists,maintain premises, acquire and maintain equipment,

furniture, &c., and be given powers to delegate to a housecommittee for each hospital in a group such functionsin the control and management of that hospital as it

thought fit.The Minister stated that he was " deeply sympathetic

with the purpose of the amendment but that he could not

accept it. The reasons he gave call for study, but beforeconsidering them, note must be taken of a remarkablestatement which the Minister propounded. It was asfollows :

" The whole tendency of the argument has been thatwe can make these people [i.e., the hospital managementcommittees] responsible bodies and give them higher statusonly by decanting into them specific rights under the Bill,so that they can have rights-not responsibility-whichI don’t want to give them. Responsibilities, yes but statutoryrights, no ; because once they begin to have statutory rightsthey begin to achieve independence, and once they begin to

achieve independence we can no longer hold them responsiblefor certain things they do."

Perhaps this statement was framed in the heat of debateand is not the Minister’s considered view. Let us hopethat this is so. Otherwise it would give solid groundfor the fears of many-and they include those as anxiousas the Minister to see the aims of the National HealthService fully realised-that the service as at presentplanned will be overcentralised and excessively bureau-cratic. The idea that a body or person with statutoryrights cannot be held responsible for the performance ofadministrative duties is nonsense, and surely is alien to -

the British conception of democracy based upon law.And it may be asked why, if the Minister’s contentionwere true, he should apparently regard it as applicableonly to hospital management committees and not alsoto the central council, the regional boards, the executivecouncils, and the rest of the administrative bodies, allof which have some statutory rights.

THE MINISTER’S ARGUMENTS

Leaving this puzzling utterance behind let us look at .the other reasons which the Minister put forward againstMr. Lipson’s proposal. They may be summarised as

follows, using so far as possible the Minister’s own words.(i) The scheme for the hospital service is experimental and

may require modification from time to time in the light ofexperience. Such organic changes would become impossibleif on every occasion there had to be an amending Bill.

(ii) If the Minister had to accept the powers of everymanagement committee as defined in the Bill, bad manage-ment committees would be perpetuated by the Bill itself.

(iii) It may be necessary in different places to have differentschemes.

(iv) The officers appointed by hospital management com-mittees must be in contract with the regional boards, becauseotherwise it will not be possible to bring about a necessarydegree of uniformity, not in the kinds of individuals who areappointed, but in the conditions of rank.

" We cannot havethe management committees varying every contract wheneverthev like."

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(v) By having all officers in contract with the regionalboards, far greater mobility within the service will be attained.At the present time hospital staffs are " completely enchainedby their particular institutions."

This is not an impressive array of convincing reasons.Of course there must be flexibility in the operation of ascheme which, admittedly, is based largely on theoreticalconceptions ; and much must be left to be dealt withby regulations ; but on the very important question of theresponsibility of the hospital management committeeto the regional board, the Minister has in the Bill to alarge extent prejudged the issue. The Bill requires thatall officers must be officers of the regional board, that allexpenditure of a hospital management committee mustbe defrayed by the board, that the board and not thehospital management committee can sue or be sued inrespect of the exercise of functions by the latter. Thesematters cannot be dealt with or altered by regulation.

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If experience shows that in these respects a mistakehas been made, an amending Act will be necessary.What makes the Minister so sure that in these respects. there will be no need for modification ? Further, thesematters will in practice limit quite materially the extentto which the Minister will be able to carry out his declaredintention to secure " a very considerable devolution of

responsibility to the management committees." The

Parliamentary Secretary stated on the ninth day ofthe standing committee’s proceedings that the hospitalmanagement committees would be allowed to select,appoint, and dismiss the ordinary staff of the hospitalor hospitals with which it is concerned. But we mayask : since actions for wrongful dismissal will be againstthe regional board, may not that board reasonably requirethat all dismissals shall be subject to its approval. The

regional board as the employer will be the body on whichthe eyes of the staff, particularly the more senior, willbe focused. From that source comes promotion.

Mr. Bevan wishes the hospital management committeesto have powers of spending within a global budget ;but all expenditure of a committee is to be defrayed bythe regional board. Inevitably the regional board willhave to have a large accountancy staff. Is it unreasonableto expect that this staff will operate on the same lines ascorresponding staffs in the past-the forms, the returns,the correspondence over the smallest variation from

approved estimated ? ’f Freedom of expenditure within aglobal figure either by regional boards or hospital manage-ment committees is not provided for in the Bill, andthere is no solid ground for thinking that, if not fromthe start, yet within a relatively short time, the long-established practices and procedures of central financedepartments will not begin to be insisted upon ; and thengoodbye to freedom within a global figure.What about some of the other reasons put forward

by the Minister ? ’? On (ii) a management committee isappointed by the regional board ; if a bad one is

appointed, the fault will lie with the regional board.Moreover the management committee is to be subjectto specific direction by the Minister and the regionalboard, while the Minister has default powers. A queryseems permissible on (iii) ; does it mean that some

hospital management committees will have little dele-

gated power (e.g., not even the limitedright to choose juniorstaff); and if so what considerations is it expected willgive rise to such variations ? On (iv) leaving aside thequestion of whether a complete uniformity is desirable-experience of the operation of the Rushcliffe Committee’srecommendations on nurses’ salaries may be held bysome to raise doubts-it is not true that uniformity inthe terms of service can be secured only by the arrange-ments proposed in the Bill. On (v) Mr. Messer in thestanding committee voiced the view of many who havebeen concerned with the nursing service, that in regardto nurses it is essential that they should be identifiedwith a particular hospital.

THE RIGHT SOLUTION

To Mr. Bevan Hansard attributes the rhetorical

question " How will it be possible for the regional boardsto function properly if they are the puppets of -theMinister " It is equally apposite to ask how can thehospital management committees function properly if

they are the puppets of the regional hospital board. Itlooks very much as if puppets is what they will be, andas if the promised considerable devolution of responsi-bility will be more apparent than real. And that willmean that the dangers-which the Minister has beeninclined to treat lightly as the figments of imaginationsperverted by vested interests-of overcentralisation, ofexcessive strain on members and officers of the regionalboards, and of a stifling of local initiative will materialise.

These dangers were dealt with by a special correspon-dent in the Times of July 12, but he saw them from-

the angle of the burden which would be laid upon theregional boards and thought that they might bediminished by making the regions smaller and having,say, 30 regions, each with an average population of1,300,000, instead of 20 regions each containing approxi-mately 2,000,000 persons. While the special correspon.dent’s analysis of the situation seems a true one, it isdoubtful whether his solution is the best. Far thebetter plan, both from the point of view of avoiding thedangers of overcentralisation of which he and many othersare so conscious, and at the same time of making certainof attracting well-qualified people to the hospital manage.ment committees, would be to ensure, in the Bill itself,that hospital management committees were responsibleagents for the regional boards rather than rightlesspuppets. By so doing the Minister would not, in anyway, alter the main structure or objects of his Bill, andthe devolution of responsibility from the Minister tothe regional boards and from the regional boards to thehospital management committees would be effectedmore efficiently than under the arrangement at presentproposed.

Parliament

ON THE FLOOR OF THE HOUSE

WORK in the House was comparatively light last week,and several times members were able to get to their bedsby midnight. It was almost a holiday, and the Househas been in sunny mood, like the weather, with a fewthunderstorms of not very serious dimensions. Perhapsit is the sunshine, or perhaps it is the royal garden-parties at Buckingham Palace ; but things have certainlylooked brighter, especially the dresses of the womenmembers ; and even men, in disinterred morning coatsand toppers, have bedecked the summer scene with

fugitive memory of older days. Karl Marx, who knewthis country well, was of the opinion that in England asocial revolution would take place without violence andbloodshed. But it is doubtful if he realised it mighttake place according to the accustomed ritual of theBritish way of life and to the tune of the music of militarybands in the parks.We had a debate on the Colonies-a most polite debate.

Mr. George Hall began his review of Colonial affairs bypaying a warm tribute to the work of his predecessorMr. Oliver Stanley ; and Mr. Stanley reciprocated.But this song of continuity was not echoed by all themembers, some of whom evidently thought the Coloniesneed much more extensive alterations and repairs-as regards our treatment of their native inhabitants-than would be provided by the Colonial Development andWelfare Fund. Mr. Hall did not say, but he implied,that the aeroplane has now made the Colonies almostsuburban. And the close juxtaposition of races withsuch differing standards as those of Limehouse andLagos will force attention to the need of raising the

very low standards of physical health and efficiency andof purchasing-power of the African of Lagos to at leastthose of Limehouse.The only debate in which angry passions were roused

was that on the cut in the soap ration. Mr. Stracheysaid he had scoured the world -for fats, but memberswere left to consider how they could scour themselveswith one-seventh less soap per month. MEDICUS, M.P.

FROM THE PRESS GALLERY

Health Services in the Colonial EmpireIn the House of Commons on July 9 a general debate

took place on Colonial affairs. Mr. GEORGE HALL,the Secretary of State for Colonial Affairs, said thatwithout great improvement in basic economic conditionsfew of the Colonies could be expected to show substantialsocial or political progress. Improved social services