A complex system and a wild problem
London medicine is an incredibly complex system that
few if any really understand. It presents a wild problem,
difficult to define, ever changing and just as a solution is apparently in
sight, the problem alters. Often the law of unintended
consequences seems to prevail.
Hospitals are part of the wider economy. With
the NHS spending some 8% of the gross national product, and health spending
is nearer 17% in the USA, the political view that a vibrant health service
depends on a vibrant economy must be correct. The health
service has over a million staff so that merely as an employer it is a
substantial component of the economy. In some localities it is
near dominant. At one time the number of doctors who were to
be trained in the UK was geared to the likely speed of economic growth, not
the need for their services. In the 19th century
an agricultural depression devastated voluntary hospital finances, and hard
times increased the strain on the workhouses. Our current
economic problems are at the root of many issues in the NHS. Kenneth
Clarke maintains that there are positive advantages in stringency, forcing
as it does reappraisal of how the system is managed.1 Not
everyone would see matters in this way.
The desire to mitigate the effect of social
inequality on health, a Sisyphean task if there ever was one, adds to the
complexity. From Charles Booth to Brian Jarman and Sir Michael
Marmot, managers have been reminded of its importance. Voluntary
hospitals, for example The London, attempted to shoulder this burden.
Awareness that social services play a key role in health care lay
behind the drive for coterminosity of health and social care in the 1974
reorganisation, and remains on today’s political agenda. The
Resource Allocation Working Party (1976)2 redistributed
money partly with this in mind, London losing money to the north, to the
shire counties and to long stay specialties previously grossly under
resourced.
Clinical care is ever changing. Old
killers, the fevers and tuberculosis, do not dominate health services as
they once did. New methods of diagnosis and imaging have
changed the shape of hospitals, altering the balance of inpatient and
ambulatory care, modifying the functional content of hospitals and leading
to an increase in the number of patients. Fifty years ago Sir
Max Rosenheim at UCH joked that a health person was someone who had been
inadequately investigated. Joint replacement, transplantation,
minimally invasive surgery and better anaesthesia have changed the business
of the hospitals. Genetic medicine doubtless will do so in the
future, and most advances modify the site of health care delivery between
the community and the hospital in one direction or another.
Research is the life blood of a developing service. A
hundred years ago in his rather arcane style, Sir William Osler talked about
what was essentially translational medicine when he said that ‘the hospital
[specialist] units mint, for current use in the community, the gold wrought
by the miners of science. This is their first function.’
Today we have the academic health science centres that ‘make the
most of the synergies between research, education and health services to
translate research into better care and increase the speed at which research
is taken from bench to bedside and back again’.
Additionally there has always been an international
angle, from the time that Florence Nightingale studied continental hospitals
and nursing systems, to today’s clinical trials. No country’s
hospital system stands alone. Its staff and their skills move
between countries.
The modification of health systems
Changes in systems are seldom radical and are usually
firmly based on what has previously existed. They are
evolutionary, not revolutionary. Whether one looks at Bevan or
Obama, the systems they have influenced are founded on what went before. The
appointed day, 5th July, brought not one extra
doctor or nurse. The unfolding story in the book is this
evolutionary change, although it is true that a major upheaval such as the
1939-1945 war makes a new and radical departure easier. ‘Never
waste a good crisis’ has become a management doctrine. Some
saw in the Darzi proposals of 2006-20083 an attempt
to tear up the hospital service and primary care and start again. ‘Brilliant
in conception, clinical in slant, but a recipe for turbulence,’ said the
Guardian; it was a blueprint for radically different NHS. In
the event that did not happen, although some useful change did.
Centralisation and devolution
For two hundred years there has been a continual
strain between centralisation and devolution. Governance and management have
always been contentious issues. Initially decentralisation
dominated. Hospitals were managed either by ad hoc
bodies, established specially for that purpose such as the committees of the
voluntary hospitals, or by elected authorities and their committees. The
result was confusion, gaps, overlaps and chaos.
When
the pressure for centralisation came, for example with the need for poor law
hospital reform and a system of fever hospitals, or for removing London
hospitals to the places where the poor had come to live, the trouble
started. The argument for devolution partly rests upon
the need for hospitals to be sensitive to local opinion and local needs.
The centralist argument was expressed by the Royal Commission on
smallpox hospitals, commenting on the Metropolitan Asylums Board in 1882.4
‘It will bring to a focus, and will be able to give
instant and extended effect, to all the experience which will otherwise be
scattered with various results, among a variety of bodies not always
actuated by broad or accurate views. It will also be able to make the
different parts of a large system work into each other, not only for the
advancement of practical efficiency, but also for the careful observation,
collection and publication of facts systematically observed over the large
field which their operations cover. Finally, it will probably be able, from
its dignity and importance, to command a higher class of administrators. The
Board, if it is one, will be the picked men of the metropolis, instead of
the picked men of a parish.’
An uneven and incoherent hospital service had
developed in London. The voluntaries could not raise enough money, either
individually or jointly, to expand to meet the increasing demand for
hospital care as medical science developed. So the rate-supported hospitals
moved into acute care, compounding the problem of competitive and
overlapping services.
The confusion led to repeated calls for economy and
efficiency, for cooperation and rationalisation by the Select Committee of
the House of Lords (1892), 5 the
King’s Fund (1897), the Cave Committee (1920), by Neville Chamberlain as
Minister of Health, the Sankey Commission (1937) 6,
and the Nuffield Provincial Hospitals Trust (1941). Unfortunately, because
of the multitude of authorities with different perspectives, agreement on
issues of a fundamental character could seldom be reached.
The NHS ultimately provided a broader framework for
planning, but it too chose to function with many independent authorities,
each separately accountable to the Minister. Planning within a single
organisation is always simpler than coordinating the planning of separate
bodies. The creation of ‘joint planning’ and ‘liaison’ committees is
frequently a sign of a basic organisational fault. Progressive
reorganisations sometimes tried to mould the London authorities into a
pattern which would make major change possible. The establishment of a
single region for London (2002) had this aim.
Ara Darzi (2008) believed that one should centralise
when essential, for example to improve outcomes, and decentralise where
possible to improve access.3 Whatever the
advantages and disadvantages are for centralisation in clinical and
management terms, the situation differs in research and development. From
the special hospitals or the 19th century, through
the postgraduate teaching hospitals in the 20th to
our new Academic Health Science Centres networks, the need for local
autonomy is clear. London’s three AHSCs will almost certainly
develop an accent on different medical problems, playing to the strengths of
their staff. They have to if they are to fulfil their
function.
Merger and Reconfiguration
Hospital buildings have a limited life span. The
services needed change. Reconfiguration is continually needed. In
1946 the local hospital management committees began the process of reshaping
the local hospital provision, a process that has continued ever since. Amalgamation
as a method of rationalisation had always been favoured. It is less drastic
than closure and therefore more acceptable. It preserves valuable strengths
and traditions and a role can be found for supporters in the new
organisation. It is argued with little evidence that larger units may be
more economical to run, and more convincingly that they will provide a
better basis for medical education and research. Finally the merger can be
combined, if desirable, with a judicious reduction in bed numbers. The
efforts of the King’s Fund to achieve amalgamation of small hospitals have
been followed ever since by mergers, a process continuing fuelled by budget
cuts, the migration of population, the falling duration of inpatient stay
and the need to create larger units to ensure clinical effectiveness. Sadly
while in the business world a merger almost always has a clear objective,
obtaining a brand name, reducing over capacity or developing a new line,
recently in the NHS this has not always been the case. Merger
has sometimes been seen, in the face of the evidence of failed past mergers,
as the way to resolve a managerial problem. However as the
Americans say, however, three turkeys do not make a hawk as has recently
been evident in south London (2013).
Management styles
Whether it was the King’s Fund, the LCC, Lord
Dawson’s Interim report in 1920 9 or in
the NHS, the wish to provide an equitable service at a reasonable cost has
always been there. The King’s Fund relied on friendly
persuasion, the LCC on a clear management hierarchy, and at times it is hard
to see the principle behind NHS management. The clash of the
populist, the political, the professional and managerial is only too
evident. It is an axiom that in a wild problem those whose
duty it is to find a solution are frequently themselves part of the problem. This
shows no sign of ceasing to be the case. It is hardly surprising that
initiatives such as the London Health Planning Consortium, Tomlinson,7 Turnburg 8 and
Darzi 3 seldom achieve more than 20% of
their potential.
Lead time to change
As a result, the time taken to achieve necessary
changes is protracted. Sometimes it seems as if there is a
thirty year rule that from the perception that an advance necessary to its
implementation is that length of time. Whether it is the
relocation of hospitals, the merger of medical schools or the development of
clinical networks coordinating services across hospitals rather than purely
within them, this delay seems only too common. To make it even
worse, time after time, a group has become knowledgeable, expert and
effective but before the full results of their efforts are harvested, the
group has been dismantled, as after the London Health Planning Consortium,
Tomlinson and Turnberg. A central hospital board for London
was suggested 150 years ago. Only recently did we achieve one
in NHS London and it too has gone. If there is any lesson to
be drawn from the history of London’s hospital and health system it is that
nobody gains in the long run from the absence of a central focus for
London’s health problems that operates openly and transparently.
There remain great strengths in London hospital
medicine, which by any standard should be preserved as foundations for the
future. Working in London’s hospitals, and managing them, has never been
easy, nor will it be in the future. It is a memorable
experience.
References
1 Clarke
K. In The Wisdom of the Crowd. 65
views of the NHS at 65. (Ed. Nick Timmins) London. Nuffield Trust, 2013.
2 Department
of Health and Social Security. Sharing resources for health in England.
Report of the Resource Allocation Working Party. London: HMSO, 1976.
3 Darzi
A. A framework for action. Healthcare for
London, 2007. and A local hospital model for London. Healthcare
for London. 2008.
4 Hospitals
Commission on the smallpox and fever hospitals of London. London, HMSO, 1882
5 First
and second reports from the select committee of the House of Lords. London,
Hansard and Son 1890, HMSO 1891.
6 Report
of the Voluntary Hospitals Commission. (Sankey Report). London, British
Hospitals Association, 1937
7 Department
of Health. Report of the inquiry into London's health service, medical
education and research. (Chairman: Sir Bernard Tomlinson.) London: HMSO,
1992
8 Health
Services in London – a Strategic Review. (The Turnberg
review). London. Department of Health. 1997.
9 Ministry
of Health, Consultative Council on Medical and Allied Services, Interim
Report. (Chairman Lord Dawson) London HMSO 1920 Cmd 693
