993 INSTITUTE OF HOSPITAL ADMINISTRATORS THE institute held its annual conference at Hastings from May 7 to 9. Training of Administrators I In his presidential address, Mr. S. C. MERIVALE, secretary to the board of governors of the United Bristol Hospitals, examined the ways in which hospital adminis- trators are at present learning their jobs. The institute itself made arrangements for systematic instruction and examination for its diploma ; and there was the Hospital Administrative Staff College in London, where King Edward’s Hospital Fund provided special facilities for ,’ concentrated ’postgraduate study. In addition certain hospitals throughout the country were working schemes for the instruction of one or more trainee administrators. There were, Mr. Merivale thought, various dangers in this situation. For one thing, " private enterprise " schemes might remain both too " private " and too "enterprising " : " too private " because such schemes would tend to turn out people purporting to be fully trained when they had had experience of working in only one hospital group or authority ; ’’ too enterprising " because such uncoordinated individual efforts might lead to over-recruitment of able people and a glut of " regis- trars " in the administrative branch of the service. Another danger was that the Administrative Staff College might lose some of its effectiveness by an inability to link up the work which only it could do with approved practical work in the widest possible variety of hospitals and hospital authorities. The institute and its regional councils could play a big part in arranging, in cooperation with hospital authorities and the staff college, training circuits to which people who were prepared to make the necessary sacrifices could enter from within the service. These arrangements could and should be linked with the Recruitment Advisory Service which the King’s Fund had already set up at the college. To overcome the difficulties involved in moving trainee staff about the country, Mr. Merivale proposed that there should be in every region a sort of Civil Service Commission for the administrative branch of the health service, containing representatives of the regional council of the institute and the employing authorities. This body would approve appointments for designation as training posts, four to six of which would be grouped together geographically to provide the widest possible variety of experience. These posts would be held for from six to twelve months each, and they would be linked with. the staff college to ensure that a period of concentrated study and instruction was included in the normal progress round a training circuit. The number of posts in each circuit should bear some relation to the ultimate -prospects of their holders, bearing in mind the number of senior appointments that would be available. As Mr. Merivale pointed out, these proposals to ’some extent involved individual authorities voluntarily sur-- rendering their present sovereign rights to make their own administrative appointments at "registrar" level. But if the administrative service was to compete success- fully for its share of the best recruits, its training arrangements must bear comparison with those in other walks of life and the prospects of promotion must be fair and reasonable. The need, therefore, was for some practicable and acceptable compromise between the present haphazard system and its opposite-]?romotion by posting. System The Committee System ’Mr. JOHN TBEVELT-AN discussed the advantages and disadvantages of the committee system, with particular reference to its place in hospital administration. Com- mittees tended to discourage action : as the anonymous cynic put it, " a committee is a group of men who individually can do nothing. but collectively can meet and decide that nothing can be done." Sometimes, too, the power of decision on technical matters rested with the inexperienced. On the other hand, these were not always disadvantages : for precipitate action was not alwa.vs a good thing ; and in these days of specialists in every field, often with competing claims, the judgment of the non-specialist might be valuable in maintaining a balance. Moreover, history had taught us that the committee system, however cumbersome it might be, was an effective barrier to tyranny ; and in our time we had to fight against the tyraxany, not of the autocrat, but of the bureaucrat. In the hospital service executive responsibility was shared between the Ministry and the various committees-from regional hospital boards to house committees-in varying, and not always clearly defined, proportions. It produced the problem of how to blend central direction with decentralised committee administration ; there was the danger of too much central direction, -largely in the form of a tight financial rein. Remote control often led to standardisation and discouraged variations in individual hospitals. Turning to possible improvements in the system, Mr. Trevelyan thought that there could usefully be more building from the perimeter to the centre. For example, in the teaching hospital groups each board of governors might consist of some members appointed by the Minister and others elected bv the house com- mittees of the hospitals in the group. Similarly, each regional hospital board might consist of a certain number of members appointed by the Minister and other members appointed by the hospital management committees in the region ; and each hospital management committee might be constructed in much the same way. This process might be developed further by establishing a Central Hospitals Service Committee, with some members appointed by the Minister and some elected by boards of governors and regional hospital boards. Such a committee could represent the committee adminis- tration of the service in discussion with the Ministry, and cooperate with the Minister in determining policy. In this way all parts of the hospital service, down to the committees concerned with individual hospitals, could share in policy-making. Further, delegated authority should be progressively increased and should include as much financial responsibility as possible. It was to be hoped that the new committee which was -to investigate the cost of -the N.H.S. would see that the best way to save money on the hospital service was to trust the people who were running it. The individual hos- pital committee should be given as much responsibility as possible, and it was no good having committees that had no responsible job to do. -In the details of com- mittee work, committees should consider what executive responsibility could be entrusted to their officers ; it was up to the committees to see that they did not waste time discussing matters which could and should be dealt with by their officers. Mr. Trevelyan summed up with the- words of Anthony Ashton : " The Committee is one of man’s-importalzt social discoveries-like the use of money, the rule of law and thespecialisation of labour- but it is not a panacea. To solve problems it is not enough merely to set up committees. They can moderate and guide the creative energy of individual men, but they can never be a substitute for it." The Changing Function of the Hospital Tracing the changes in the work of the hospital, Dr. H. W. C. Vmrs, professor of pathology at Charing Cross Hospital Medical chool,- deplored ’the trend which was making the hospital more of an administra- tive unit and less of a place where patients "were cared for. The patient was being overlooked ; and there was
Transcript
993
INSTITUTE OF HOSPITALADMINISTRATORS
THE institute held its annual conference at Hastingsfrom May 7 to 9.
Training of Administrators
I In his presidential address, Mr. S. C. MERIVALE,secretary to the board of governors of the United BristolHospitals, examined the ways in which hospital adminis-trators are at present learning their jobs. The instituteitself made arrangements for systematic instruction andexamination for its diploma ; and there was the HospitalAdministrative Staff College in London, where KingEdward’s Hospital Fund provided special facilities for
,’ concentrated ’postgraduate study. In addition certainhospitals throughout the country were working schemesfor the instruction of one or more trainee administrators.There were, Mr. Merivale thought, various dangers inthis situation. For one thing, " private enterprise "schemes might remain both too " private " and too
"enterprising " : " too private " because such schemeswould tend to turn out people purporting to be fullytrained when they had had experience of working inonly one hospital group or authority ; ’’ too enterprising "because such uncoordinated individual efforts might leadto over-recruitment of able people and a glut of
"
regis-trars " in the administrative branch of the service.Another danger was that the Administrative Staff Collegemight lose some of its effectiveness by an inability tolink up the work which only it could do with approvedpractical work in the widest possible variety of hospitalsand hospital authorities. The institute and its regionalcouncils could play a big part in arranging, in cooperationwith hospital authorities and the staff college, trainingcircuits to which people who were prepared to make thenecessary sacrifices could enter from within the service.These arrangements could and should be linked with theRecruitment Advisory Service which the King’s Fundhad already set up at the college.To overcome the difficulties involved in moving
trainee staff about the country, Mr. Merivale proposedthat there should be in every region a sort of CivilService Commission for the administrative branch of thehealth service, containing representatives of the regionalcouncil of the institute and the employing authorities.This body would approve appointments for designationas training posts, four to six of which would be groupedtogether geographically to provide the widest possiblevariety of experience. These posts would be held forfrom six to twelve months each, and they would belinked with. the staff college to ensure that a period ofconcentrated study and instruction was included in thenormal progress round a training circuit. The numberof posts in each circuit should bear some relation to theultimate -prospects of their holders, bearing in mind thenumber of senior appointments that would be available.As Mr. Merivale pointed out, these proposals to ’someextent involved individual authorities voluntarily sur--
rendering their present sovereign rights to make theirown administrative appointments at "registrar" level.But if the administrative service was to compete success-fully for its share of the best recruits, its trainingarrangements must bear comparison with those in otherwalks of life and the prospects of promotion must befair and reasonable. The need, therefore, was for somepracticable and acceptable compromise between thepresent haphazard system and its opposite-]?romotionby posting. System
"
. The Committee System’Mr. JOHN TBEVELT-AN discussed the advantages anddisadvantages of the committee system, with particularreference to its place in hospital administration. Com-mittees tended to discourage action : as the anonymouscynic put it, " a committee is a group of men who
individually can do nothing. but collectively can meetand decide that nothing can be done." Sometimes, too,the power of decision on technical matters rested with the
inexperienced. On the other hand, these were not
always disadvantages : for precipitate action was notalwa.vs a good thing ; and in these days of specialistsin every field, often with competing claims, thejudgment of the non-specialist might be valuable in
maintaining a balance. Moreover, history had taughtus that the committee system, however cumbersome itmight be, was an effective barrier to tyranny ; and inour time we had to fight against the tyraxany, not ofthe autocrat, but of the bureaucrat. In the hospitalservice executive responsibility was shared between theMinistry and the various committees-from regionalhospital boards to house committees-in varying, andnot always clearly defined, proportions. It producedthe problem of how to blend central direction withdecentralised committee administration ; there was
the danger of too much central direction, -largely inthe form of a tight financial rein. Remote control oftenled to standardisation and discouraged variationsin individual hospitals.
’
Turning to possible improvements in the system,Mr. Trevelyan thought that there could usefully bemore building from the perimeter to the centre. For
example, in the teaching hospital groups each boardof governors might consist of some members appointed bythe Minister and others elected bv the house com-mittees of the hospitals in the group. Similarly, eachregional hospital board might consist of a certain numberof members appointed by the Minister and other membersappointed by the hospital management committees inthe region ; and each hospital management committeemight be constructed in much the same way. Thisprocess might be developed further by establishinga Central Hospitals Service Committee, with some
members appointed by the Minister and some electedby boards of governors and regional hospital boards.Such a committee could represent the committee adminis-tration of the service in discussion with the Ministry,and cooperate with the Minister in determining policy.In this way all parts of the hospital service, down to thecommittees concerned with individual hospitals, couldshare in policy-making. Further, delegated authorityshould be progressively increased and should includeas much financial responsibility as possible. It wasto be hoped that the new committee which was -to
investigate the cost of -the N.H.S. would see that the bestway to save money on the hospital service was to trustthe people who were running it. The individual hos-pital committee should be given as much responsibilityas possible, and it was no good having committees thathad no responsible job to do. -In the details of com-mittee work, committees should consider what executiveresponsibility could be entrusted to their officers ; itwas up to the committees to see that they did not wastetime discussing matters which could and should be dealtwith by their officers. Mr. Trevelyan summed up withthe- words of Anthony Ashton : " The Committee isone of man’s-importalzt social discoveries-like the use ofmoney, the rule of law and thespecialisation of labour-but it is not a panacea. To solve problems it is notenough merely to set up committees. They can moderateand guide the creative energy of individual men, butthey can never be a substitute for it."
The Changing Function of the Hospital
Tracing the changes in the work of the hospital,Dr. H. W. C. Vmrs, professor of pathology at CharingCross Hospital Medical chool,- deplored ’the trendwhich was making the hospital more of an administra-tive unit and less of a place where patients "were caredfor. The patient was being overlooked ; and there was
994
even a danger that standards of hospital care wouldbe determined by those who had never seen a patientand who would be no wiser if they did. Professor Vinesconfessed that he was bored with the massive anduninformative financial statements that came from thehospitals, for they gave very little indication of the
efficiency with which the patients were being cared for ;and they certainly did not take into account the potentialfinancial return achieved by the hospital service whenit restored its patients to work-a return which wasforgotten when urging economies in the service. Hecould see no very vivid future for the hospitals now thatthe inspired service of their earlier days had given placeto a mediocrity oppressed by bureaucracy.
Emphasising the need for a more preventive approach,Professor Vines said that a large burden of nationalsickness had long been accepted as inevitable, and thisburden was a measure of society’s failure to provide forhealthy living. There was still little professional interestin preventive medicine, and the bed remained the chiefoperational tool of the hospital service. On the adminis-trative side, too many administrators thought that thecare of inpatients was their only job, whereas in factthe outpatient department often afforded a much betterchance of preventing serious deterioration in health.But little money was spent on outpatient departments ;and present conditions encouraged the admission of
outpatients when a really efficient outpatient departmentmight have saved a hospital bed and the expense of
inpatient care. It was said that we needed about 75,000more hospital beds in this country : to build and pay forthese beds in the next fifty years was probably impossible ;to staff them was almost certainly impossible ; and itwas very doubtful whether we could afford to maintainthem even if we had them. Professor Vines was surethat successful development did not lie along the
unimaginative lines of building more and more beds.These missing beds must be written off, and the bedmust recede as a therapeutic weapon, while the out-
patient department came forward. We must reduce theno-man’s-land between health and disease by persuadingthe patient to seek earlier advice and by encouraginga more inquisitive outlook by the doctor. Moreambulant patients and more outpatient work should bethe aim. Along these lines, the polyclinic might becomethe centre of the hospital service. This would involve acomplete reorientation of medical thought, and the firststep was a drastic overhaul of outpatient clinics-notjust a bit of paint here and there, but replanning andrebuilding. Many " hole-and-corner" clinics would haveto go. No hospital should offer an outpatient servicewithout adequate radiological and pathological facilitiesimmediately to hand to save the time of both patientsand staff. Fluoroscopy rooms and pathological
" sub-
stations," which would relieve the main departments ofmuch routine work, could be usefully introduced into theplan. As the emphasis of the hospital service movedfrom beds to outpatient clinics, more of the bedded
hospitals might be situated in the outskirts of towns,leaving the unbedded clinics in the centre.
Opening the discussion, Mr. S. W. BARNES, secretaryto the board of governors of King’s College Hospital,said that no-one regretted the domination of administra-tion, to which Professor Vines had referred, more thanthe hospital administrators themselves. They did notlike the cold, impersonal, centralised machine, and
they were not responsible for it ; it was the outcome ofa central bureaucratic control which knew little ofactual conditions in hospitals. Commending ProfessorVines’s proposals for extending the outpatient service,Mr. Barnes said that all would be wishful thinking unlessthe control of policy and finance by the Governmentcould be reconciled with independence and variation inindividual hospitals. Mr. W. A. JAMES (Leamington)wondered whether advances in treatment might not
help matters by enabling a reduction to be made in thenumber of beds for acute cases. But Professor Vineswas not sure that such a reduction would be an advantage,for the chronic sick of tomorrow were the treatable sickof today. Mr. F. A. WEAVER (Windsor) suggestedthat the medical staff of the hospital service were
terrified of making a diagnosis because of the threat oflitigation. They tended to " pass the buck " in a waywhich complicated the working of the service. Mr. S. G.HiLL (Northampton) would have liked Professor Vines’scriticisms to have been heard by the Ministry of Health,the local health authorities, and the doctors ; for pre-ventive medicine was not the business of the hospitaladministrators, or even of the hospitals, and the pre.occupation with inpatient beds was the - result of theMinistry’s attitude.
JOINT CONSULTANTS’ COMMITTEETins committee met in London on April 29, under the
chairmanship of Sir Russell Brain, P.R.C.P. ,
B- The committee again discussed the senior-registrar
establishment, with particular reference to displacement.Figures furnished by the Ministry of Health showed thatthe number of senior registrars did not now greatly" exceed the establishment agreed with the committee
in 1951. The number of senior registrars in their fourtht or subsequent years, however, whose appointments werefdue to be terminated in the course of the next few months,
substantially exceeded the expected consultant vacancies,.
and furthermore a large proportion of these senior. registrars were in general medicine and surgery, in which’
specialties there were few new consultant appointments.’
Representatives of the committee had impressedupon the Ministry that many of these senior registrars
,
were in fact undertaking consultant work, and that if’
they were dismissed a serious situation would arise.They had again urged that the ultimate solution layin the expansion of the consultant establishment, andthey had made certain suggestions regarding immediatemeasures which the Ministry had received sympathe-tically. It is hoped that a further statement on thesubject will be available for publication shortly.The committee also considered a report from a sub-
committee on discussions with representatives of themedical defence organisations on the increasing litigationinvolving members of hospital staffs.
Pending further discussions with the Ministry, the com-mittee expressed full agreement with a statement on the
subject which had been drafted by the Central Consultants’and Specialists’ Committee with a view to publication bythe council of the British Medical Association. The com-mittee’s attention was drawn to a statement on the furnishingof medical reports on hospital patients to solicitors, publishedin the Law Society’s Gazette after discussions between thecouncil of the Law Society and the Ministry. The committee
deprecated the issue of this statement without consultationwith the medical profession ; and the statement was referredto a subcommittee for detailed examination.
Dr. Peter Edwards, chairman of the tuberculosis anddiseases of the chest group committee of the BritishMedical Association, attended the meeting to discussmatters of interest to chest physicians.
Dr. Edwards said that in most other specialties hospitalboards often offered consultants an option of whole-timeor part-time service, where the needs of the service permitted,and the group committee felt that this principle should beapplied to chest physicians. The Chairman explained thatthis matter had already been discussed with the Ministry,but there appeared to be certain difficulties connected chieflywith the duties carried out by chest physicians on behalf oflocal health authorities. The matter was referred to a
subcommittee for further discussion with the Ministry.Dr. Edwards also expressed the views of his group com-
mittee on the shortage of nurses in sanatoria, and on the’participation of chest physicians in the work of pneumo-coniosis panels ; and these matters also were referred fordiscussion with the Ministry.
