SIXTY YEARS OF THE NATIONAL HEALTH SERVICE Supplement editor Emma Dent RICHARD VIZE Art editor Judy Skidmore Production editor Jane Walsh EDITOR Sub editors Jessica Moss, Amit Srivastava Picture editor Frances Topp Six decades that have transformed the NHS HSJ is delighted to bring you this celebration ‘Managers have of the extraordinary journey the NHS and its metamorphosed from clerks staff have taken since the service was launched six decades ago on 5 July, 1948. into strategic leaders; It charts the currents that have shaped the clinicians have moved from modern NHS, from management, politics, hierarchies into teams and clinical practice, campaigns and public expectations to architecture, the media and the focus on healing is giving popular culture. ground to prevention’ Reminiscences of those who were in post on the first day vie for your attention with stories from three managers who were born in those first hours, and frank recollections from former secretaries of state. We discuss five days that shook the NHS, and see what the service has to learn from the only two institutions on earth with more staff: Indian Railways and the People’s Liberation Army of China. We also reveal the 60 people identified by our panel of judges who have had the greatest influence on the NHS. The stories and analysis reveal a service that has been transformed. Managers have metamorphosed from clerks into strategic leaders; clinicians have moved from rigid hierarchies into multidisciplinary teams; mental health has moved from the asylum to the community; the focus on healing the sick In partnership with is giving ground to prevention. The area that has changed least is the power accorded to the patient. But progress is finally being made; perhaps by the time the NHS marks its 75th anniversary it will be able to celebrate the arrival of a truly patient-centred health service. I am delighted to thank our partners in these NHS 60th celebrations – BT, Tribal, Lloydspharmacy, Humana and Airwave – for their support, which has made this publication possible. We hope you agree it is a fitting tribute to 60 extraordinary years.

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2 0 0 8 LIFEL IN 1948 left). priority (below became a child welfare Reserve, and Hospital Service the National nurses to join poster urged ex- An advertising causes of death. most common cancer were the disease and right), and heart rickets (below affected by children were women. Many and 70.3 for was 65.9 for men Life expectancy 50.065 million. population was In 1948 the UK during the war. houses were destroyed in bombing raids prefabricated homes after one million but thousands of families were living in T h e

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1 9 4 8 While a male teacher could expect to earn £615 a year, a male manufacturing worker aged over 21 earned on average the equivalent of £6.86 a week; for a female manufacturing worker aged over 18, the figure was just £3.70p a week on average. The Attlee government nationalised the coal industry in 1948 (below left) and the first babies to be born in the NHS arrived that year. On 22 June, the Empire Windrush docked at Tilbury with 492 immigrants from Jamaica, of whom 192 made the voyage on the decks as the cabins were full.

BBreadread rrationing,ationing, LIFELIFE IINN which11948 had begun in 948 1946, came to an end in July 1948. Jam was no longer rationed from December. Clothes had been de-rationed from March. A pint of milk cost the equivalent of 2p, a dozen eggs 9p, a pint of beer 7p, a litre of petrol 3p and a The “new look”, cinema ticket 7.5p. introduced by Paris fashion house Dior the previous year, was in vogue in 1948 (left) and the Olympic flame arrived at Wembley for the 14th modern Olympiad (above).

hsj.co.uk 3 July 2008 HSJ NHS60 anniversary ssupplementupplement 3 FIVE DAYS THAT SHOOK THE NHS community. “The trouble was, The NHS has weathered countless scandals, speeches, policy nobody had asked the community if launches and inquiries. Peter Davies and Daloni Carlisle they did care,” he says. “They didn’t give a damn.” discuss five landmark events and talk to those involved History shows the angels won the battle. “Hospitals began to close incredibly rapidly,” says Dr Rollin, 1961: ENOCH POWELL’S them, with services to be replaced psychiatrist at Horton Hospital in who retired from the NHS in 1975. WATER TOWER SPEECH by care in the community. What Surrey, was among them. “I sided By 1969, 24,000 beds had gone. In March 1961 then health minister psychiatric beds there were would not with the angels,” he says of his “The situation when I retired was Enoch Powell made what became be relocated in general hospitals. decision to fight the bed closures. heartbreaking. All the work we had known as his “water tower” speech The move to close old psychiatric He did not recognise the picture done was destroyed. The to the annual conference of the institutions was already underway, Mr Powell painted of the horrors of community services were not there National Association for Mental he told his audience. “There is not a the institutions, described in the and the patients have simply ended Health, later known as Mind. Mr person present whose ambition is 1962 Hospital Plan as “majestic, up in prison. It is very, very sad.” Powell, of course, is now better not to speed up those present brooding structures, dominated by Dr Rollin’s view is not popular remembered for a rather different trends. So if we are to have the the twin ideas of isolation and today. “Of course closing the speech. But his description of courage of our ambitions, we ought custodialism, housed in depressing institutions was the right thing to asylums as “isolated, majestic, to pitch the estimate lower still, as and decaying buildings, suffering do,” says chief executive of the imperious, brooded over by the low as we dare, perhaps lower.” from acute staff shortages”. Mental Health Foundation Andrew giant water tower and chimney How wrong he was. A gladiatorial Nor did he recognise the running McCulloch. “It was the clear result combined” heralded a shift in battle ensued, fought largely in the down of status of the hospital; he of evidence-based medicine and mental health policy. pages of medical journals the BMJ saw bed numbers at Horton rising. evidence-based health policy.” Mr Powell envisaged the closure and The Lancet, as doctors slugged Dr Rollin was sceptical about He points out that Mr Powell’s of at least half of Britain’s out the rights and wrongs of the whether local authorities would be speech was preceded by the 1959 psychiatric beds, some 75,000 of policy. Dr Henry Rollin, then a capable of setting up facilities in the Mental Health Act, which he

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4-7 FIVE DAYS...-asAS/JW.indd 1 24/6/08 15:52:08 FIVE DAYS THAT SHOOK THE NHS 4-7 FIVE DAYS...-asAS/JW.indd 2 hsj.co.uk failures in social policy.” services get tarred with the brush of bigger picture. Mental health is because we have not grasped the in the community is not working, it out the whole system. approach to care but have not sorted have a complex, evidence-based health services. The trouble is, we are achieving world-class mental deinstitutionalisation. Some people that used to be in the asylums. have taken up part of the population yes, Mr McCulloch adds, the prisons been an unqualified success and expressing his own view.” My personal belief is [Powell] was deinstitutionalisation into policy. was key in that it made the legislation around the world”. legislation that put its mark on describes as “a benchmark piece of “If there is a perception that care “But that’s not a criticism of Care in the community has not “The water tower speech and chimney”’ giant water tower brooded over by the majestic, imperious, as “isolated, described asylums ‘Enoch Powell please the system’s critics. institutions. But the results did not committees” into several instigated “enquiries by special details to the health minister, who wide publicity Ms Robb passed on hospitals or patients, after receiving discussions about solutions. people in hospitals, along with undignified suffering of elderly passionate cry of distress at the Hospital in London. Her book was a Amy Gibbs at Friern Barnet involvement in the care of patient Institutions in 1965, following her for the Elderly in Government disquiet over the quality of care. stay institutions, it sparked major elderly, mentally ill people in long- answer published In 1967, campaigner Barbara Robb SANS EVERYTHING 1967: THE PUBLICATION OF Although the book did not name Barbara Robb had founded Aid . A critical look at the care of Sans Everything: a case to 3 July 2008 1967 a further scandal occurred story. Dr Denham says: “In rebuked the minister. the Council of Tribunals, which and complained to supervisory body they said. Ms Robb was indignant numbers of better trained nurses, care. The answer lay in greater often impressed by the quality of emotional.” misinterpretations or over- vague, lacking in substance, were considered inaccurate, unreliable evidence. The complaints were unfounded or were based on majority of allegations of cruelty “The committees considered the about hospital scandals, he says: in 1984 delivered a scholarly report work of Professor John Martin, who and its impact. Drawing on the Society, has written about the book president of the British Geriatric But that was not the end of the The committees were instead Dr Michael Denham, past HSJ NHS60 anniversary supplement 24/6/08 15:52:54 Ë 5 6

TOPFOTO, MARY EVANS 5Á at the Ely Hospital in Cardiff in carried out by teams of problem of abuse continues,” adds when supermarket chief Roy a unit for the mentally subnormal. A professionals: consultant Dr Denham. “As late as 2000, Griffiths’ long-awaited report on nursing assistant made allegations geriatricians or psychiatrists, senior episodes of abuse of older people in health service management was [in the News of the World] of cruelty nurses, paramedics, administrators hospital were still being recorded published. to patients and pilfering of their and later social workers. and pejorative terms like demented, The next day’s papers scarcely food and property. Geoffrey Howe “It is best considered as a form of crinklies or crumblies continue to reflected the report’s significance, QC chaired an inquiry in 1969, peer review,” says Dr Denham. “The be used. with coverage restricted to the which confirmed the allegations hospital visits lasted one to three “In 2007 the Healthcare inside pages. But that did not alter and reported that the whistle blower weeks and reports remained Commission still felt it necessary to the effect it had on health had been victimised.” confidential to the unit concerned, reiterate the need to improve professions. Griffiths’ When the Ely scandal broke, then although many years later reports dignity, nutrition, privacy and recommendation that general health secretary Richard Crossman were made public.” training in the care of older people. managers be appointed at every felt he had been caught on the hop Later the service was renamed It is enough to make one weep.” level of the service was to because he had no inspectorate to the Health Advisory Service when it reverberate far and wide. warn him of bad performance. took on a social/community 1983: THE GRIFFITHS “I don’t think you could have Dr Denham says it turned out component and is now the Health REPORT done the internal market without “that the Department of Health and and Social Care Advisory Service, On 25 October 1983, the day the US the Griffiths report and Social Services had known – but did run as an independent charity. invaded Grenada and a 41-year-old management reform. It was nothing. This led Crossman to Meanwhile debates in Parliament Neil Kinnock made his Commons absolutely crucial,” says Norman create the Hospital Advisory Service prompted by Sans Everything led to debut as leader of the opposition, (now Lord) Fowler, then health and in 1969, to act as his ‘eyes and ears’, the 1972 NHS Reorganisation Bill life changed in the NHS for rather social services secretary. but [it] would not investigate that set up the health ombudsman different reasons. Roy Griffiths, managing director individual complaints”. The service system. The foundations were laid for a of Sainsbury’s supermarket, had started work in 1970 and visits were “What is sad to report is that the decade of radical change in the NHS been appointed the previous year as ‘I felt quite resentful that this bloke from a supermarket had been brought in’

prime minister Margaret Thatcher’s adviser on health policy. Frustrated at perceived inefficiency, she instructed him to investigate “consensus management”, under which responsibility for decision making in NHS organisations was shared – or shunned – by senior officers from the main professions. “As a long-serving public servant, I felt quite resentful that this bloke from a supermarket had been brought in,” says Ken Jarrold, then district administrator of Gloucester health authority. “I was not alone in feeling that. But once people met him and saw what an able guy and experienced manager he was – and how deeply committed to the NHS – that feeling dissipated.” Originally from a mining family, Mr Griffiths tended to confound expectations. “He was a good man though he wasn’t everyone’s cup of tea. But he did a great service for the NHS and produced a very good, succinct report,” says Lord Fowler. In a dozen pages, couched as a letter of advice to the secretary of state, Griffiths diagnosed the problem and proposed the solution, famously remarking: “If Florence Nightingale were carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge.” Reaction ranged from the skittish to the downright hostile. Trade union COHSE dubbed it the “Sainsbury report”. The British Medical Association declared it a threat to clinical freedom, unless

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4-7 FIVE DAYS...-asAS/JW.indd 3 24/6/08 15:53:07 doctors only were eligible to be some of them were about finding general managers. The Royal out what had happened”. He also College of Nursing feared nurses saw a need for catharsis and for would lose influence on boards. those involved to understand what “I was doing meetings around had taken place. the country with 300 nurses turning Sir Ian designed the inquiry up,” says Ray Rowden, then the chamber himself with the help of an RCN’s national management officer architect. “I created a theatre in the in charge of campaigning against round. Centre stage was the general management. Ironically, Mr witness.” He chose soft furnishings Rowden later became a general and blinds to create a calm manager himself. “With hindsight atmosphere and installed television Griffiths was absolutely right and sets that showed not just who was remains right to this day,” he says. speaking but also which document they were speaking about – and 1991: LAUNCH OF THE there were 980,000 of these. INTERNAL MARKET The images were relayed to Would the government suffer a family rooms and locations in the pratfall on April Fool’s Day 1991, West Country for families who when, as if with the flick of a switch, could not travel to London for 90 the NHS became an internal days of hearings. market? In the two years since the When the inquiry started there initial proposal to divide the service were two factions among the into “purchasers” and “providers”, parents. By the time the report was preparation had proceeded apace published, they approached Sir Ian but without proper trials, although jointly, asking him to lay a wreath at a simulation exercise had predicted the hospital in memory of the rapid collapse into chaos. children who had died. “I said it Nervousness in Downing Street would not be appropriate but I was had set in months before. “You delighted,” he recalls. could see why [then prime minister] The report made 196 Margaret Thatcher was concerned,” recommendations and was, says Sir says Peter Griffiths, then NHS deputy chief executive. “It was so ‘The central thesis sketchy. How it would work in practice was very much left to senior was that care should NHS managers.” But managers were excited. “For be centred on the first time in people’s living memory – probably since 1948 – patients and not there was a reorganisation not on those looking planned by civil servants in Whitehall,” says Mr Griffiths. But in flagship trust for the reforms. systemic failures that led to the after them’ the Department of Health those Discovering its finances had gone death and disablement of children same civil servants “sat on their awry he announced a staff freeze, who underwent heart surgery at the Ian, “a blueprint for modern 21st hands and waited for disaster to translated in the press as 600 infirmary over 10 years. Reporting century healthcare based on the happen”, he adds. redundancies. in 2001, it changed everything. lessons of what had happened”. The reforms had been “This was... just before local Sir Ian recalls the mindset at the “We were commenting on the masterminded by then health elections. The Conservatives did time. Doctors were disenfranchised whole way in which you perceived secretary Kenneth Clarke. Health very badly and one reason was the after the Thatcher years of penny or delivered healthcare. It came as a workers suspected they were a Guy’s announcement – proof pinching, he says. surprise to everybody except preliminary step to privatisation. positive of what would happen if The General Medical Council’s government,” he says. “With hindsight I’d concede it you let the Tories privatise the NHS. treatment of doctors involved in the The government immediately would be perfectly sensible to pilot a And I’d been a proponent of the scandal was viewed as picking on accepted all but eight of the major change to any system of this smooth take-off message for the profession. Managers, recommendations and since 2001 kind but the politics were just months.” meanwhile, just wanted to be these have been slowly against it,” says Mr Clarke. “I ran a In the event Guy’s (albeit merged allowed to get on and meet their implemented. Some – such as the kind of debating society with my with its neighbour St Thomas’) and new targets. Healthcare Commission and the little team, arguing it through and the internal market survived. “There was before Alan Milburn emphasis on safety – are now part refining it. I was always prepared to “Those reforms are still a huge and after Alan Milburn,” says Sir of the fabric of the NHS. Others are listen to why a particular part influence. Their principles changed Ian, referring to the then secretary still in the pipeline, for example wouldn’t work, but 99 per cent of the NHS for ever.” of state for health. “Before, there revalidation of doctors and the the argument was politics, vested was a kind of sense in which debate over recognised interest and fear of change.” 2001: THE BRISTOL politicians do not get involved in the qualifications for managers. By April 1991 Mrs Thatcher had INQUIRY REPORT details of quality or safety and left it Sir Ian says it is hard to left office and Mr Clarke was no The Bristol inquiry – Learning from to professional management.” disentangle his legacy from that of longer health secretary. But anxiety Bristol: the report of the public The Bristol inquiry changed all other changes in the NHS and that some managers might take inquiry into children’s heart surgery that. Mr Milburn introduced the society as a whole. And there is still competition too far too quickly had at the Bristol Royal Infirmary 1984- 2000 NHS Plan, which sowed seeds some way to go. “The central thesis prompted the NHS management 1995, to give its proper title – is one for the debate on quality and safety of the report was that care should be executive to order a smooth take-off of the most influential reports in that the report would spark. centred on patients and not on and soft landing for the policy. NHS history. Coming after inquests into the those looking after them,” he says. Two months earlier Mr Griffiths Chaired by Sir Ian Kennedy, now deaths of children and the GMC “We are still trying to work out how had become chief executive of chair of the Healthcare striking off the doctors involved, Sir best to listen to and engage with London’s Guy’s Hospital, seen as a Commission, it looked into the Ian had several objectives “and only and involve patients.” ●

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n 1948 the most senior Daloni Carlisle charts The restructuring in 1974 created managers in the National four layers of management: Health Service were men who 60 years of the hospitals, districts, areas and Iwore suits and ties and had regions. The advent of district large offices with big desks. developing role of management teams in that year In 2008, the most senior finally saw the title of secretary managers in the NHS are still the NHS manager dropped in favour of administrator mostly men in suits in large offices – a much more suitable title in Mr with big desks. But beyond that Eric Smith, who joined the Smith’s view. superficial similarity, the two are National Administrative Training “At that time, of course, the worlds apart. The roles performed Scheme in its first intake in 1956, district administrator became the by managers today have evolved recalls where power lay in the chief executive of the district health dramatically from those seen 60 early days. authority, with a much wider range years ago. “At the outset of the NHS in of health services, including child The language used to describe 1948, two hospital management and public health,” he says. them is just one way of tracking systems existed as a legacy of the The area health authorities were such changes. In 1948 the top dogs past: those hospitals run by local supposed to be aligned with local were called hospital secretaries; authorities and those run as government and therefore to today they are chief executives voluntary hospitals,” he says. generate what would now be called and directors. Although they were quite “joined-up thinking”. In 1948 the lower ranks were different and had distinct roles, in In practice, something quite clerks and their roles could 1948 the two had to come together different played out. “What include tasks as mundane as to adopt a single approach under happened was that people fought weighing out slabs of Genoa one management structure: the over territory,” explains Mr Jarrold. cake for patients. Today there is hospital management committee. “There was crowding and a welter of titles and jobs to go “They were welcomed by some confusion and it was very rapidly with lower-ranking managers, with great anticipation and loathed realised that the wrong thing had from communications to human by others with some foreboding,” been done.” resources to commissioner. says Mr Smith. Although there was a “grey book” The job of a junior manager in Group secretaries were at the top available with a very clear diagram those early days was very mundane, of the ladder, with hospital of accountability, in practice people says Anthony Dalton, who joined secretaries on the next rung. Their were not clear about where their the NHS in 1955 as a junior clerk. roles were wide-ranging, with a accountability lay because there “The work was about as boring general responsibility for the were too many layers, he adds. as it could be,” he affirms. “It welfare and running of their Jan Filochowski, who joined the was supposed to be a training hospitals. “They were very much NHS in 1978 and has worked in programme where you spent six a partner with nursing and medical numerous senior NHS management ‘Management was months working with the chief and colleagues,” adds Mr Smith. jobs, most recently as chief then six months in the office, executive of West Hertfordshire welcomed by some manually recording all the patient Secretaries no longer Hospitals trust, also remembers with great admissions and discharges and Then, for two-and-a-half decades, those days. There was almost no deaths and cremations. It was NHS structures stayed remarkably national interference in hospitals anticipation basically cheap labour. As a graduate unchanged. “It is something today’s and power was concentrated in the who had been to Cambridge managers will find hard to believe, regions. and loathed by University, it was a hell of a shock.” but there was no national “Richard Crossman [Labour But if the lowly tasks were reorganisation from 1948 until health secretary from 1968 to others with some boring and mundane, the chaps 1974,” says Ken Jarrold, who joined 1970] referred to regional health foreboding’ in the top jobs wielded significant the NHS in 1969, going on to be a authorities as ‘semi-autonomous

power and influence. senior manager. governors in the Persian Empire Ë10 ALAMY

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8-11 role of managers-jm-jw-JWas.indd 2 24/6/08 12:49:43 9Á – they do what they damn well authorities were abolished and in course it didn’t mean you could do like’,” he recalls. Power moved away 1983 leading businessman Sir Roy ‘I remember one of as you liked. from hospitals. “The people Griffiths reported his findings, “As chief executive, you could not managing hospitals were quite low leading to the introduction of the medical journals do anything that would not be grade and all the important jobs general management in 1984. carried in the organisation and were sector administrators in the Mr Smith recalls: “It wasn’t until saying that as the chief executive you had to districts and areas. The further away Griffiths that management giving power to have antennae to know what from the hospital you were, the responsibility was focused more at would work.” more important you were,” says Mr hospital level, when so-called administrators was Nor was it a popular move Filochowski. administrators were designated among medics. Mr Dalton recalls: At the time, consensus or team managers; and, with the demise of like giving whisky “I remember one of the medical management was in vogue, with district management teams, senior journals saying that giving power to the notion that every staff group managers of hospital units were to red Indians’ administrators was like giving should have a say in running the properly given a wider range of whisky to red Indians.” NHS, not just doctors. Mr Dalton authority.” The other notion that gained remembers it well. currency at this time was that “It became very discredited,” The Griffiths revolution somehow managers from outside he says. “When you have a team For Karen Lynas, director of the NHS could do a better job. They with difficult people, it can be leadership at the King’s Fund, were duly wheeled in from the army tremendously hard to get Griffiths was the trigger for radical and industry, but generally did not agreement. And if you don’t get changes that saw managers become last long. Mr Dalton explains why. agreement, there is no team decision.” involved in strategic and system “The big challenge of the health Mike Brown, another retired management. He shook up a health service – and one that does not NHS manager, who is now director service that had been in the grip of change – is how to manage of the NHS Retirement Fellowship, consensus management – a service, doctors. also remembers this era. he famously found, where there was “That’s what makes NHS “There were lots of meetings,” he no one in charge. management different from says. “Often you got the lowest Griffiths recommended the NHS education or retail management. common denominator decisions should do away with some layers of At the heart of it is a relationship made just so that you were not administration and reform the between a doctor and a patient.” offending anybody on the team.” remaining staff into managers at Mr Dalton and an entire cadre of But the NHS does not exist in a hospital level. NHS managers who had come up vacuum and this was “I think this is where everyone through the National Management the 1970s. The country was in will draw the line,” says Ms Lynas. Training Scheme were well schooled financial crisis, with the Labour “From this point forward, there was in this and had learnt how to government taking a loan from the much more management and marshal arguments, negotiate and International Monetary Fund and leadership – although that was not persuade, use peer pressure and the conditions that went with it: a word used at the time. That’s frankly, how to sit it out, knowing workers took to the streets during where managers became that change takes time in the NHS. the 1978-79 “winter of discontent”. professional and autonomous.” Outsiders were not savvy on this “This was a defining moment for The introduction in 1984 of and in one senior manager’s words: public services,” recalls Mr Jarrold. general management wrought “The consultants just ganged up on “It was the moment when financial momentous changes, so Mr them and forced them out.” restrictions and accountability Filochowski also sees Griffiths as a In the early 1990s the became a reality for the first time.” turning point. Conservative health secretary When in 1979 Margaret “The big step for Griffiths was the Kenneth Clarke began to hold the Thatcher’s Conservative government introduction of managerial NHS to account not just for came to power, “the Tories said it accountability: the ability to identify spending but also for the service’s was much more important what a manager who could be called to horrendous waiting lists. This was goes on near the patient,” says Mr account.” done through the mechanism of the Filochowski. “Their view was that Mr Brown agrees. “Suddenly the internal market. we needed strong and powerful chief executive carried the can and Mr Jarrold says: “[Clarke] created managers managing what goes on you could override the consensus the hospital trusts, which in turn in our hospitals and wider facilities.” management. created clear accountability on the In 1982 the area health “That was good, although of provider side. The national agenda

1948-2008: MAJOR MOVES AND CHANGES 1948-1960 Scheme, later to become introduces the all public service is too A small band of the National Management area health services to complicated and administrators support Training Scheme. authority to sit focus on consensus management doctors in delivering between the finances and for too slow. care and treatments. 1960s districts and the first time Power is vested in the The 1967 Salmon report regions and new tiers of management gains 1980s hospital medical board, on senior nursing management take power some control in this area Sir Roy Griffiths, a senior with the most senior structures brings senior outside the hospital. but little influence over manager with manager, the hospital nurses more overtly into Consensus management clinical matters. In 1979 Sainsbury’s, secretary, running the management. is the flavour of the prime minister Margaret examines hospital management decade, allowing all Thatcher receives the NHS board. In 1956, the NHS 1970s groups of staff a say in report of a Royal management launches the National The 1974 NHS how the NHS will be run. Commission on the NHS, and finds Administrative Training reorganisation Financial crises force which concludes that the that “no one is

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8-11 role of managers-jm-jw-JWas.indd 3 24/6/08 12:49:54 8-11 role ofmanagers-jm-jw-JWas.indd 4 hsj.co.uk introduced in 1984, management is leadership. General greater emphasis on team structures and making, more flexible planning and decision accountability for authority and to encourage clear management should introduce general recommends the NHS in charge”. In 1983 he trust, says: “You had to carry your chief executive of a large Manchester director among its executives. medical director and a nursing doctor, with each trust having a triumvirate of manager, nurse and They also reintroduced the old from a wide range of backgrounds. board, with non-executives drawn the provider to account.” was for the purchasing side to hold Mr Brown, who at the time was Trusts reintroduced the hospital see managers beginning first waiting list targets market principles. The is managed according to market, in which the NHS creates the internal Working for Patients for Working 1990s of them do not last long. the private sector; most non-NHS managers from along with a cadre of The 1989 white paper,

communicating across the service. found away from their desks and Daily dialogue: managers can now be and he threw the report down, was then district general manager] in my office in Carlisle [where he from one of the consultant surgeons early 1990s. “I sat across the desk endorsing day surgery in the Surgeons, produced a report who then led the Royal College of day surgery. Sir Brendan Devlin, them to meet central targets. through changes that would allow matters as they tried to push accused of interfering with clinical suddenly found themselves being good answers.” your board and come up with some complex issue, kick it around with for that. It was good too to take a for a single person to be accountable taxpayers’ money and it was not fair you were spending large amounts of I think it was a good thing because individuals from different fields. knowledgeable and competent board with you and these were Mr Dalton recalls the debate on However, targets meant managers , p c 1 t c t power on comes to 1997 New Labour territory. In clinical to impinge on e o o l 9 o i r

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over NHS fat cats. rise and with it public resentment trusts, chief executives saw their pay caught in the middle. In acute out from cleaners – with managers wages from nurses and contracting unrest, with protests about low was a good thing. introducing urology as a specialism consultant workforce that persuade his resolutely generalist specialism in medicine and had to national programme for greater responsible for seeing through a says Mr Dalton. saying it was second-class surgery,” Institute of Health Management. by the NHS Confederation and the celebratory event – a joint conference Tony Blair attended the main of the NHS, the then prime minister the NHS. On the 50th anniversary market and to put more money into pledge to get rid of the internal in the general election, partly on a again. New Labour won a landslide Then, in 1997, everything changed Blair’s targets culture It was also a time of industrial As a manager, he was also i a in the NHS and a promise to invest n

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Performance delivering these. accountable for managers become targets, and out a wide range of The NHS Plan sets 2000s poured into the NHS. priorities. Investment is is distorting clinical with claims management targets begin to bite, 3 July 2008 areas for managers’ cannot be any no-go basically said there was a revolution. It ‘The Bristol inquiry counterpart in 2008. suit in 1948 would not recognise his NHS, it is fair to say the man in the On the 60th anniversary of the develop. But that is for another day. role in primary care trusts will roles and how the commissioner’s trusts will lead NHS management speculation over where foundation history into current affairs and their tenure, not accountable. somehow, despite the insecurity of the notion that managers were conduct was introduced to counter deemed to be failing. A new code of penalised if their organisation was for fiddling the figures. They were to meet targets. They were sacked could no longer say ’.”‘hands off managers, and doctors realised they there cannot be any no-go areas for Filochowski. “It basically said that governance. change in terms of clinical 1984 and 1995 saw the whole arena the Bristol Royal Infirmary between complex cardiac surgical services at the care of children receiving the inquiry into the management of of reforms. in 1999, introduced a tranche Milburn, appointed health secretary management but also star ratings. just personal performance says Mr Jarrold. With this came not and performance management,” through a huge edifice of targets his ability to reform public services It is at this point that we tip from Managers were sacked for failing “It was a revolution,” says Mr Then in 2001 the report of After a few false starts, Alan “Blair had this Messianic belief in HSJ NHS60 anniversary manager relationships. the landscape for doctor/ 2001 radically changes Bristol inquiry report in accountability. The management adds to ● supplement 24/6/08 12:49:59 11

PHOTOFUSION, REPORT DIGITAL, GETTY, TOPFOTO, PA ICING ON THE CAKE

12-14 birthday-jmas/JW.indd 1 23/6/08 19:11:50 12-14 birthday-jmas/JW.indd 2 At one point they occupied the filing and ward management staff. meant overseeing 300 reception, patient services officer. The role officer in outpatients and then 1978, becoming medical records Brown joined Addenbrooke’s in days to sort out.” There were thousands and it took out which x-ray belonged to who. take over an empty ward to work in through the window. I had to not open the door and had to climb up. There was such a mess, I could cards and all the records got mixed library went down like a deck of Balham. officer at St James’ Hospital in became an assistant medical records qualifying in medical records, she becoming supervisor. After Westminster Hospital, later took a job as receptionist at the old was only 20 and just needed a job.” still be in the NHS 40 years later. I I would never have thought I would that we would never allow now. But full of people committed for reasons The hospital was a big institution, learning how to deal with people. amazingly useful experience in hospital in Colchester. “That was an nursing auxiliary at a psychiatric to have a long career in the service. Brown did not intentionally set out born in Crawley under the NHS, Ms reorganisation of the health service. lengthy CV is a track record of the PCT. With 14 jobs in 40 years, her employer, South Cambridgeshire her when she was with her previous of service in the NHS, awarded to is a certificate marking her 35 years Cambridgeshire primary care trust In Jenny Brown’s office at JENNY BROWN F hsj.co.uk well-earned retirement later this month. Sue Hood, right, looks forward to her NHS baby and has worked in many roles. Jenny Brown, left, was Crawley’s first reflect on lives shaped by the NHS. local paper. Twenty years on, they being pictured on the front of the 1988, a day marked by the three celebrated their 40th birthday in Cambridge when they and the NHS Addenbrooke’s Hospital in careers in the service. service and went on to enjoy lengthy the world on the same day as the 2008, they do too. All three entered does the NHS turn 60 on 5 July, “There was strong union activity. Returning to East Anglia, Ms “Once the shelves in the x-ray Ms Brown moved to London and She first started work as a Although she was the first baby All three were also working at unforgettable events. Not only this year are especially and Sue Hood, their birthdays or Chris Pelloe, Jenny Brown about their long careersbirthday in the servicewith the NHS talkThree to managersEmma Dent who share their 60th were designing contracts but there healthcare purchasing manager. We internal market programme as a in and I moved into the East Anglia breast screening programme. of public health to implement a authority, working with the director manager at Cambridge health offered the role of screening services “a real eye opener” – before she was gained a diploma in management – Addenbrooke’s for 11 years and outpatient appointment booking.” and we were at the leading edge of impressed with the quality of staff porters’ bonus schemes. But I was expended on issues such as the I don’t know how much energy was needs and not those of the patients. was all so much more about staff children’s notes to be taken away. It allowed cancer patients and medical records library and only “Then the internal market came Ms Brown worked at Cambridgeshire primary care group yet another move, to South groups in 1999 saw Ms Brown make fundholders – my bread and butter.” performance management and with acute services. “It was working on authority as assistant director of Cambridge and Huntingdon health health economics, she joined time Ms Brown did a certificate in 15 months ago.” apply for my job again as recently as looking at her lengthy CV. “I had to change in the NHS,” she says wryly, Health Commission. the Cambridge and Huntingdon more senior role in purchasing at understanding the data.” me in good stead when it came to My medical records experience held was no written guidance or rules. The launch of primary care After four years, during which “You have to be able to adapt to Ms Brown then moved again to a 3 July 2008 by the King’s Fund which included on a management programme run management. As a result, she went Griffiths award for innovative admitted.” what was causing people to be worked with the local authority on to get the consultants on board. We doing. A lot of work had to be done did not really know what we were new clinical audit department. Chelmsford, Essex, managed its move to Broomfield Hospital in in general medicine and after a Ms Hood went on to be a manager transferred into clinical directorates. and all medical secretaries were took over from electric typewriters to walk half a mile to find someone.” all over the hospital; sometimes I had Addenbrooke’s. “They were scattered managing all medical secretaries at trousers,” she recalls. Women were not supposed to wear and always had to wear a smart suit. allowed to use first names at work was all fairly formal; we weren’t different from in the civil service. It authority. a secretary at the Cambridge health NHS in 1982 when she got a job as a civil servant before joining the on a local newspaper, Ms Hood was care,” she says. not have to pay for the hospital midnight and realising they would as the town hall clock chimed standing on the steps of the hospital the NHS. “They remembered had been born on the same day as Sue Hood’s parents never forgot she SUE HOOD hours now.” much harder and for much longer has speeded up – managers work she says. “The whole tempo of life myself – I need a work-life balance,” to continue local voluntary work. retirement, though, albeit with plans strides here.” things happen; we have made great Brown remains enthusiastic. planning since December 2006, Ms based commissioning business Cambridgeshire PCT was formed. change when PCTs merged and management, only to face more of service and capacity again, to become assistant director years later, Ms Brown changed jobs became primary care trusts three community services. When PCGs times” of her career in developing and some of the “most enjoyable In 1998 she won the “We had no office, no carpet and Shortly afterwards, computers Five years later Ms Hood was “Day-to-day life was not very After working as a junior reporter “It is time I had a bit of time to She is looking forward to “Cambridge is a place where Now deputy director of practice- HSJ NHS60 anniversary supplement HSJ Roy 23/6/08 19:11:56 13

MALCOLM WATSON a placement at a rural ambulance for Papworth service. ‘I took redundancy. Hospital for Ms Hood stayed in the audit heart and lung department until 2002, when she I had worked in the machines. They was made redundant. A move to a had never been on community health council proved NHS for 28 years. I contract before and I short-lived when they were loved my work and achieved a saving of abolished three months later. £47,000 plus VAT; Another move to a primary care I was gutted’ money that went back trust was also short, as it was into the health service.” subsumed into a larger one in the NHS Supplies saw a recent reorganisation. club, swimming pool, squash court wave of redundancies Ms Hood now works as a and cricket club. in 1996. Mr Pelloe temporary medical secretary, mainly When Mr Pelloe’s job in supplies was one of those who at Broomfield Hospital. She is due was moved to Cambridge’s took redundancy. “I had to retire this month and is looking Fulbourn Hospital in 1978 he was worked in the NHS for 28 forward to having more leisure. promoted to senior purchasing years. I loved my work and I “I have enjoyed nearly everything officer, a job he did until 1986, when was gutted.” I’ve done but especially when it has supplies was transferred to the Mr Pelloe started a really helped patients, particularly regional health authority. consultancy talking to some work with local GPs on living Mr Pelloe later became team equipment and supplies with the aftermath of a stroke. And leader, setting up a contracts companies about how the NHS once, a few days after I had started database, and then contracts works, but this came to an end working at the medical secretaries’ manager in medical and surgical as “the NHS kept changing”. He unit, where my office was on the supplies. When NHS Supplies was now works in the wine and spirits edge of a ward, I found two people formed in 1992, with all equipment department of his local Waitrose. in tears. I put my arm around them. shipped across the service from “The change of work did me I found out later they had just regional warehouses, Mr Pelloe was good. Getting more exercise and not turned off their son’s life support responsible for negotiating prices socialising with clients meant I lost machine. I was in the right place at for the Suffolk site. four stone in weight.” the right time and I think it helped “We had to renegotiate all the He misses former NHS that I wasn’t wearing a white coat.” prices every six months, on about colleagues and helping patients. 2,500 lines. It was enjoyable but But his greatest regret is having CHRIS PELLOE also high pressure as we were also to leave the NHS two years Chris Pelloe’s father also never doing specific contracts for short of being entitled to a forgot that his baby shared his birth individual hospital departments. full pension. Future date with the NHS. An administrative The most difficult thing I did was plans include oversight meant he was still charged being charged with saving travelling with his for the birth at the London Hospital, £500,000 one year and we achieved wife to see relatives although Mr Pelloe has brought his a saving of £750,000. But a real in the US and birth certificate along to his meeting highlight was procuring products Philippines. ● with HSJ to prove he was entitled to free care. He joined the NHS in 1967 because his mother decided he should. “You did what your parents told you to then,” he says. After he had spent nine months as a hospital porter at the Royal Berkshire Hospital in Reading, the family moved back to London and Mr Pelloe began work in the accounts department of Guy’s Hospital. This involved marking all payments in huge ledgers. “I didn’t think about working in the health service, it was just a job, although I did make a great friend while working there; we are still friends to this day.” His next move, initially to become a clerical officer, also at Guy’s, began a career in hospital supplies. Mr Pelloe’s subsequent position involved helping supply all capital equipment for the new Charing Cross Hospital in Fulham. When the site was opened by the Queen in 1973, he acted as a steward on the day. A move in 1975 to Cambridge was supposed to be temporary but he Chris Pelloe found his career in found he loved the city and working hospital supplies “enjoyable but at Addenbrooke’s, with its social also high pressure”.

14 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk

12-14 birthday-jmas/JW.indd 4 23/6/08 19:12:02 BT is dedicated to a future where information ALL ROADS technology works for healthcare on all fronts, says LEAD TO IT Lyn Whitfield s the NHS approached its really was a good way to pay for and “More of the population now while concentrating specialised 50th anniversary, it to organise care. One of the things expects access to the highest quality acute and tertiary services on fewer launched a major public Wanless concluded was that the and the safest care,” notes Mr White. sites. This will only work if people Aconsultation that led to the service should be spending much “Scandals from a decade or so ago – can move easily between different creation of the NHS plan, a 10-year more on IT, because IT spend is a the Bristol heart surgery inquiry in services and teams, wherever they blueprint for reform. reliable proxy for whether you are particular – really raised awareness are based. Yet since that plan emerged, the doing things in a manual, of the fact that not all hospitals are “The Darzi model challenges the health service has been the subject cumbersome or, in the case of the equal. Since then, we have seen the estate-based model of healthcare of at least two further inquiries: one NHS, potentially dangerous way. development of pathways of care for that we are all used to,” says Mr conducted for the Treasury by former Effectively, he concluded that you patients, new regulators and new Major. “It will only work if IT is NatWest chief executive Sir Derek cannot be doing things well if you emphasis on patient choice.” there to glue it together, to tell Wanless and, most recently, by are only spending about one per Such moves “bring us back to IT” people who you are and how they junior health minister Lord Darzi. cent of your budget on IT [as the because all depend on information need to treat you.” All have grappled with deep- NHS was doing in 2002].” – for policy makers to plan, for This kind of change is difficult. seated issues and all have concluded commissioners to buy care Clinical practice, in particular, will that more investment in better IT will New demands pathways, for frontline staff to need to change as policy and IT be key to addressing these points. BT London chief executive Paul operate them, for auditors to asks frontline staff to do things “The first New Labour White lists some other underlying monitor their effectiveness and differently. “A lot of this comes government arrived in office with pressures on the NHS from an ageing safety and, increasingly, for patients down to trust,” adds Mr Major. an election promise of bringing population and increasing prevalence themselves. “Many doctors still only trust radical NHS reform,” says client of conditions such as obesity. “There is a real need to get the themselves and those they work engagement director for BT’s At the same time, medical right information in the right with to do things [such as] take a London NHS Programme Brendan advances continue to be made and format to the right people at the case history. They need to start Major. “The first rational step was the NHS is facing new kinds of right time – starting with the working with the information in to review it – to find out whether it demands from its patients. fundamental fact that you’ve got front of them – to accept that the the right patient, who, increasingly, record is the case history.” may be dealt with remotely,” says He adds that the “prize” of this Mr White. change will not just be doing things The Wanless report helped to faster or even more safely, but also pave the way for the National doing them more efficiently. Programme for IT in the NHS. BT’s For example, by making effective involvement with the programme use of an electronic patient record, “a includes winning the contract to GP might be able to directly book a replace NHSNet with broadband patient into a hospital bed, and the network N3 and to create the NHS consultant’s ‘grand round’ could be data “spine” that will eventually replaced with a remotely delivered, hold the summary care record of clinically targeted and less intrusive every person in England. process. Or a GP might be able to Meanwhile, BT became the local prescribe electronically.” service provider for London, tasked with standardising administrative Force for change and clinical systems into NHS trusts Both Mr Major and Mr White feel (which will continue to hold their the future of IT in the NHS lies own, “detailed” care records) – and in making good use of technology getting them to interact with each that is on the verge of widespread other. BT adopted a “best of breed” adoption. strategy, using different suppliers “What chief executives are for GP, mental health and hospital interested in – or should be departmental systems. interested in – is not IT as such, but “We have successful deployments in how they can use it to change at many sites. The next step is to their organisations,” says Mr White. join things up and get that proper, “That means really investing in coherent record, with role-based the change process. Big corporations access for staff,” says Mr White. might [invest] three or four times The need for truly joined-up IT what they are spending on IT continues to grow. on deployment and change The Darzi report on London’s management – something not many health services recommended NHS organisations are doing.” creating new community service But Mr Major adds: “There are

16 HSJ NHS60 anniversarysupplement 3 July 2008 hsj.co.uk

16-17 bt/jm/JW/SJ/JW.indd 1 23/6/08 19:14:42 16-17 bt/jm/JW/SJ/JW.indd 2 drive even more interest in access going to do for me?’ And that will my bit, now what is the service going to start saying, ‘I have done Mr White. “The effects faced by the health service,” says population is one of the challenges service user. a more consumer-minded health NHS to try and do everything it services. People will not rely on the again supported by IT-enabled supported by computer models. diagnosis will be carried out, virtual consultations, for example.” that will be most interesting – coalescence of existing technologies here in London. But I think it is the New York to perform operations and how it will allow surgeons in he would be talking about robotics exciting IT. “If Lord Darzi was here, technologies will produce some care of themselves as I have?’” I pay for people who have not taken also lead people to say, ‘Why should although the danger is that it could to efficient and safe services, clients. “But we say, bring it on. and to get things working for them.” organisations to be early adopters chief executives who want their hsj.co.uk does now.” take more responsibility for to get people to government is successful in its drive are unpredictable, particularly if the HealthVault, which presage Health and Microsoft’s healthcare IT, such as Google arrival of consumer-centred are no longer in the game. delivering excellence may find they services and show they are cost and effectively provide their we can really add value.” paper and suicidal to apply is where management stuff can look dull on projects. Where programme BT has a history of handling big their health. “Dealing with a better informed “There will be more self-care, And he suggests that more self- Mr White adds that emerging This makes them demanding Both men are keenly aware of the Meanwhile, trusts that cannot “If they do, I think they are ●

existing technologies that will be most interesting – virtual consultations, for instance’ 3 July 2008 ‘It is the coalescence of HSJ NHS60 anniversary supplement 23/6/08 19:14:53 17

KELLY DYSON PATIENTS FIRST

18 HSJ NHS60 anniversary supplement 3 July 2008

18-19 patients/jm/JW/SJ3rd/JW.indd 1 24/6/08 09:26:00 18-19 patients/jm/JW/SJ3rd/JW.indd 2 more resonance than dropping Dropping a bedpan, it seemed, had minister’s table was the patient. represented around the health concluded that the only person not potential user of the service” and group representing the user or of the time found “no organised them succour”. this House of Commons to give who are reaching out their hands to of sick people all over the country, T the whispers and piteous appeals the declamations of partisans, but “what will reach our ears will not be He told the Commons he hoped obstreperous medical profession. margin, their voice drowned by the Bevan painted them in at the very patients were not in the picture. Nye real change may be at hand. remains largely unrealised. But a pathways and the shape of services to influence their consultations, care grown, the potential for patients truly the strength of the patient voice has has existed since at least 1979 and and lack of power. exclusion, frustrated communication categories of need remained outside but consolidation meant whole earnest. The service consolidated, control NHS expenditure began in was too much and the great effort to their patient lists with them. choice, their doctors did, bringing service. But they did not make the the population was signed up to the a patient. the service. “Need” had not been A study of pressure group politics At the founding of the NHS, While a rhetoric of “patients first” However, by 1951 public demand Within two months 93 per cent of defined at the foundation of the service and remained

but also of paternalism, satisfaction, loyalty and trust, NHS is one of tremendous he history of patients in the determined by what ministers felt was hsj.co.uk affordable and

The views of the most important person looks at how patient powerconsidered has evolved in the early indays. the Donhealth Redding service were scarcely “social”, not a medical, question example. Doctors saw this as a groups began. slowly the rise of patient pressure their issues onto the agenda, so “medical”. Patients could not force doctors considered properly profession into family planning.” factor brought the medical professional advice. This decisive “Oral contraception required in her history of family planning: arrived. As Audrey Leathard noted but that changed when the pill to participate in and influence strategy. charities on the new cancer – witness the joint work of cancer previously bedevilled co-operation overcoming the turfism that has policy development and are even are now more integrated into health has often been diffused or defused. technology industry. But their threat politicians and the health groups, such as doctors, managers, previously dominant pressure represented a challenge to demands. They certainly increasing visibility to patients’ notes that these organisations gave to around 500 by 2000. Such groups grew from 230 in 1979 of political and medical priorities. working to place it higher on the list providing support for sufferers and focused on a specific condition, patient-oriented associations This prefigured the later rise of Pressure groups Family planning was an early Another thread is patients’ ability However, patients’ associations Social historian Rudolf Klein

respondent to the Cartwright study. can talk to them now,” said one were like little demi-gods [but] you practice. “The old family doctors trained doctors came into family primary care as younger, NHS- present-day research. explanations” – is echoed in and their ability to understand both patients’ desire for information “Doctors tend to underestimate information. Her conclusion – “consistently passive” in relation to inactive – only 10 per cent were charity”. century “condescension and system that perpetuated 19th- doctors as “inaccessible gods” in a having curtains around their bed. Only half the patients reported dignity” were often sorely lacking. child,” said another. never mind. You were treated like a for, you were told to take them and hysterectomy,” said one patient. straight out why they did a total condition, treatment or progress. find out all they wanted about their One-fifth said they were unable to difficulties in obtaining information. fifths of the sample reported Hospital Care inpatients, remains the case today. underlying problems, which reported satisfaction hid suggested that high levels of Cartwright’s 1960s studies free care. But sociologist Ann deferential about their new access to patients were grateful and the assumption is and was that about the first 15 years of the NHS, decisions. With few early studies trivial matters. thought many consultations were for ask for help and advice” and most to demand their rights rather than GPs agreed “patients nowadays tend already foreshadowed; over half of that patients are too demanding was The new intake showed far more This picture was changing in But patients did not want to be Ms Cartwright described hospital What we now call “respect and “If you asked what the pills were “I think I should have been told Her 1964 survey of hospital The Picker Institute’s more recent interest in issues their older peers had neglected, Human Relations and cervical smears. gynaecology and notably obstetrics, , showed that three- However, today’s fear

3 July 2008 treated like a child’ mind. You were them and never you were told to take the pills were for, ‘If you asked what Don Redding is head of policy people’s independence, control against their capacity to support to be registered and inspected social care providers in England are intends, all 25,000 health and a system? If, as the government centredness in the NHS. approaches that embed patient- forward to find whole-system in 1979. blueprint for health reorganisation minister Margaret Thatcher’s first was the title of the then new prime Institute Europe. and communications at Picker decisive corner. perhaps we are finally turning a of care and decision sharing, rhetoric is not new. to “patient-centred healthcare”, the and only rarely effective. remains incoherent, unsystematic wanted in decisions. were not involved as much as they and one half (inpatients) say they between one third (primary care) And in any national patient survey, side effects of prescribed medicines. not have enough information on people leaving hospital said they did service users and 63 per cent of cent of community mental health cent of primary care patients, 62 per required, however. In 2006, 42 per services, are extraordinary. satisfaction that, among public who express levels of trust and explanation is given to patients, largely been overcome; much more hospital sector in particular have hierarchical approaches of the Clearly the most demeaning and surveys of patients’ experiences. has had co-ordinated national health resources. appropriate and cost-effective use of and even contribute to a more also create better health outcomes and experience of healthcare. It can improve their knowledge, confidence decisions about their health can understanding and making But engaging patients in the UK rates poorly for delivering it. more share in the decisions and that work shows that patients want Do we stand on the brink of such The difficulty has been to move Although everyone now signs up “Patient and public involvement” Massive improvement is still For the past five years, England HSJ NHS60 anniversary ● Patients First supplement

24/6/08 09:26:03

19

ADVERTISING ARCHIVE You might have expected the birth of the NHS to be greeted with a cheer, but it got a muted press reception, says Jo Stephenson WHAT THE PAPERS SAID n 5 July 1948 the Daily The words of prime minister how the nation can co-operate in a Association. “In contrast to this Express said: “Doctors and Clement Attlee, who begged for great enterprise,” said the paper’s 6 dilatoriness on the part of people collaborate today in patience in a broadcast on the eve of July leader. “Only one bit of bother bureaucracy, the dental profession O a tremendous social the historic day, were also reported. draws attention like a raw tooth – was forced by the Ministry of Health experiment. The new National “There are bound to be early the odd-man-out isolation of a to negotiate the complicated scale of Health Scheme is launched. Wish it difficulties with staff, number of dentists.” fees in three weeks.” success.” accommodation and so on… We The Mirror continued: “The State Nevertheless The Manchester And so the NHS began, not with shall have to be a bit lenient with has done well by dentists. Not long Guardian foresaw a promising a bang, but more with a very British the service at first,” he said. ago it gave them professional status future predicting “the scandal of polite round of applause. Even so, 19,000 doctors across and stopped the disgrace of tooth- ‘under-doctored’ areas will slowly Its birth was not exactly front Britain were expected to join the pullers who toured with brass disappear”. Hmm, where have we page news, being eclipsed by an air service and “of 3,000 hospitals in bands. The financial terms now on heard that before? crash that killed 39 and the Berlin Britain, 2,751 passed under the offer are good. It is the turn of The next day it published a photo Blockade, one of the first major control of the new boards appointed dentists to help the State.” showing nurses in capes and frilly crises of the new Cold War. at midnight”. All hail the first health Unfair, retorted the dentists, white caps greeting Mr Bevan at Health minister Aneurin Bevan service managers. whose gripes, reported in The Times Davyhulme Park Hospital in did make headlines though – for a But there were gloomy on 5 July, included the fact few had Manchester. “The handing over of scathing attack on the Conservatives. predictions about the NHS from been sent forms to enrol. “This this hospital to the Minister was a He “told 7,000 people at Manchester some. “No spectacular changes can delay is entirely due to the symbol of the transfer that took yesterday: ‘I have a deep, burning be expected in Britain’s health overworking of the bureaucratic place all over the country,” intoned hatred for the Tory Party’,” reported services,” said the News of the World. machine, which is creaking to a the caption. the Express. “Why? Because too few of Britain’s standstill,” said the British Dental And finally, an early success. In an early warning about young girls are taking up nursing as “New happiness for the deaf” was reporting of the NHS, Mr Bevan a career.” It was hoped a the headline in The Times on 8 July said he did not expect it to be given government recruitment campaign ‘The scandal of as it reported one of the first a fair chance by some sections of the including “attractive posters” and a under-doctored innovations of the new health press. “For a while the newspapers new uniform designed by “one of service: free hearing aids. of our enemies will give the Britain’s top-rank dressmakers” areas will slowly “Mr Bevan said that it had been impression that everything is going might do the trick. asserted that the aid did not look wrong. Don’t be deceived,” he told Meanwhile some doctors were disappear, said very handsome and was rather the Manchester crowd. not playing ball, revealed the Daily awkward. But the most important In fact most papers – right and Mirror on 30 June. “It is alleged that The Manchester thing about it was its efficiency and left wing – gave a cautious welcome in some parts of the country, doctors – he could not entirely ignore the to the service, although not are applying a ‘means test’ before Guardian’ point – its cost.” ● everyone was thrilled. The Express’s acceptingaccepting patients,patients, refusingrefusing thosethose 4.30am slot for breaking news likelylikely toto requirerequire specialspecial care,”care,” revealed that students had hung a reportedreported thethe paper.paper. “Another“Another skull and cross bones on the front of complaintcomplaint isis thatthat residentsresidents inin a St Mary’s Hospital in London. blockblock ofof flatsflats hadhad beenbeen unableunable toto The paper’s leader was optimistic registerregister becausebecause locallocal doctorsdoctors hadhad but could have been written by the mademade a pactpact notnot toto acceptaccept anyany British Medical Association: personperson inin thethe blockblock becausebecause theythey “The public should be mindful of werewere ableable toto paypay fees.”fees.” However,However, the sacrifices and difficulties of the otherother GPsGPs embracedembraced thethe scheme.scheme. doctors. Their personal skill and “Some“Some havehave eveneven sentsent cardscards ofof knowledge and in certain cases welcome,”welcome,” saidsaid thethe MirrorMirror. genius, are being nationalised,” it Meanwhile,Meanwhile, thethe dentistsdentists werewere said, before urging readers to “be accusedaccused ofof spoilingspoiling itit all.all. “Last“Last reasonable”. nightnight membersmembers ofof thethe BritishBritish DentalDental “It is no use pretending that the AssociationAssociation inin onlyonly eighteight outout ofof 200200 scheme can begin at anything like areasareas hadhad decideddecided toto taketake partpart inin thethe maximum efficiency. There are not scheme,”scheme,” saidsaid thethe NewsNews enough doctors, not enough nurses, of the World. TheThe not enough hospitals.” Mirror was The Ministry of Health also iindignantndignant atat thethe “warned the public not to expect too news. “The much”, reported The Daily NNationalational HealthHealth Telegraph. “People can help SServiceervice hashas gotgot enormously by not rushing the new off to an service… and above all by judging eencouragingncouraging the results after a few months and start... an not after one day or one week.” example of

20 HSJ NHS60 anniversary supplement 3 July 2008 0000 MonthMonth 20082008 Heealthalth SSeervicevice JJournalournal 1

20Mediawatch-asas/JW.indd 1 23/6/08 19:16:41 The scene then The Bentley purred into the reserved parking space opposite the portals of his hospital, at exactly 9.30 am. The most junior member of staff ushered Dr Michael in. Matron, two ward sisters and four junior doctors of varying rank greeted him for this weekly ward round. Patients were neatly TOUGHERix decades on, how far have AT THE TOP Over the past six decades the working life packaged into the two rows of beds the mighty fallen? Perhaps as the consultant proceeded from the definitively of consultants may have lost some of its one end to the other, graciously S transformative event in the stopping at some beds, questioning consultant journey since the glamour. Now their role has to evolve if with wisdom and insight, probing inception of the NHS has been the with manicured hands and relatively recent adoption of the they are to regain their standing in the discovering hitherto missed or consultant contract. It is important health service, writes David Kerr unimagined pathology. to remember what the drivers were There was also a nurse to hand that led to this potentially employment law to limit the leadership needed to prevent such a with a stainless steel finger bowl, a revolutionary overhaul of consultant working week. high degree of local variation in nurse who carried linen hand towels working practice. Meanwhile the Department of interpretation and delivery. and a nurse to twitter excitedly. The move was rooted in a widely Health was engaged in a master It still seems the process is driven Such was the patients’ tension – held, predominantly London-centric plan to renegotiate the consultant by local cost pressures rather than a warned so severely by Sister to be view that consultant staff regularly contract to improve working true reflection of workload and that on their very best behaviour – that abandoned their patients to largely patterns and introduce objective setting remains weak, two elderly gentlemen undoubtedly unsupervised junior staff so they management levers to lead to indicating a disconnect between job suffered extensions of their hitherto could pursue their private practice consultant-led service improvement. planning and consultant appraisal. uncomplicated myocardial infarcts. with relative freedom. I remember Five years later it is worth reflecting On the plus side, there is greater Three hours later he met the other august bodies such as the Socialist on how many benefits have been transparency of consultant job visiting consultants in the silver Health Association getting terribly wrought by its implementation. A planning and the capacity to link service dining room. He then worked up about “gaps in 2006 authoritative review by the pay progression to agreed summoned the hospital availability of information King’s Fund (Assessing the New NHS objectives. superintendent to review his concerning consultants’ activities” Consultant Contract) made it On the down side, consultant considerable waiting list, did a little while seeking to engage the Inland obvious that the DH grossly earnings have increased – the cost teaching and was conducted down to Revenue in the quest for clarity on underestimated the scale of the task of which has been far greater than the Bentley at 3pm precisely. earnings across both sectors and and its implementation and failed to anticipated as the initial funding invoke European Union provide the quality of national formula was based on flawed

22 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk

22-23dr power-jmas/JW.indd 1 23/6/08 19:18:43 TOUGHER AT THE TOP 22-23dr power-jmas/JW.indd 2 clinicians in the redesign competitive if it can engage senior internally cohesive and externally are likely to be much more England’s NHS, I firmly believe we the modern watchwords of competition and contestability are improvement in service redesign. If to be better linked to reform and involvement in job planning. trust board and more oversight and greater executive support from the improving capacity and competency, needs to be strengthened by general terms, medical management strategic goals of the hospital. In consultant working week to pay to performance and the the managerial side towards linking likely we will see a greater move on evolve over the next decade? It is clinical benefit to patients. yielded much in the way of obvious to trust cost pressures but has not assumptions. This must have added financial and workload Consultant job descriptions need How will the consultant role redesign’ reform and service to be better linked to descriptions need ‘Consultant job clinical outcomes. redesign which directly links to key consultant’s role in initiating service be more logical to reaffirm the correlation with outcome. It would targets for which there is no proof of collecting data on irrelevancies and reduce the effort that goes into setting, we should make an effort to seem to be reconsidering target in service delivery. to lead to sustainable improvement to drive consultant support required incentivisation through the contract support from management and movement. This requires training, At a time when policy makers measurable benefits for patients. if achieved will result in definite, clinically appropriate targets which clinical leaders of the NHS. perhaps regain) our standing as evolve further if we are to retain (or it is clear the consultant role must network. own practice, hospital or cancer not have available figures from my pros and cons of any therapy, as I do US, when I describe the relative publications, often generated in the quote average figures from registration and data collection, I as arbiters of clinical worth. publications and globally accepted measures used routinely in all oncologist, I have a consistent set of Pharmacology, Oxford University. Department of Clinical and cancer therapeutics at the professor of clinical pharmacology Professor David Kerr is Rhodes I would suggest we describe So another 60 years beckons but Yet despite investment in cancer In my own field as a medical

3 July 2008 ● maximum bonuses. maximum points and therefore general practice’s achievement of from medical school to celebrate his dinner being held by his best friend He heads off at about 7pm to the waiting times, following complaints. junior manager to review his clinic available. the blood tests and scans are hours. As usual, only 50 per cent of overbooked into the remaining two hour empty and 28 patients system has misfired, leaving the first down to the outpatient clinic. Mike grabs a sandwich on his way After two circuits of the hospital, he is told to “bog off” by a patient. round, but it goes pretty well until seem too busy to attend the ward junior medical staff. The nurses given the lack of continuity between heading up to do the ward round. yesterday’s clinic notes before new front entrance. He types up littered McDonald’s restaurant at the managers only) and pushes past the handsome portals (now for executive 7.30am. He bypasses the hospital’s deducted from his salary. It is BMW, the hefty parking fee being Mike rushes to park his battered The scene now HSJ NHS60 anniversary supplement Later Mike is summoned by a The hospital’s electronic booking This is something of a lottery, 23/6/08 19:18:47 23

FRANCES CASTLE DÉJÀ VU

Healthcare has moved on apace since 1948, with treatments that would have amazed medics of the time. Yet in other areas time seems to have stood still, says Niall Dickson

f by a miracle of medical even yet rid ourselves of the scourge technology we were able to of measles. bring Nye Bevan back to life, But we are seeing a shift in I how would he regard his emphasis from infectious to chronic creation 60 years on? disease, which is largely a product He might raise an eyebrow at the of greater longevity and affluence. scale of the operation – when it was Arthritis, diabetes and dementia are those challenges have resonated launched, the service cost around all increasing year by year, on top of with Nye and his colleagues? £400m (roughly £11.5bn in today’s the impact of rising obesity, much Medical scepticism over the role prices), compared with more than higher levels of drug abuse and of government in health has a long £107bn today. He would certainly probably higher levels of alcohol and, some would say, creditable be impressed by transplant surgery, abuse. history. But it has led to a fractious announced “the NHS of the future chemotherapy, how we have relationship and a feeling, from the will do more than just treat patients combated AIDS and improved the Obesity levels outset, that medics were not fully who are ill; it will be an NHS care of mental illness. In his report for the King’s Fund, committed to the project. offering prevention as well”. On the face of it, today’s health Our Future Health Secured, Derek The fact that the British Medical And that is precisely what Sir challenges are very different. Both Wanless identified obesity as Association opposed the type of John Maude, permanent secretary at disease patterns and the means of requiring substantially higher levels health service engineered by Bevan the Ministry for Health in 1941, had combating them bear little of funding over the next 20 years – describing it as regimented units in mind for the new health service resemblance to 1948. For example, unless worrying trends in unhealthy “repugnant to the tradition of for the post-war era. He said it must antibiotics and vaccinations have lifestyles are tackled. The rises in British medical practice” and aim at “creating and maintaining transformed the treatment and both adult and child obesity are comparing plans for the new NHS good physique, energy, happiness or prevention of infectious disease in already much greater than even the with the healthcare system in Nazi resistance to disease” and not children – in the case of polio, most cautious predictions of his Germany – has allowed critics to merely “patching up ill health”. eliminating it entirely. earlier review for government. portray it as unremittingly To be fair, the health service has The challenge of infectious All the same, being concerned reactionary. Bevan in his turn done more to live up to that disease remains, though. We have about children’s weight is nothing described the BMA as a “small body challenge than is often not yet found a way round the new, although in the past we of politically poisoned people”. acknowledged. Screening, regular appearance of a flu worried they were too thin and At a speech in January this year, vaccination, smoking cessation pandemic or the risk of a new strain undernourished. prime minister Gordon Brown programmes and statin prescription jumping from another species. Last summer, announcing the are testimony to that. Yet it has Globalisation and a sexual Darzi review, health secretary Alan struggled to secure the right revolution have led to a huge rise in Johnson identified critical issues, ‘The NHS of the balance, with the urgent calls of the sexually transmitted infections, including “improving clinical sick taking precedence, especially including HIV/AIDS. Drug-resistant engagement… investing in future will do more when budgets are tight. strains of tuberculosis as well as prevention, providing accessible There is a chance now that the healthcare-acquired infections care closer to home and ensuring than just treat NHS could move to being a much present new variations on long- services are responsive to patients patients who are ill’ more proactive system that tries to standing challenges. We have not and local communities”. Would keep people as healthy as possible.

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24-25 challenges nhs60jmas/JW.indd 1 24/6/08 09:54:34 24-25 challenges nhs60jmas/JW.indd 2 of being run by local authorities. new there then. between 10 and 20,000”. Not much centres serving populations of doctors working from health envisaged “groups of six to 12 practices. In 1942 Sir John Maude needs are met”, including GP where most routine healthcare proposed that “the polyclinic will be Stage Review: interim report services.” So said Lord Darzi’s population a range of convenient be offering all members of the local in easily accessible locations should every home in July 1948. the leaflet on the NHS delivered to still have your own doctor.” So said their own surgeries, but you will accommodated there instead of in your district. Doctors may be as health centres may be opened in resonate. “Special premises known preventive strategies. hsj.co.uk The NHS came within a whisker The London Darzi review “Newly procured health centres Other themes continue to better resourced will be calling for minister of the day bet the prime in 2048, it is a fair the NHS turns 100 however. When sick will remain, the well and the resources between start of the NHS. persisted since the concerns have services, most health the role of acute health behaviour and management, public issues such as disease have shifted between Although focus may Competition for . Next capacity”’ always exceed “expectations will remarked ruefully, ‘As Nye Bevan centrally raised resources. allowing party political control over unresolved consequences of and partly because of the which feared local council control, appease the medical profession, Bevan rejected the idea, partly to will always exceed capacity”. remarked ruefully, “expectations service was launched. As Bevan took place almost as soon as the used wisely. The first financial crisis whether those resources were being industry to consume resources and the insatiable capacity of the health funding, it would worry both about once the state took responsibility for for money. It was inevitable that more change looks certain. accountability of local services, minister promising to increase varying success. With the prime accountable at local level, with efforts to make services more There have since been numerous Local accountability Another abiding theme is value 1940s. Tension between local and not necessarily the same as in the factors pushing change today are surgeries or health centres and the “right” answer for the size of GP problems. There probably is no system. doctors and payers confined to our care. Nor is the strain between more efficient ways of delivering costs and the apparent failure of or governments – bemoan rising individuals, insurance companies Payers everywhere – whether health systems across the world. instances they can be found in standing tensions? In some managed to resolve these long- productivity is increased. resources will be needed unless reports have said that more From 1952 to 2007, King’s Fund different from any other payer. Others are simply intractable So why has the NHS not In this, government has been no 3 July 2008 ça change, plus c’est la même chose any time without difficulty”. change your doctor, you can do so at controversially) “if you want to her own doctor” and (even more aged 16 and over can choose his or – choice. It states that “everyone one familiar theme of modern times have been unthinkable in 1948. professional performance would of publishing data on individual between service and user – the idea also change the relationship will bring new challenges. deference and digital technology rise of consumerism, decline in (which is unlikely), will remain. entirely in one direction or another with the NHS and unless it moves national accountability was born King’s Fund. Niall Dickson is chief executive of the Aspirations and challenges – The 1948 leaflet does mention Wider access to information will Meanwhile the growth in wealth, HSJ NHS60 anniversary supplement 24/6/08 09:55:18 plus . 25 ●

GETTY, MEDISCAN, SCIENCE PHOTO LIBRARY, MAGNUM, CORBIS he National Health Service 20th century medical practice that embodies the best of 20th- was expert-based, illness-focused century medicine. Its public and professionally controlled – was T health and primary care built around the expertise of the systems are the envy of the world. care-givers and not around the Now it has the opportunity to needs of individuals. develop a health system that reflects The operating principles for the our new health problems – next generation NHS have already preventable chronic disease, new been adopted. An NHS that is technologies – through pervasive patient centred and patient led. That and ubiquitous technologies that moves it from being a sickness allow people to manage their service to a health service. That conditions in their homes, outside of embraces the responsibility for traditional clinic settings. New health and wellbeing as well as for expectations of healthcare include a curing illness. desire for more independence, Now, at this turning point of the personalisation and control. NHS’s 60th anniversary, is the We can liken the NHS’s transition chance to turn those aspirations into into its new generation to the way reality. The next generation NHS the internet has been transformed requires us to think in a new way from its first generation – “Web 1.0” about personalising public health. It – into its current state – “Web 2.0”. requires both NHS and patients to The first stage of web architecture become more active creators of was built by a network of experts health and it will require a new level and the user interface reflected an of mutual trust. expert-to-user relationship; content Technology will enable this was loaded to the web by experts change, but at its heart is a new and the rest of us downloaded it. form of social relations. Web 1.0 was the first generation of The first generation of these knowledge transfer over the web. technologies has already decentralised care, given Social network patients more control and In the past five years, though, a new permeated the boundaries model of information exchange has between the health system emerged. Web 2.0 is more densely and the community. social, decentralised, participatory, These technologies egalitarian and democratically support a more personal controlled. This new model is built level of healthcare, more on peer-to-peer sharing, social conveniently delivered and networking and open platform more integrated with innovation. It represents a new everyday life. model of information exchange For instance, personal blood- through group participation, glucose monitoring enables sharing and community support. diabetics to monitor themselves at Web 2.0 is anti-hierarchical. home, allowing patients to integrate Fundamentally networked, it enables their care into their lives and relationships between and among reducing dependency on the health people. Knowledge is democratised, system. Most importantly, it contributed and organised by users. provides immediate feedback on Expertise is an emergent property of glycaemic control, based on the community, residing in the personal eating, sleeping and networks themselves – conferred by activity patterns, rather than a one- the collective judgments of the time snapshot in a lab. The patient many rather than the personal is more knowledgeable so there can judgments of a few. be more informed decision making This is personalisation, between them and their doctor. In independence and equality, conjoined this first phase of change, the focus with communication, participation of care shifts to home, but is not yet and engagement. The social supported by systems or implications of these technologies communities. are profound and paradoxically But imagine a health system that profoundly individualising and is continuously informed about each socialising at the same time. individual’s health risks, attitudes and In much the same way, the first behaviours, how they prefer to receive generation of the health system – an information and what influences “industrial” model typical of mid- their healthcare decisions. Such a

THE26 HSJ NHS60 anniversary supplement 3 July 2008 EXPERT hsj.co.ukPATIENT

26-27 NHS 60 humana-jw/jm/JW.indd 1 23/6/08 19:20:36 THE EXPERT PATIENT 26-27 NHS 60 humana-jw/jm/JW.indd 2 hsj.co.uk and experiences’ their treatments people to track community allows ‘This patient putting it equally in the hands of democratises medical knowledge, democratise healthcare. It the patient. And it will radically an entirely different experience for user in the foreground. It will create background as it is simple to the technologically sophisticated in the social as it is personal, as environment of the clinical trials. treatment outside of the controlled to learn about the impact of clinical and generate better data for clinicians for encounters with their doctors but make patients better prepared provide better support to patients time data in a real-life context. environment that generates real- creating a real-time experimental their treatments and experiences, provides patients with tools to track rather than rely on anecdote, it to a collective experience. And of a single patient, it exposes people relying on the individual experience a whole community. Instead of interaction, PatientsLikeMe links to modelled on a one-to-one with a difference. Instead of being disease effectively – and scales it, learned to live with and manage the experience of those who have chronic disease to tap into the concept – getting people new to community takes the expert patient to a community of other patients with support. And the person is connected messages, coaching or other clinical personal health risk can trigger monitored, so that changes in host computer to be analysed and glucometer transmits its results to a this health system, the home medicine or talk to their clinician. In adhere to their care plan, take their messages to help the individual to system could deliver context-sensitive in concrete, measurable terms. This says Humana’s Tom Granatiruser participation in healthinformation, services, we are enteringweb ofa ordinarynew age ofpeople sharingJust as the internet has evolved into a monitor and share their experience The next generation NHS is as Communities like this will not only similar conditions who can use online tracking tools to condition and treatment and support each other to develop information about their an online community of evolving. PatientsLikeMe is mood disorders who share better disease management people with amyotrophic communities are already strategies. These patient multiple sclerosis, HIV and motor neuron disease), lateral sclerosis (a form of 3 July 2008 challenge today? be limited by it. Are we up to that guided by our experience but not to challenged us to do in 1942. To be this is what Sir William Beveridge beyond it to try something new. Yet by our current experience and reach to take risks, avoid being bounded programme, because to innovate is challenge for any government for the NHS. Bold innovation is a and innovation to create it. people, technology, experimentation vision and deliberate investment in will take bold commitment to the already under development. But it the technology underpinning it is fetched as it may sound. Much of 60 years. Health 2.0 is not as far- integrated rather than fragmented. healthcare experience will be being isolated and alone. And our be community supported rather than rather than one-size-fits-all. We will It will be personal and customised distributed rather than centralised. rather than hierarchical. It will be It will be networked and matrixed data-driven rather than event-driven. acting rather than reactive. It will be approach to health. It will be forward- ecological and not an industrial kind of health service. It will take an NHS 2.0 will be an entirely different Bold vision the Wanless review in 2002. engagement” scenario envisaged by health, the embodiment of the “full- platform for the co-creation of and that meet us where we are. offer us services that are right for us anticipate our needs so that it can and analytics to understand and don’t. It harnesses the power of data when we ask it to but even when we system that works for us not only community to support us and a people in their own health. And it strives, above all, to engage priorities and personal preferences. individual to express their health It creates an opportunity for every control over when, where and how. communication, with patient It individualises health risk and personal health trajectory. understanding of personal health assessment, with a rich patients. It personalises needs director at Humana Europe. Tom Granatir is policy and research This last point is a true challenge This will be the NHS for the next NHS 2.0 will be the participatory In NHS 2.0, we have a HSJ NHS60 anniversary ● supplement 23/6/08 19:20:37 27

KELLY DYSON ocal government has done every four hospital beds until the and health education. Every county more for health than the NHS. creation of the NHS. and county borough council had its In the 19th century, borough The medical profession, who saw medical officer of health, who L councils organised street subordination to local councillors as presided over community health cleansing, refuse collection, water interfering with their clinical services such as child welfare and supply and sewerage systems. Local independence and lowering their district nursing and took government secured adequate status in society, strongly opposed a responsibility for slum clearance. housing and clean air to complete local government takeover of the Needing advice on how to run the the key elements that made good new service. Having had to stuff the hospitals newly under its control, health attainable by all. doctors’ mouths with gold, health the government turned to their Local authorities later took minister Aneurin Bevan was not former manager, local government, charge of physical illness, building going to let local democracy for expertise. Alderman Albert infirmaries to cater for infirm frustrate his plans. The local Bradbeer prescribed the tripartite paupers which often operated side democratic element was removed split of doctors, nurses and by side with hospitals supported by from hospitals, a step that he later administrators, each occupying charity. In 1885 the law that confessed to regretting. Bowing to distinct territories. required people to become paupers the doctors, he installed a national before using the infirmaries was system with a command structure Three-way division abolished. Once publicly provided going up, in theory, to the secretary Between 1948 and 1974 there was infirmaries were open to all, of state. continued misgiving over the something approaching a universal Local authorities had lost the division of health services into system took shape and local hospitals, but they retained their hospital, GP and community authorities ran over three out of grip on community health services services. NHS planning bore no MEET THE

LOCALSCouncils have done more to improve the nation’s health than the NHS – but the relationship between the two is still evolving, says Rodney Brooke

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28-29 loc gov-jmas/SJ/JW.indd 1 23/6/08 19:25:46 relation to primary healthcare or priority. The Lancet said: appointed. Joint children’s trusts patients’ needs, while chronic “administering the health service is ‘The shared have been created. Local authorities disease management required long- too serious a matter to be shared must establish health scrutiny term care outside hospital and with the citizenry”. Richard boundaries of the commissions, through which they patients required the social care Crossman, then secretary of state can hold to account the local health package provided by local responsible for local government, NHS with local providers and commissioners. government. argued for area health authorities Health and social care inspection Both the Conservative and with substantial local authority government have are to be merged in the new Care Labour parties wanted unification membership, though he thought the greatly aided Quality Commission, facilitating a of the NHS and local government government was being forced into joint examination of both health services. Former health secretary Sir “a miserable middle way”. joint working’ and social care services. Keith Joseph became a convert to His Conservative successors did As the 2006 White Paper Our the cause of local government, after not share his misgivings. The 1974 care soared, prompting the 1988 Health Our Care Our Say makes reporting that when he went to a reorganisation of local government Griffiths Report. It placed plain, the government is committed hospital, he would be shown the removed the medical officer of responsibility for community care to encouraging more joint working. dingiest and most dilapidated health from local authorities and firmly with local government, with An integrated health and social care building to demonstrate the local authority health departments, budgets redirected to local authority information system for shared care hospital’s need for more hospital management committees social services departments. Then is planned, through which there can government funds. But in a local and teaching hospital boards of prime minister Margaret Thatcher be a joint health and social care plan authority, which then did not governors were replaced by area thought hard about giving the for those with complex health and depend on the government for its health authorities. A quarter of their responsibility to the NHS. The idea social care needs. The White Paper income, the mayor would proudly members were nominated by the floundered over finance. The NHS even contemplates GPs prescribing conduct him round the smartest local authority. Ministers were still is free at the point of delivery. Social a social care package for patients. and newest residential home. not prepared to challenge doctors services are charged for and means- One significant advance is the Ironically, the catalyst for change on behalf of local democracy. tested. Merger with the NHS would concept of individual social care in the health service came from While successive reorganisations make the difficulty – still a bone of budgets, enthusiastically advocated local government through the 1969 of the NHS preserved for a time the contention – even more obvious. by the government. There is talk of Redcliffe Maud Royal Commission, minority of local authority members Reluctantly she implemented the individual health budgets. An which recommended that the NHS on the health authority, the hybrid Griffiths proposals. example: one patient, dependent on be brought within a new system of system did not work well. Clinician The new shared geographical oxygen cylinders from the NHS, has local government. members of the health authorities boundaries of the NHS with local had air conditioning installed in one But the recommendation had the found the intrusion of politics government have greatly aided joint room in her house, saving the NHS opposite effect. It faced the difficult irrelevant and councillors found working. Relations have matured its spending on oxygen cylinders as (though not insoluble) problem of themselves impotent to affect much and valiant attempts are made to well as greatly improving her creating an independent source of health policy. work together. The purchaser/ quality of life. But the air- revenue sufficient to enable local Eventually, councillors were provider split and the creation of conditioning was paid for by the authorities to run the NHS. It also removed from health authorities primary care trusts co-terminous local authority, not the NHS. faced the opposition of doctors, who and a succession of bodies were with local authority boundaries Major tensions remain, usually feared that education and other created to represent the community encourage this. about money. PCTs still fear services might receive higher or patient interest to the NHS. “bedblocking” by local authorities, Local authority social services Common goals and councils believe PCTs shunt were reorganised, with generic Despite public attention to the acute costs onto them. The division social services departments sector, co-operation between PCTs between free healthcare and implemented from 1970; a move and local authorities increases year charged-for social care is unclear. unscrambled only in the past on year. A succession of appalling Local government continues to three years. child abuse cases has prompted hanker after direct involvement in Over the next 20 sharing of information between the NHS. Indeed, the gradual years, public doctors and social workers. Local transformation of PCTs from spending on authority directors of adult services providers to commissioners social are routinely co-opted onto PCTs. removes one ideological barrier to There have been constitutional the idea. It would solve some of the changes and pooling of budgets is issues over the relationship of the more common, especially in NHS with the wider community mental health and learning and social care. Comprehensive area disabilities. The occasional assessments may increase demand joint chief executive for local democratic accountability. has been One thing is certain. The public will expect better and more joined- up services and demarcation disputes between health and social care will not be acceptable. The public finds politics a turn-off. But if their local health services were decided locally and were paid for in a more explicit local way, might that not excite their interest? Might they rebel if decisions continue to be taken without their democratic involvement? ● Sir Rodney Brooke is chair of the General Social Care Council. He was formerly the chief executive of West Yorkshire County and Westminster City Councils and secretary of the Association of Metropolitan

Authorities. TOPFOTO

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28-29 loc gov-jmas/SJ/JW.indd 2 23/6/08 19:25:57 NICK BOSANQUET Professor of health economics at Imperial College and consultant director of Reform. On its 60th anniversary, the NHS is poorly positioned to face the approaching “perfect storm”– an ageing population, costly new WHAT’S THE technology and a more informed society will increase demands and expectations. Medium- term investment is required in many areas but funding will be restricted. So this year has to be seen as a turning point, with two possible futures: a positive one of NHS opportunity or a negative one managing NHS decline. VERDICT? In the positive scenario, greater efficiency and productivity would release resources for new investment and local innovation. Excellent service and immediate access would be achieved for 9 to 10 per cent of gross domestic product. The negative scenario would see cost increases eat away at the margin for investment. The service would suffer from the illusion that progress is measured in extra resources. Substandard quality and access would be achieved for 11 to 12 per cent of GDP. The performance gap would widen. The Department of Health’s rhetoric is consistent with the positive view, with 2008 seeing the completion of current reform programmes, bar payment by results. But our research at Imperial College shows this is a national mantra rather than a local reality. In conception the reforms are good, shifting the balance of power towards consumers and allowing competition and choice to drive innovation while reorienting services towards integrated care and prevention. But in practice programmes are far from reaching full implementation. Demand side programmes have failed to drive significant change in the interests of patients. Management ability, flexibility and, increasingly, financial surpluses lie on the side of providers. Most primary care trusts have not embraced competition or sought to reorient services. While practice-based commissioning is widespread, practices still lack timely and credible budgets. The widening of payment by results and its unbundling have been delayed and less than half of patients are being offered choice. The independent sector remains far short of the provision identified by the DH in 2005. The return to surplus does not signify a new settlement in which investment can take place but is due to a temporary combination of the last major funding rises and a pause in centrally prescribed cost rises, already building up again.

Optimistic outlook Decline is not inevitable, however. Accelerating real change would unlock the benefits of reform. Key is an economic constitution to define duties to create value at all levels, realign priorities and give more power to consumers. Key elements would include stronger independent commissioning, provider pluralism, flexible labour markets, a clear success and failure regime modelled on the private sector, quality-determined prices and cost, and separation of central regulatory and political/ strategic responsibilities. A constitution could create incentives for better financial management and give staff the capability to achieve value for money and meet the focus on public health and inequalities. A preventive as opposed to a reactive service would be created. If this was the key outcome of the DH’s current landmark review, we could look with optimism towards the 70th anniversary of the NHS.

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30-31 polemics-jm-JW/JW.indd 1 24/6/08 19:40:23 30-31 polemics-jm-JW/JW.indd 2 the NHS the past and future of their judgments on punches and deliver pundits to pull no We invite three health lecturer at Coventry University pause and listen’ use this anniversary year to perhaps ministers should of a patient-led NHS, ‘Amid their hollow rhetoric later New Labour’s relentless programme of with planning and collaboration. But 60 years In 1948 the NHS replaced chaos and competition Di JOHN LISTER radical modernisation and keep our NHS public. the spirit and principles of Bevan’s historic and evidence-based policy. It is not too late to rescue care instead of surplus-centred care. Let’s see needs and not profits. Let’s have patient-centred anniversary year to pause a while and listen. NHS, perhaps ministers should use this reforms of a so-called Labour government. would be eclipsed by the far more comprehensive Conservatives’ privatisation of support services up 25 years ago, nobody dreamed that the new costs and tiers of management. training and research. Every reorganisation adds questionable care while undermining medical sector treatment centres deliver high-cost, monumental financial blunder. Independent sector. the private sector at the expense of the public healthcare, instead serving to inflate costs and they improve efficiency, equity or access to support, they are totally lacking in evidence that alone sees as the good old days before the NHS. foundations, these hark back to what New Labour organisations” and “social enterprises”. Like services and set up “arm’s-length trading fragmenting services, forcing PCTs to divest equitable access to healthcare. They are which has no brief to ensure universal and surpluses and answerable only to a regulator public with foundation trusts, now piling up insurance system to advise on commissioning. inefficient and socially exclusive US healthcare services, or bring in executives from the build new hospitals, or privatise primary care demanded ministers use private sector cash to to avoid complex, chronic and costly cases. for straightforward elective patients while seeking to go back to a system of rival hospitals competingpresent government. Only this government aspires doctors to focus on patients’ needs. Access to care free at the point of need liberated resources according to population and local need. possibility of planning services and allocating market with a system that later offered the perfect, but it replaced Britain’s failed healthcare overhead costs and creating a new market system. structure, bloating its bureaucracy, inflating back the wheel of history, fragmenting the NHS so-called modernisation and reform is rolling rector o Let’s invest in public services targeting health So amid their hollow rhetoric of a “patient-led” When London Health Emergency was set The private finance initiative is emerging as a Not only are such policies devoid of popular Ministers have also lumbered an unwilling No mass demonstration or patient group ever This model is still popular with all but the Nye Bevan’s 1948 NHS was inevitably far from f London Health Emergency and a senio

r

personal medical accounts. Accounts for the some National Insurance contributions into poor or unemployed could be topped up as other markets, and health should be no providers. Such moves are taken for granted in help exercise choice and encourage new Allowing doctors to advertise for patients would create a strong incentive to drive up quality. Publishing patient-based outcome data would towards funding medical services. should shift decisively away from providing and same terms as state ones. The government’s role new providers can compete for patients on the payment by results tariff should be established so market reforms must be followed through. A full make the NHS more accountable to patients. More to the point, it has undermined attempts to accounting and created layers of bureaucracy. distorted clinical priorities, encouraged creative interference has discouraged innovation, Whitehall-imposed targets. Relentless political accompanied by centralisation and endless starts – have attempted reforms. governments have realised this and – in fits and inadequate market discipline. Successive faults: lack of responsiveness to patients and management spring from the same underlying yet some NHS organisations remain in deficit. public spending on the NHS reached £92.6bn, things have not got much better since. In 2007-08 year. In fact it cost £305m in its first year and estimated that the service would cost £132m per in life expectancy are widening. than the semi-skilled and unskilled. Inequalities than 40 per cent more NHS spending per illness Professional and managerial classes receive more infection rates remain high and rising. denied to patients and healthcare-associated and potentially life-saving drugs are routinely Europe for cancer, strokes and heart disease, new healthcare available, free at the point of use. promise to provide everyone with the best than ever that it has never delivered on its As the NHS reaches its 60th birthday, it is clearer Policy director of the Adam Smith Institu TOM CLOUGHERTY improve the quality and cost of healthcare, encouraging value for money. But to really for accountability, putting patients first and exception. to be financed by the taxpayer. money. Major medical expenses would continue they truly believe are necessary and value for patients an incentive to demand only services costs of processing small service items, giving remains by far the best alternative. payments for smaller healthcare expenses medical savings accounts to allow direct purely out of general taxation. Introducing Britain should move beyond funding services universality and equity. compromising its founding principles of health service for the 21st century, without a welfare benefit. Further steps to empower patients are needed. The policy steps needed are clear: internal But while delivering benefits, these have been Low-quality care and poor financial This all comes at great cost. Aneurin Bevan On equity, the picture is disheartening. Britain has some of the worst survival rates in They would give providers autonomy in return This could be introduced by diverting Such a scheme would eliminate the excessive The above moves could create a top-quality 3 July 2008 HSJ NHS60 ●

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PAUL THURLBY FRONTLINE PHARMACY

32-33 lloydssponsor-jmas/JW.indd 1 23/6/08 19:27:07 32-33 lloydssponsor-jmas/JW.indd 2 cost-effective for the NHS. convenient for the patient and more dispensing will be both more home- or care-facility-oriented, Highly efficient, automated and radically different in 60 years’ time. way dispensing is done will be to be a key requirement. But the conditions, dispensing will continue available to treat long-term ever increasing numbers of drugs and expectations the NHS faces. reflecting the spiralling pressures prescription items in England, figure was around 750 million 13,000 pharmacies. In 2006 the prescriptions were dispensed from forgotten. In 1937, 65 million dispensing task should not be meaningful incentives. prescription” role has lacked difficult. Often the “non- public health issues has proved healthcare advice and addressing prescriptions versus providing the balance between dispensing need to dispense prescriptions. NHS, becoming dominated by the dramatically with the advent of the the 20th century. This evolved significant frontline role well into field. Pharmacies kept up a growing professionalisation in the Britain was formed, marking the Pharmaceutical Society of Great dispensed advice. In 1841 the I hsj.co.uk delivering the future England: building on strengths – recent white paper we can add for primary care trusts.” services. This is the value we think conditions and conduct clinical management of long-term ailments, as well as help with the training and ability to treat minor awareness of pharmacists’ specialist not just dispensers,” he says. needed to be healthcare advisers, pharmacists have the competencies recent years to ensure that their have made significant investment in date. Community pharmacy chains Lloydspharmacy. of community pharmacy Andy Murdock, pharmacy director to dispense prescriptions, argues view that pharmacists are just there trust and getting away from the spent giving advice on health. full circle with much more time pharmacists’ role coming almost One view of the future sees the Full circle With an ageing population and The sheer growth of the More recently, efforts to restore Mr Murdock goes on: “In the “The challenge now is to raise “Frankly, it is a view that is out of Success depends on consumer made and sold medicines and to their local pharmacist, who could not afford a doctor went n the 19th century people who Pharmacy in , the government advice, while those requiring care ‘worried well’ who proactively seek professionals; it is generally the contact with healthcare social information. help to bring together NHS and professional pharmacist may well another area in which the part of healthcare provision is prescriptions to become an accepted centres.” well as health and community Millennium Point visitor centre as two biggest football clubs and the services. This was done at the city’s evening and weekend screening ‘at risk’ over-40 men with access to Lloydspharmacy to provide 10,000 and Wellbeing Partnership engaged exercise in which the city’s Health to them. risk people in ways that will appeal and communicate to the most at- stakeholders to agree it is a priority heart health, we need all interested a discernible result, for example on and education is critical. To achieve consistency of public health advice our stores,” says Mr Murdock. out to the people we help through in-store radio – in an effort to reach Lloydspharmacy’s case we also have in print and online – and in and easily accessible source. better heeded if given by a trusted basic health education this will be where there is a requirement for “healthy” and “unhealthy”. are now bombarded about what is access to health information, people and today is education. With more consumer (or patient) of the 1840s differences between the health connected to the community.” long-term conditions to stay living and be a place for those with advice and guidance on healthy conduct clinical services, provide which highly trained staff can have private consultation rooms in 1,700 pharmacies. The majority enable. Lloydspharmacy has around pharmacy is uniquely well placed to community, something that begins with individuals in the care delivery network. integral part of the NHS’s primary commitment to pharmacy as an expressed its continued healthcare services, says sureLloydspharmacy to expand into deliveringin dispensing some primaryprescriptions The andcommunity advice pharmacist’sis invaluable role “Many people have very little The potential for information “An example is the Birmingham “But the profession also realises “Pharmacies give advice verbally, But in areas of health inequality One of the most significant “Tackling public health issues points of contact for patients.” economy, providing a variety of provision remaining as a mixed I would like to see healthcare conditions. That’s one of the reasons services to people with long-term powers to deliver a wider range of pharmacies to be given greater health inequality requires education, redressing the blight of Murdock. “Beyond health consultation,” continues Mr often avoid any form of in all likelihood would not have condition. These are all people who high probability of developing the had a high, very high or extremely tests, identifying 50,000 people who more than one million diabetes consumer at the point of delivery. screening services free to the company’s record in the provision of long-term proposition. competitive costs make this a viable live and/or work), combined with and location (close to where people of time (no appointment necessary) consumer of convenience in terms programmes. Advantages to the context of national screening primary care, particularly in the services maps out a clear future for pharmacy provision of clinical departments,” says Mr Murdock. attending accident and emergency an estimated 8 per cent of people Equally pharmacists could manage equivalent of one hour per day. pharmacy we can save every GP the treating minor ailments in- more serious health issues. By support to enable GPs to focus on about providing well qualified GPs as the patient owner but it is around 800,000 a year. ailments services from 500,000 to an increase in visits for minor million more prescription visits and medicine use reviews, over 100 part by a 5.4 million increase in increase is expected to be driven in over 420 million a year. This increase in the UK by 41 per cent to anticipated pharmacy visits will is already there,” he continues. the infrastructure and network that polyclinics and ends up destroying everything gets consolidated into danger in this case will be if “There is never just one answer. The More than one way “Since 2003 we have carried out Mr Murdock cites his own The white paper’s emphasis on “This is not about challenging In just the next two years it is 3 July 2008 qualified support’ but about providing the patient owner challenging GPs as ‘This is not about primary care services.” and social care providers to deliver accessible to all accredited health fair, effective, sustainable and The funding mechanism must be quality service delivering fair return. investment in a comprehensive encourage competition and must be funded in a way that will Murdock. increase capacity,” says Mr pharmacy in an innovative way to competencies and potential of health needs by utilising the sufficiently flexible to meet local that will be value for money and services and sustainable business quality of healthcare services. factor in both the quantity and will continue to be a controlling serviced at Kwik-Fit garages. waiting while their cars were provision of heart “MoTs” to men programmes such as the recent into the community with innovative out of its conventional confines and both these cases, taking healthcare delivery of effective healthcare in health inequalities are still rife. doctored areas and those where their support to the NHS in under- likely to see pharmacies extending of the community pharmacy and is a policy that plays to the strengths is for the NHS to be patient-centred, patient’s needs.” behavioural advice tailored to each testing and for the provision of compete to deliver services both for would then be in a position to he says. “Community pharmacies effective as well as value for money,” screening services that would be establish contracts for providing appropriate service providers and outcomes, accredit a range of priorities, agree their expected meet local needs. best to commission these services to providing guidance to PCTs on how tariffs for screening services and government setting primary care reviews.” and over 400,000 medicine use separate free blood pressure tests We have also carried out 500,000 recognised any symptoms or risks. “The framework for innovation “The challenge is to develop Another solid bet is that funding Accessibility is the key to the The government’s oft-stated aim “PCTs would identify health Mr Murdock wants to see the HSJ NHS60 anniversary supplement ● 23/6/08 19:27:07 33

KELLY DYSON ALWAYSALWAYS OONN OOURUR MINDSMINDS

Mind), the then health minister Enoch Powell The regimented tyranny of the old asylums that came into spoke passionately against the grim isolated the NHS in 1948 is consigned to history, but the rhetoric of asylums “brooded over by the gigantic water- tower and chimney combined”. This speech community care has struggled to win adequate resources cemented the shift in focus from asylum to general hospital and community care and the 1975 white and understanding, says Simon Lawton-Smith paper Better Services for the Mentally Ill led to more day hospitals, day centres, residential homes, hostels and community nursing provision. n an article for the British Journal of Wales to 32,000 in 2006-07 in England alone. Sadly, the rhetoric of community care was not Psychiatry on the 50th anniversary of the The number of patients resident as certified or backed up by adequate NHS or local authority NHS, the then president of the Royal College formally detained under the Mental Health Act resources. Progress was slow and public I of Psychiatrists Robert Kendell suggested has plummeted from 123,464 in 1948 to 15,300 perceptions of its failings were formed by that it was “easy to forget, in the face of our and the proportion of people per 1,000 occasional high-profile incidents involving care present difficulties and discontents, that population certified or detained has dropped in the community patients, which continue to psychiatric services have improved out of all from 2.89 to 0.3. this day. But community services were boosted by recognition in the past 50 years”. On its 60th A range of factors has been cited for this the NHS and Community Care Act 1990, which anniversary, this sentiment still rings true. change. New medication that better controlled provided a backdrop for multidisciplinary In 1948, mental healthcare for those with symptoms of mental illness allowed many community mental health teams and the care serious disorders was largely provided in more patients to be discharged. The increasing cost of programme approach, which gave some patients than 100 asylums dotted around the countryside inpatient care turned politicians’ thoughts an assessment, a care plan and a key worker. or suburbs. These had 145,000 residents. Out of towards cheaper community care. The Percy Despite this, implementation was inconsistent. sight was out of mind. There was minimal Commission of 1957 highlighted concerns independent supervision of standards of care, about hospital conditions and occasional ‘There have been radical while treatments were limited and – to our hospital scandals hit the headlines through modern sensibilities – pretty barbaric. Outpatient the 1960s, 1970s and 1980s. Social policy improvements since clinics or other forms of community support were developed a more libertarian view of mental few and far between. Those with less serious illness and new welfare benefits enabled people 1948. But the job is by problems generally made do as best they could in to survive in the community, even if they were family settings. not capable of work. no means done and we are Yet mental health services nearly did not make However, there were no overnight changes. it into the NHS. The chief medical officer’s report For many years after 1948, life in mental faced with new challenges’ of 1946 which looked forward to its creation hospitals continued much as before, with bed made no mention of mental health, and some numbers peaking at over 150,000 in the mid- An attempt to address these inconsistencies politicians argued that it should be the preserve 1950s. Asylums only started to close in any was behind New Labour’s generally admirable of local authorities rather than the NHS. The numbers in the late 1970s and early 1980s, programme for modernising mental health eventual decision to include mental health although many had by then transferred some services. This involved a national service services was hugely important in bringing patients to general hospital psychiatric wards or framework for mental health and specific service psychiatry into the broader family of medical to the community. provision targets overseen by a National Institute disciplines, legitimising its professional for Mental Health, all driven from the centre by a aspirations and establishing mental hospitals and Community care national director. Importantly, all this was backed staff within the same operational framework as Alternative community services were prompted by significant new money. other health services. by new legislation setting out local authority There have been radical improvements since The most evident change in the provision of responsibilities of care. The Mental Health Act 1948. The regimented tyranny of the old asylums specialist mental health services over the past 60 1959 gave impetus to local authorities to develop is a thing of the past. There is a national years has been the move from first-line treatment a range of community support such as group framework for services, some good empirical in hospital to first-line treatment in the homes and day centres for those who did not evidence for what works best and comprehensive community. The mental hospital population has need hospital care. In 1961, at a conference of the guidance for professionals on best practice. The fallen from 145,779 in 1948 in England and National Organisation for Mental Health (later workforce has expanded and achieved greater

Workforce hospitals in 1948 would be community development (“particularly valuable” with much covered by Since 1948, the mental amazed by the range and workers… the list goes on. in the treatment of guidance from the National health workforce has seen nomenclature of mental schizophrenia) and Institute for Health and enormous growth in health professionals Treatment prefrontal leucotomy Clinical Excellence. numbers and professional today: psychiatrists, The 1950 Ministry of Health (believed to have a However, the continued acceptance. psychologists, psychiatric report set out the various “usefulness” in “properly focus on medication, the Psychiatry was then a nurses, primary care mental treatments available in selected cases”). efficacy of which has been relatively new medical health workers, support, hospital. It highlighted It would be good to think publicly questioned and discipline and the time and recovery workers, therapeutic convulsion that a considerably more which can have severe side establishment of the Royal specialist advocates, prison treatment (“a potent humane and evidence- effects, the sheer quantity College of Psychiatrists in inreach staff, approved weapon for cutting short based approach to of prescribed drugs (over 1971 proved a landmark. social workers, child and depressive illness”), treatment exists today – 90,000 prescription items Staff working in mental adolescent services staff, insulin shock treatment which of course it does, for antidepressants issued a STAFF, PRACTICE AND AND PRACTICE STAFF, FOR CHANGES PATIENTS: 1948 SINCE ALL

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34-35-mental health-jm-as-JW/jm/SJ/JW.indd 1 24/6/08 10:36:50 ALWAYSALWAYS OONN OOURUR MINDSMINDS

professional recognition. The patient voice is slowly growing stronger. Treatments are more humane and care standards are better monitored. But the job is by no means done. Our understanding of what causes mental illness remains uncertain and diagnosis can be an inexact science. Prevalence rates remain obstinately high. Services remain cash-strapped, many with limited access for patients. Reports of overcrowding, poor environment and staff shortages in hospitals are common to both 1948 and 2008. Legislation remains focused on compulsion rather than rights. The stigma attached to mental illness remains and public attitudes and behaviour are often negative. And we are faced today and in the future with new challenges, such as the increasing numbers of patients with substance misuse problems, high levels of diagnosed disorders among some black and minority ethnic, refugee and asylum seeker communities and an increasingly ageing population creating a dementia “time bomb”. We should rightly applaud the advances made in the past 60 years and recognise the contribution of the thousands of NHS staff who have been – and remain – committed to caring for people with mental health needs. But we still experience the “difficulties and discontents” of 10 years ago. To progress, we must constantly be developing new ways of working with service users and effective new interventions. ● Simon Lawton-Smith is head of policy at the Mental Health Foundation. CORBIS, SCIENCE PHOTO SCIENCE CORBIS,

day) and the lack of 1972) established a recent years. As mental local service user groups available alternatives national organisation health system survivor across England, many of suggest treatments that could lobby for Peter Campbell says in which have established have not advanced as better services, the Beyond the Water some local involvement rapidly as might have creation of the NHS did Towers, a study of mental with services. been hoped. little to empower service health services: But the battle for users. Life in institutions “Speaking in broad genuine participation is Service user scarcely changed, and terms, in 1985 service a long way from being empowerment local community service users were nowhere; won, with real choice, While the creation of the developments were top- in 2005 they are involvement and National Association for down rather than everywhere.” influence still only a Mental Health in 1946 bottom-up. It has been estimated distant dream for many 1951: a patient receives electro-convulsive therapy. (which became Mind in Much has changed in that there are 700-800 service users.

34-35-mental health-jm-as-JW/jm/SJ/JW.indd 2 24/6/08 10:37:06 A ramshackle collection of impoverished hospitals dotted the NHS landscape in 1948. Anthony Harrison charts the transformation that has created the modern secondary care scene THE REINVENTION OF THE HOSPITAL he hospital sector today bears 1960s that a serious attempt was little resemblance to that of made to reshape those assets into a 1948. Back then the NHS national system of hospital T took over around 3,000 provision. hospitals previously run by local The 1962 Hospital Plan for authorities or charities. Now a few England and Wales represented the hundred much larger institutions first national attempt to provide an are carrying out much more work, acceptable standard of hospital with far more staff, and treating a services across the whole country. much wider range of conditions The plan proposed that the future than was possible in 1948. How has pattern of hospital services should this transformation come about? be based on the “concept of the The hospitals the NHS inherited district general hospital”. This were in poor shape. According to would bring together a dispersed NHS historian Charles Webster, it pattern of provision into a single was “a system verging on a state of institution offering nearly all the dereliction”, with decaying services required to serve a buildings, out-of-date services and population of 100,000-150,000 “untenable” staffing arrangements. people. Turning this “ramshackle and It acknowledged some hospitals largely bankrupt edifice” into a would provide some specialised modern system was inconceivable services for a larger catchment area “without revolutionary and also that small hospitals would reorganisation and a secular remain to provide maternity and increase in capital and revenue long-stay geriatric services, expenditure”. particularly in more remote areas. Surveys both before and after the Second World War had identified Second thoughts large variations in different parts of But almost as soon as the plan was the country in both the quality and published, second thoughts began quantity of hospital provision. to emerge. A third of consultant staff were For the next 40 years, a series of located in London while some parts documents – official, professional of the country had virtually none. and academic – argued for bigger Facilities were duplicated as a and for smaller hospitals, for result of parallel developments by general and for specialised hospitals local authorities and voluntary and for various combinations of bodies. these. Only a small amount of solid A maintenance backlog remains evidence was available to enlighten even now and some hospitals built the continuing debate. before 1948 remain in use. But the In the meantime, while the gross disparities between different debate continued, the role of the parts of the country have been hospital changed radically. Two reduced and most of the physical conflicting trends soon became fabric of the hospital sector has apparent: further concentration of been transformed through a services beyond that envisaged in massive building programme set in the 1962 plan on the one hand and motion by the New Labour dispersal away from the hospital government in 1997. sector on the other. It took a long time, however, From the time of its inception before the task of updating the onwards, the NHS reduced the hospital sector was addressed. number of hospitals under its While the need for both an control. Many facilities such as upgrading of the hospital system isolation hospitals had outlived their and a rebalancing of its resources in purpose while others were favour of areas of under-provision physically worn out. were evident, economic difficulties The 1962 plan lent impetus to the in the post-war period ruled out any process. Its emphasis on “general” immediate rationalisation and meant that both very small and modernisation. It was not until the specialised facilities were to be

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36-38_Hospital Evolution/jm/as.indd 40 23/6/08 19:32:37 THE REINVENTION OF THE HOSPITAL 36-38_Hospital Evolution/jm/as.indd 41 hsj.co.uk offer a higher standard of care. larger numbers of medical staff can equipment can be better used and larger hospitals, where expensive the scale of provision, has favoured evidence linking care outcomes to opinion, sometimes supported by more recent years, professional terms of staffing, it had to be. In hospital could do, the larger, in supporting staff. The more the own team of consultants and specialties available, each with its without a much wider range of hospital could claim to do that now physicians and general surgeons. No care with a handful of general all its population’s need for hospital hospital was expected to serve nearly specialties rapidly increased. medical knowledge, the number of With rapid and sustained growth in that made for further concentration. transferred onto a single site. closed and their activities Although accident and emergency of the service on offer has risen. change as concern about the quality has become a driving force for doctor in training. emergency by an unsupervised might be seen in accident and nature of their condition. They take” at the time, whatever the whichever specialist team was “on themselves under the care of medical emergencies found This meant patients admitted as to the main business of the hospital. was regarded almost as a sideshow recently, the emergency function emergency medicine. Until very through the development of This trend is perhaps best illustrated Emergency care under its control’ number of hospitals the NHS reduced the inception onwards, ‘From the time of its In 1962 the district general But other forces came into play In recent years, however, this area 3 July 2008 with effectively in other settings emergency cases that could be dealt Hospitals continue to treat community did not materialise. expected would be developed in the or polyclinics the hospital plan partially realised. The health centres community”. prevention and for care in the development of the services for complementary to the expected development of hospital services is do. It noted that “any plan for the hospital would do what only it could vision it embodied was that the hospital plan was published, the hospital to community. When the now in decline. number of inpatient days, which is moved upwards, except for the the past 60 years shows they have number of diagnostic tests – over of clinics, number of admissions, hospital activity – be it the number Every broad indicator linked to require any inpatient stay at all. short. Many procedures do not care. Lengths of stay are typically role of the hospital is now in acute entirely. into other settings or out of the NHS most mental health services moved people with learning difficulties and Long-stay care for the elderly and were losing their role in old ones. treatments became available, they their role into new areas as more particularly safety. clinical concerns about quality, cancer care, led for the most part by apparent in maternity, stroke and recent years. care have become common in in the name of safety and quality of proposals to close A&E departments district general hospital, while larger catchment area than a small feasible in units serving a much at all times. But this was only consultant presence in the hospital to ensure there was an emergency emergency consultants were seeking mid-1990s some accident and its own right in the 1970s, by the was only established as a specialty in That vision has been only And activity has moved from As a consequence, the dominant While hospitals were expanding Similar trends have been HSJ NHS60 anniversary supplement Ë 23/6/08 19:32:45 37 38

PHIL WRIGGLESWORTH 37Á and to carry out tests and procedures that do not require access to their expensive and specialised facilities. Nevertheless their role has been effectively diminished as a result of new medical technology, particularly drugs. This has enabled GPs and other professionals to care for patients, especially those with long-term conditions such as diabetes without recourse, except in emergencies, to hospital facilities. This development has been strengthened in recent years by changes to the GP contract and other measures which reward the provision of structured care to people with long-term conditions.

Closer to home In addition, governments from the early 1990s onwards have actively promoted the notion of “closer to home” through schemes such as hospital at home. This policy gained a new impetus with the 2005 publication of the white paper Our Health, Our Care, Our Say, the government’s response to the finding of patient surveys which supported the notion of care assumptions on which it was based prevention or anticipation of need closer to home. This set in train a ‘The only safe would be undermined by and care is more widely dispersed. number of initiatives designed to developments in medical In such a world, the demand for reduce the hospital’s role; the latest prediction is that technology that transformed the large acute hospitals would tend to manifestation of which can be hospital sector. Any prediction now shrink. found in Lord Darzi’s proposals for healthcare will keep is subject to the same risks. But unless prevention is more a network of polyclinics for London. being transformed The only safe prediction is that effective than it currently shows But the debate about the the healthcare sector will continue signs of being, dealing with appropriate structure of the hospital by new technology’ to be transformed by new emergencies will continue as the system and its relationship with the technology. There will be wider use hospital’s core business. And unless community services continues. of new private sector providers has of technologies such as telecare, mobile intensive care units become From 1997 onwards, government taken away some of the acute implants, robotics and gene an economic as well as a clinical has supported, largely through the hospital’s bread and butter business. therapies; new technologies such as possibility, complex procedures – private finance initiative, a massive As a result, the smaller acute nanotechnology will lead to albeit procedures carried out by hospital building programme – by hospital – often a district general innovative forms of diagnostics and clinician-controlled robots in far the largest in the NHS’s history. hospital built in line with the entirely new therapies. whatever country offers the best And the 2000 NHS Plan provided precepts of the 1962 plan – is beset combination of clinical skill and for a rapid growth in consultant by a range of forces tending to Online advice cost – will continue to be performed numbers. reduce or undermine its role. We might imagine a new form of in a central “place of safety”. But these commitments were On the one hand it is under medicine in which specialties are One message of the past 60 years made with only limited threat from pressure to transfer replaced by a new integrative is that the hospital can reinvent consideration of what the future some services to large institutions discipline based on a more itself by introducing new treatments role of the hospital and structure of and others to private sector or fundamental understanding of the and therapies. Any attempt to guess the hospital system should be. The community providers. genome and the functioning of the its future role involves taking a view NHS Plan paid little attention to In many parts of the country, body’s many sub-systems. as to where the introduction of new either. So while government proposals are on the table – The information resulting from technologies will lead. After decades encouraged hospital trusts to enter typically made in the face of fierce much more effective diagnostic of promoting large units – not just into contracts with the private local resistance – for either closure procedures would allow patients, in healthcare – the tide now seems sector for up to 60 years, it has also of facilities or more commonly for a advised by professionals, to take to be flowing in the opposite embarked on a series of initiatives reduction of roles from general charge of their own treatment much direction. But whether it will designed to reduce demand for their hospital to community facility with more effectively than they can now. continue to do so for the next 60 services. Lord Darzi’s proposals a narrower range of services. They would be able to put years is anyone’s guess. ● suggest it is set to pursue that aim But although so much has themselves online for monitoring, Anthony Harrison is a senior even more vigorously. changed during the past 60 years, advice, or even resetting of their associate of the King’s Fund and the At the same time, pressure for the the essential issues remain the inbuilt control panels. co-author of Acute Futures, a study creation of larger units continues to same: how to get the right balance, The hospital would remain – as it of hospital policy. be driven by the same combination for the full range of hospital always has been – a place of last of factors that has operated for the services, between quality, access and resort, but for ever fewer numbers Find out more past 20 years but with the addition cost. The same lack of evidence of people. ËThe Health Services Since the War, of new ones. In restricting the hours about the benefits of different In the shorter term, news of the Volume 1: Problems of Health Care, of junior doctors, the European configurations also persists. hospital’s imminent death may be Charles Webster, HMSO, 1988 working time directive has made it The authors of the 1962 plan exaggerated. The future that ËThe Hospital: from centre of excellence harder for small units to maintain could not have anticipated as they current trends suggest is one where to community support, Norman Vetter, 24-hour cover. And the introduction wrote it how soon the main more resources are devoted to Chapman and Hall, 1995

38 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk

36-38_Hospital Evolution/jm/as.indd 42 23/6/08 19:32:53 WANTED: FEMALE ORDERLY, MUST BE CHRISTIAN Emma Dent on six he birth of the NHS saw the were now separate sections for work posts no longer appeared, Public Assistance Journal and professional and technical public health positions – decades of job Health and Hospital Review appointments and for administrative, particularly those working in HIV/ T get a new name. But in the clerical and supervisory roles. Jobs AIDS services – were featured adverts in HSJ first few issues of the Hospital and as diverse as home work organiser, regularly. The private sector Social Service Journal, there were few home teacher of the blind, and increasingly reared its head, with – and how they have advertisements for the then new handwork instructor all appeared in overseas and private healthcare been a barometer role of administrator. the former section. The latter covered firms promising higher pay than the Indeed, in the first weeks of the everything from a shorthand typist NHS. The service fought back, using ofof ppolicyolicy new service, most jobs continued to to male clerk and organising glossy recruitment companies to be for roles advertised by councils secretary (woman). But adverts for appoint to senior roles. rather than the new hospital nursing and ancillary staff, as Fast forward to the 1990s and a management committees. orderlies, cooks and “experienced post-internal market and more Roles in local authority on steam stokers” were now termed, business-like NHS. Although services such as children’s homes, still took up many pages. readers in 1948 might have foster homes, homes for elderly recognised adverts for jobs such as people and approved schools were The hard sell outpatients manager and patient still common. Domestic jobs such By the 1970s the jobs pages took on services manager, areas of work as resident cook, laundry a more professional look. On such as corporate services and superintendent, maids or even adverts for senior posts, the logos of barbers were as likely to be organisations began to appear, ‘What, readers advertised as those for nurses, giving candidates the opportunity to physiotherapy or matrons. compare the design taste of varying in 1948 might When hospital management health authorities. Organisations committees did begin to advertise, it also began to actively sell themselves have asked, is was still for nursing and midwifery on their location, and facilities for roles, perhaps unsurprisingly as staff. “A new and demanding post in a business manager many pages in the Journal were still a magnificent setting,” trilled one. taken up with discussions over what But although in the post-Sex doing in the NHS?’ remuneration and service Discrimination Act days of 1978 conditions should be for NHS references to the gender of commissioning would have not administrative and clerical staff. prospective candidates were a no- been so familiar. What, they might Gradually however adverts began go, subtle references to potential have asked, is a business manager to appear for roles such as senior candidates’ ages still made it in. The doing in the NHS and what is a salaries and wages clerk. It was the most senior administrator posts director of strategic development? start of a trend for HSJ adverts to such as district administrator were In 2008, many of the ads are for act as a barometer of policy in the also appearing in job pages. posts that would have not been emerging health service. Adverts for clerical officers were heard of in 1948, including many By late 1948 more jobs such as appearing in force, but those for roles in the private sector. Salaries supplies officer, finance officer and building, engineering and ancillary are at a level beyond the dreams of chief clerk in charge were staff still featured. Clinical jobs such 1948 staff. The commercialisation of appearing, although nursing and as occupational therapists and healthcare is also increasingly in domestic jobs continued to audiologists and those in social evidence, with roles for contracts dominate. Whatever the role, work were also still being managers and risk managers. discrimination was given little advertised, catering, one presumes, But some things remain: thought. In addition to salary, the for the broad church of Health and organisations still assert that joining age, gender and religion a candidate Social Service Journal readers. them could be a life-changing should be were also often stipulated. By the time the NHS turned 40 in experience; and if a job in As the NHS turned 10, job adverts 1988, the magazine had become healthcare is worth having, it still had changed little, although there Health Service Journal. While social appears in the jobs pages of HSJ. ●

hsj.co.uk 3 July 2008 HSJ NHS60 anniversary supplement 39

39 jobadsAS-tj/JW.indd 2 23/6/08 19:35:21 name, multidisciplinary teams have been around for a long time. “The role of the senior nurse was pre-eminent as a director of quality and they were usually just the person the junior doctor would learn from and go to when they were stuck,” Dr Cheshire explains. “Teams have THE TEAM certainly grown, with occupational therapists and speech and language therapists for instance joining them. “In my experience, it was only where things weren’t working well that doctors had an undue influence over the functioning of a team. I have worked with nurses, therapists and medical colleagues who have all equally been team members and DREAMThe germ of multidisciplinary teamworking existed even in 1948 tremendous clinical leaders.” Pyramid of power and has blossomed in recent years, reports Stuart Shepherd Others, however, including Robert Arnott, director of the Centre for the ultidisciplinary clinical tutor at St Mary’s Hospital perceptions. “Doctors weren’t ruling History of Medicine at University of teamworking is well in Portsmouth, something of its the roost. It was much more the Birmingham, are less persuaded. established throughout ethos was evident in the pioneering case that they and nurses formed “Multidisciplinary teams have M every sphere of NHS spirit associated with the formation parallel hierarchies, where each only really emerged in the last 20 activity, clinical and beyond. In fact, of the NHS. group and each level within it knew years,” says Professor Arnott. “You it is hard to imagine a type of care “We were very much a family, its place and responsibilities,” says just to have to look at films like where the mutual collaboration and working together and relying on Dr Rivett. Doctor in the House [made in 1954] reliance it engenders is not central each other at a very exciting time, to “Senior nurses had no problem to get an accurate sense of how the to doing best by the patient. improve standards, fight hospital looking after their own interests and hierarchy operated. The consultants Its universality, however, is infections and work with new God help the young house officer were at the pinnacle, with junior matched by a lack of uniformity processes and equipment. You had who was disrespectful of a ward doctors, nurses and others beneath across and even within organisations. to have good working relationships sister. His chief and the matron them. This pyramid of power existed Membership can vary and is often and a regard for each other. It was would have had him for dinner.” before the NHS came along and fluid, in turn an indicator of the the only way to survive with such Mike Cheshire, who qualified in 1948 did nothing to change it.” informal origins of many a changing patient population,” 1976 and has since gone on to According to Professor Arnott, the multidisciplinary teams and their she recalls. become clinical vice president of the make-up of the modern-day team organic qualities of development. It is a sentiment that Geoffrey Royal College of Physicians and a depends to some extent on the To what extent they existed in Rivett, a former GP and civil servant consultant at Manchester Royal personality of the medical 1948 is debatable. For those such as and now NHS historian shares and Infirmary, believes that while they consultant. The occasional irascible Mary Verrier, who at the time was a one that challenges common might have gone by a different Sir Lancelot Spratt can still be

40 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk

40-41 multidiscipline-jw/jm.indd 1 23/6/08 19:36:36 40-41 multidiscipline-jw/jm.indd 2 attributes make a modern doctor, when I asked candidates what panels for medical students and kind of role model. found, but is far from being any hsj.co.uk effective machine. Boundaries were any longer as simply a cog in an even unconsciously, considered itself medical schools, neither profession, eligibility for entry into nursing and of discipline and a widening of the colleges, societies and unions. the spheres of influence of collective walls of the hospitals and outside Others include forces beyond the themselves within the system. associations sought to reposition come about as different groups or over the last 60 years. Some have refashioning of the clinical team been at play in the fashioning and becoming more integrated.” and in many ways the team is increasing amounts of autonomy health professionals are gaining are emerging, nurses and allied assistant and anaesthesia assistant professions such as the clinician’s adds Professor Arnott. members of an integrated team,” they are signing up to become surviving the course. look favourably on their chances of of commander-in-chief, we didn’t are at the top of the pile, some kind skills. If they thought that doctors teamwork and communication I was looking for two things: good “I recently sat on admissions “Come the 1960s, with a relaxing Many and varied factors have “These are exciting times. New “They need to understand that

long time in the making. by today’s standards, have seemed a changes in status and practice may, as they were, some of the resultant roles and responsibilities. Welcome contributed to the renegotiating of increasing personal liberties all living, shifting social mores and Improvements in the standard of Professional status not angels,” says Dr Rivett. proclaiming themselves as workers, unions marched with placards from a feminist perspective and the in nursing began to rewrite roles challenged, educational influences working continue to be shaped by College of Nursing Jane Naish. says policy adviser at the Royal the person best suited to deliver it,” but rather a position to be taken by matter for one particular profession of clinical lead in a team is not a a joint statement saying that the role Royal College of Physicians released the Royal College of Nursing and broken down. “Just a few years ago with our armoury of treatments.” could and did achieve for patients more than the doctor about what we was clear even by then that we knew more or less as technicians. But it chair Sarah Bazin. Chartered Society of Physiotherapy autonomous practitioners,” says should be entitled to function as it was agreed physiotherapists in 1920, but it wasn’t until 1977 that “Our royal charter was granted Dynamics within multidisciplinary Such boundaries are now often “Prior to this we had been seen

communication skills’ good team work and needs two attributes: ‘A modern doctor 3 July 2008 the community.” how we might get rid without walls’ to start looking at coined the embryonic term ‘teams and General Practitioners have foundation trusts,” says Dr Cheshire. across general practice and model that can work, for instance, secondary care interface, with a service spanning the primary and start looking at teamwork is in the dramatic changes is the community. perhaps undergoing the most multidisciplinary working is management, the arena where term conditions under self- on supporting patients with long- nearer the home and more emphasis With the shift to care delivered Teams without walls belong neither in the hospital nor form flexible new services that of multiple transaction costs and care at times. single-handedly managing patient members other than the doctor are practitioner roles mean team clinical specialist and nurse care environment, nurse consultant, modern matron now looks after the professional groups. While the huge impact on the parts played by cohesion. around continuity of care and team medical staff and created difficulties patterns particularly of junior Time Directive has changed working recent years the European Working internal and external forces. In “The Royal Colleges of Physicians “The next place that we really Modernisation has also had a HSJ NHS60 anniversary ●

supplement 23/6/08 19:36:38

41

ALAMY here has been no yyouou havehave successfulsuccessful clinicalclinical buy-inbuy-in overarching policy on the Experts predict a future in which primary iintonto whatwhat youyou areare doing.doing. YouYou cancan future role and nature of care will be delivered by a variety of wwriterite lovelylovely plansplans butbut theythey maymay T primary care since the nneverever comecome toto fruition.”fruition.” Conservatives left power in 1997. suppliers in integrated packages tailored to BButut NHSNHS AllianceAlliance chairchair DrDr MikeMike Although the Labour government DDixonixon sayssays a lacklack ofof clinicalclinical has presented a raft of initiatives, individual needs, reports Ingrid Torjesen eengagementngagement remains.remains. “We“We stillstill havehave shifting care out of hospitals, re- a veryvery strongstrong hierarchicalhierarchical investing in community services mmanagerialanagerial cultureculture inin thethe NHSNHS and increasing the focus on wwhichhich containscontains intrinsicintrinsic antibodiesantibodies prevention and self-care, these going to see gay and lesbian Confederation’s PCT Network David ttoo realreal clinicalclinical engagementengagement andand realreal objectives have not been articulated suppliers, ethnically based suppliers Stout does not think top-up payments ppublicublic involvement.involvement. ThereThere isis almostalmost into a real vision of what primary and in particular long-term would have much impact on the a tussle between the PCT and the care should look like. So says Nick condition suppliers,” he says. way care is commissioned because he practice-based commissioner as to Goodwin, a senior fellow in policy at “If you have Parkinson’s, that is sees commissioning becoming much who is to commission. The patients the King’s Fund. the dominant factor in your more individualised. Patients could and frontline clinicians should be “You have a conflicting vision at existence and you want somebody even start commissioning, as has the commissioner. The PCT’s role is the centre and that filters down to who is going to manage your care been intimated by Gordon Brown. to make sure that they are enabled GPs and others providing the care,” with that in mind. It’s bonkers that “You can pitch it as choice rather and empowered to do so.” says Mr Goodwin. “They are saying if you suffer from that sort of than budget-holding, that sense of Mr Goodwin of the King’s Fund ‘what do they really want us to do?’” condition, you still have a GP who individual control over what it is says that, although he can see the What patients require is doesn’t know anything about it.” they actually access, making choice benefits of taking commissioning changing. If the 20th century was Mr Manning anticipates that the of not only provider but also type of closer to the patient through characterised by the demand on review by health minister Lord care for themselves,” he says. practice-based commissioning, episodic hospital care for acute Darzi will take the first steps retaining a commissioning role for illnesses, there is now a growing towards integrated suppliers by Potential changes PCTs is vital. “While a GP is good at need to manage the long-term allowing foundation trusts to move Just as primary care is being assessing the needs of the patient in incurable conditions of an ageing into primary care, effectively cutting encouraged to take work from front of them or perhaps the population. Although the government out the primary care trust as secondary care, Mr Stout expects to patients on their list, they are really has recognised that this will require middleman. He adds that extension see some hospitals running primary not capable of being able to integration of services – both lateral of choice may allow patients to opt care services. He says going fully understand what the future and vertical – it has not made it to have their care provided by down the route of a US-style demographic needs are of the clear how the work should be done. practitioners from outside their PCT insurance-based system would not people in their community.” Mr Goodwin says the demand for patch, particularly in urban areas. be impossible, but would be Professor of health policy and more personalised care will require He believes it is “inevitable” that “hellishly disruptive” as it would management at the University of multidisciplinary “medical homes” there will be some kind of co- require massive reorganisation. Birmingham Chris Ham says the rather than GP practices. Such payment system. “The government However, if world class problem with world class homes will not only care for common will be driven down that route commissioning does not deliver, commissioning is that the PCT is illnesses and refer patients on but simply by the fact that legally they this is a potential route forward. But the commissioner and separate also help co-ordinate medical and won’t be able to stop it.” the general view is that world class from providers, whereas it is social care. He predicts the quality One patient with cancer has commissioning cannot fail, only important to “muddy the waters”. and outcomes framework will recently taken legal action after PCTs can – and if they did, there “If you are both a commissioner evolve to “some collective incentive health secretary Alan Johnson ruled would be consequences. “A health and provider and the incentives are to manage the person”. she was not allowed to top up her system that appears not to be strong enough, it enables you to do Health consultancy Newchurch NHS chemotherapy with drugs working tends to get reorganised,” a lot more work in a cost-effective chief executive Kingsley Manning bought privately. If she or someone Mr Stout says. way under your own steam rather believes such care management else is successful in court, the Clinical engagement will be vital than always having to place organisations will evolve to reflect market for co-payments will to the success of world class contracts with other people.” patients’ requirements and explode, says Mr Manning. commissioning, he adds. “You can’t He acknowledges this

JANET SKIDMORE, PHIL SOFER, GETTY SOFER, PHIL SKIDMORE, JANET characteristics. “I think we are Director of the NHS be a successful commissioner unless arrangement results in a conflict of

42 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk

42-43 primarycarefuture/ASasSJ/JW.indd 1 23/6/08 19:39:26 interestinterest butbut sayssays whatwhat isis neededneeded isis mmoreore effectiveeffective PCTPCT oversightoversight ofof servicesservices providedprovided byby commissionerscommissioners ttoo ensureensure theythey areare valuevalue forfor money.money. EEmpoweringmpowering cliniciansclinicians toto tailortailor sserviceservices toto communitiescommunities isis alsoalso thethe rrightight wayway toto gogo aboutabout integratingintegrating sserviceservices ratherrather thanthan rigidlyrigidly imposingimposing mmodelsodels suchsuch asas polyclinics,polyclinics, ProfessorProfessor HHamam says.says. “If“If youyou givegive eentrepreneurialntrepreneurial GPsGPs andand nursesnurses inin pprimaryrimary carecare thethe toolstools toto dodo thethe jobjob ttheyhey willwill workwork outout whatwhat isis mostmost aappropriateppropriate forfor theirtheir areas.areas. I don’tdon’t tthinkhink thethe government’sgovernment’s jobjob isis toto ccomeome upup withwith a blueprintblueprint forfor a newnew ppolyclinic-typeolyclinic-type modelmodel becausebecause itit isis nnotot goinggoing toto workwork everywhere.”everywhere.” GGPsPs worryworry polyclinicspolyclinics areare a wayway ofof bbringingringing competingcompeting privateprivate firmsfirms ‘I‘I tthinkhink wwee aarere goinggoing ttoo sseeee ggayay aandnd lesbianlesbian ssuppliersuppliers andand eethnicallythnically bbasedased suppliers’

into primary care. Professor of social policy at the London School of Economics and a former Number 10 adviser Julian Le Grand does expect big corporate players such as Virgin and United Health to get more work, especially as United Health’s experience in Derbyshire (where it runs two GP practices) has been positive. But he adds: “I don’t see the GP driven out of business.” Instead he says competition will “ginger up” GPs a bit and improve their services with, for instance, longer opening hours. “In 30 or 40 years’ time, I see a fairly competitive environment but still with GP small businesses being the dominant provider,” he says. ●

hsj.co.uk

42-43 primarycarefuture/ASasSJ/JW.indd 2 23/6/08 19:41:23 t is unlikely there is an NHS it as shallow and as short-lived as to recognise and acknowledge the If any of the first three factors is chief executive in the land who possible.” emotional cycle associated with missing or low, then change will not has not experienced first hand A typical public-private transition at the start of the process. take place successfully because the I the emotional cycle of policy partnership scheme, especially the Part of this is to communicate policy will not be capable of introduction. Best described as a large new hospital private finance honestly to all stakeholders at the overcoming resistance. transition curve (Fisher 2006), it initiative schemes currently being outset that things will go wrong and Tribal director John Farenden starts on a high when an initiative is built, provides an example of the will fail, but to see this as part of the says: “Gleicher’s equation is a really first introduced. At this point, natural curve at work. Everyone is implementation journey and to useful tool for NHS policy people are highly motivated, focus more on the destination and implementers. It’s also highly inspired by the promise of a better the steps to reach it. desirable that it is applied locally, way forward and the vision of a ‘Communicate to all because the value and applicability brighter future for patients. stakeholders at the Final prize of any new policy will vary from one Later, on realising the enormity “If people know it’s going to place to another. of the work involved, enthusiasm start that things will happen, they will not be surprised,” “If, in carrying out an begins to dip. Frustrations creep in, says Mr Keenan. “But nor will they assessment, the implementer finds perhaps caused by unforeseen go wrong but this is expect to be kicked when they are that any of D, V or F are absent or resistance to change, lack of down. The chief executive’s job is to low, it is up to them to devise capacity or resources, or simply part of the journey’ support them through the low ebb strategies to strengthen the first half delays in getting things off the and keep them believing. Tribal’s of the equation and ensure the ground. At this lowest ebb, it is easy role in working on NHS policy product of the factors for change is to lose focus and find justification on a high when the investment implementation is often to keep greater than resistance or inertia.” for lesser performance. proposal is approved by the everyone’s eyes on the final prize Rather than ignore resistance or But the policy implementer’s job Department of Health, but through being less emotionally inertia, implementers should work is not to return the policy to whence confidence begins to fall as they attached.” to understand where it comes from it came, saying “sorry, it can’t be spend two or three years waiting for Of course, it is not enough to so that they can successfully identify done” but to carry on and find the it to reach financial agreement with deliver the warning, stand back and the levers available to help them way back up. A strong vision of the private sector partners. hope for the best. For any policy to tackle it. Strategies aimed at helping destination point which is clearly It often falls a little more when succeed, a leader has to first ensure stakeholders recognise that and consistently articulated by they realise the facility will not be as the seed of change falls on fertile, leaders can help the tide to turn and they envisaged, or that time has not stony, ground. Gleicher’s change start to improve things. Some early moved on and it needs to change equation D x V x F > R provides a and tangible results help to grow a shape with new service models. It is useful framework here. broader support base. This might be at this nadir in the emotional cycle According to Dr David Gleicher, a start date for a new development that some good news arrives as associate professor of economics at or a reduction in waiting times. innovative health planners and Adelphi University, New York, in “The point is not to fight the architects work out how a new order for change (or policy) to be emotional cycle, but to understand facility and service can be made successful, the product of that it will happen and that it is affordable. A start date is set and the Dissatisfaction with the status quo, usual,” says Tribal business curve is back on the up. the Vision of a more desirable future development director Tim Keenan. The point at which everyone hits and the knowledge of the First “Once implementers accept this, the base of the curve is obviously concrete steps to moving towards they can start to plan how they too late to start managing that future, must be greater than the might best manage the dip to make expectations. Instead it is imperative Resistance to change.

The Tribal consultancy says policy change sets off an emotional cycle in those affected – but resistance can be smoothed out OIL IN THE

WHEELS44 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk

44-45 Tribal-sponsor-jmas/JW.indd 1 23/6/08 19:42:37 44-45 Tribal-sponsor-jmas/JW.indd 2 programmes and development, it central support for training messages about competencies and by providing clear and consistent effectiveness at commissioning. But about their own skills and inertia may be caused by PCT fears care trusts. provides expert support for primary Support for Commissioners, which Framework for procuring External steps include publication of the the vision via roadshows and first new vision. Work is underway to sell lots of people are signing up to the commissioning status quo because see there is dissatisfaction with the world class commissioning we can clearly help map the first steps. communications programme can designing an articulate Using strong role models and to show the benefits of change. polls and pointing to best practice highlighting trends and opinion dissatisfaction exists would include hsj.co.uk The DH recognises resistance or If we apply Gleicher’s equation to them the momentum they need to outside organisation could give to go round. Support from an only so much management energy should be acutely aware that there is fits − to manage the mix − but they make the decision about how it all balance is restored earlier. of the change period, normal the critical friend leaves at the end policy. This often means that when to the implementation of new the energies of all their own people capacity without having to divert executives can increase interim of consultancies such as Tribal, chief change. By drawing on the expertise the dissonance associated with on the end vision, while managing helping organisations stay focused a critical friend well versed in dip is to bring in external support – class suppliers. commissioning and procure world implement world class can tackle this by helping them It is up to chief executives to Another way to prepare for the value is added’ is often where most emotional support enthusiasm and ‘Delivery of energy, value is added. For example at and yet that is often where most enthusiasm and emotional support ask for delivery of energy, “deliver tasks”, but rarely do they working effectively making sure existing policies are between introducing new policy and introduction. It is a fine balance stagger the start point of each policy around the implementation task. much needed injection of positivity is at its lowest. And it can supply a keep driving forward when energy Clients often ask Tribal to help Chief executives also need to 3 July 2008 they did it themselves.” programme, is that the client thinks success, come the end of the so that it’s all sustainable. Our to develop confidence and capacity change team. We then transfer skills way that we can celebrate with the there are some quick wins along the programme deliverables, ensuring momentum going by focusing on everyone knows what is happening. operationalise new thinking, so that patients and carers on how to consultation events with NHS staff, formed the basis for a series of Investing for Health strategy as in the West Midlands where the strong communication programme, profitability. effectiveness, efficiency and dramatically to improve Programme Enterprise, aiming forward changes as part of the alongside the trust staff to drive with our partners Boxwood Dudley Hospitals trust we worked Mr Keenan says: “We get the We also ensure we design a HSJ NHS60 anniversary supplement ● 23/6/08 19:42:43 45

KELLY DYSON RUNRUN WITHWITH A RODROD OOFF IIRONRON

rom large London teaching called on a hospital secretary’s hospitals to modest municipal The formation talentstalents forfor discretiondiscretion andand diplomacy.diplomacy. facilities and public assistance of the NHS But it was rare for junior F institutions, the foundation of managementmanagement andand clericalclerical staffstaff toto the NHS covered brought together havehave writtenwritten protocolsprotocols onon howhow toto a vast array of organisations. conductconduct themselves.themselves. TheirTheir proximityproximity Along with this mixed heritage many different toto locallocal powerpower brokersbrokers waswas reminderreminder came staff, many already imbued enoughenough thatthat theythey werewere honour-honour- with, and stridently loyal to, the organisations, with boundbound toto upholduphold thethe hospital’shospital’s histories and traditions of their own reputation and traditions. particular place of work. their own ideas of BButut oneone rulerule extendedextended toto justjust And while most of the 1,100 hierarchy, writes aboutabout everybodyeverybody workingworking inin a 19481948 voluntary and 1,500 municipal hospital:hospital: youyou diddid notnot wanderwander onon toto hospitals would fall under the Stuart Shepherd a wardward withoutwithout sister’ssister’s permission.permission. control of new regional health NursingNursing waswas a prestigiousprestigious careercareer boards, teaching hospitals remained tended towards the practices of thatthat attractedattracted talentedtalented candidates.candidates. accountable to the secretary of state. voluntary hospitals. CompetitionCompetition forfor trainingtraining placesplaces atat “The Ministry of Health was not Eric Smith, who at the time held thethe teachingteaching hospitalshospitals waswas toughtough going to get too involved in telling junior clerical roles in Hampshire, andand matron,matron, thethe seniorsenior nursenurse whowho these landmark institutions – which says: “Virtually on the appointed alsoalso ranran eacheach institution’sinstitution’s schoolschool ofof had previously been answerable to day of the start of the NHS, the nursing,nursing, hadhad herher pickpick ofof thethe crop.crop. ItIt nobody other than the Charity house governor of the Royal isis widelywidely heldheld thatthat sometimessometimes sheshe Commission – how to set out their Southants voluntary hospital pickedpicked a certaincertain “look”“look” withwith whichwhich management structure. So they became group secretary of the a hospitalhospital becamebecame associatedassociated – palepale simply rolled the previous one hospital management committee. andand willowywillowy atat London’sLondon’s StSt Thomas’Thomas’ forward,” says NHS historian This made him responsible not just Hospital,Hospital, forfor example;example; petitepetite andand Geoffrey Rivett, a former GP and for what had been his own hospital outgoingoutgoing atat thethe RoyalRoyal London.London. civil servant. but also a number of other hospitals A mutuallymutually highhigh regardregard existedexisted “In fact, such was their relative and institutions in the 20-mile betweenbetween thethe matronmatron andand nursingnursing autonomy, it is said that the chief radius of the new catchment area. sisterssisters andand seniorsenior consultants.consultants. executive at Bart’s (then known as “There was a deputy group ““AsAs a juniorjunior doctor,doctor, ifif youyou offendedoffended the treasurer) never opened a letter secretary under him and then youryour wardward sister,sister, youryour bossboss wouldwould from the ministry unless he knew in gradually posts like group soonsoon findfind outout andand pullpull youyou intointo line,”line,” advance it contained a cheque.” engineering manager, group sayssays DrDr Rivett.Rivett. “Sisters“Sisters werewere a In a large voluntary hospital, the catering manager and so on were permanentpermanent fixturefixture andand eveneven inin 19481948 treasurer, otherwise known as the recruited too.” manymany ofof themthem hadhad accommodationaccommodation governor or bursar, was accountable onon thethe wardward andand wouldwould sleepsleep overover to the management board. They The real power somesome ofof thethe time.time. TheThe consultantsconsultants typically worked with the consultant In Torquay, Fred Payne had been tooktook theirtheir long-termlong-term observationalobservational head of the medical committee, working as an administrator in public experience very seriously. a matron and finance officer. health. The 1948 reorganisation saw ““SisterSister waswas alsoalso thethe keeperkeeper ofof thethe Local authorities ran municipal him offered the committee clerk job consultant’sconsultant’s protocolsprotocols andand wouldwould hospitals, which by 1948 provided at Torbay for the South Devon educateeducate househouse officersofficers toto theirtheir at least three out of every four hospitals group – a management individualindividual ways.ways. AsAs juniorjunior doctors,doctors, hospital beds. The medical officer of committee made up of hospital staff, wewe livedlived inin thethe messmess andand werewere a county or city council oversaw GPs and lay members. alwaysalways onon call,call, butbut ifif a patientpatient several hospitals, each in turn “There weren’t many of us on the becamebecame illill inin thethe nightnight andand sistersister oror managed by a salaried medical administrative side and we worked staffstaff nursenurse knewknew youyou werewere tired,tired, superintendent, supported by long hours, including Saturday theythey wouldwould trytry toto protectprotect youyou andand various advisory committees. mornings. The group secretary was ask for someone else.” These traditions of management in charge of the hospital secretaries YYetet nursesnurses werewere expectedexpected toto bebe existed side by side until the 1954 and ran our hospital under a hardworkinghardworking andand subordinate.subordinate. Bradbeer report introduced a more tripartite system with matron and Self-disciplineSelf-discipline meantmeant keepingkeeping a uniform national model to the the chair of the medical staff spotlessspotless starchedstarched uniform,uniform, thethe service (with hospital secretaries in committee,” he says. shades and hues of which charge of administrative affairs, a Consultants and medical designated seniority. hospital management committee committees were powerful bodies, “You stood up when sister and a medical staff committee) that and working alongside them often came into the room and you

46 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.ukhsj.co.uk

46-47_1948 hierarchy-jm/as/JW.indd 1 24/6/08 10:31:35 ‘When‘When tthehe cconsultantonsultant wwasas about,about, yyouou sstoodtood wwithith yyourour handshands bbehindehind yyourour bback’ack’

openedopened thethe doordoor forfor themthem inin tended to have little to do with tthehe diningdining roomroom asas theythey left,”left,” anyone outside their own rrecallsecalls OlgaOlga Spavin,Spavin, a studentstudent departments. nursenurse inin 19481948 atat thethe nownow defunctdefunct As a former student at the WesternWestern GeneralGeneral HospitalHospital inin Hull.Hull. radiography school of the Newcastle “When“When thethe consultantconsultant waswas about,about, upon Tyne United Hospitals group, youyou stoodstood withwith youryour handshands behindbehind Ethel Armstrong clearly remembers youryour back.”back.” that its standards of discipline were NursesNurses livedlived inin andand observedobserved a the equal of any nursing school. curfew.curfew. MarriageMarriage waswas a barbar toto “The superintendent ran his continuingcontinuing inin thethe profession.profession. department with a rod of iron and “One“One eveningevening wewe werewere allowedallowed a strong sense of correctness,” she toto seesee a midnightmidnight screeningscreening atat thethe says. “We had inspection every locallocal cinema,cinema, butbut wewe hadhad toto bebe morning at 8.45 to make sure our escortedescorted byby thethe housekeeper,”housekeeper,” sayssays white coats were clean and properly MsMs Spavin.Spavin. “We“We werewere alwaysalways buttoned, that our brown brogues supposedsupposed toto backback byby 10,10, soso wewe usedused were shining and our stockings free toto keepkeep a keykey onon a piecepiece ofof stringstring of ladders. throughthrough thethe letterboxletterbox – untiluntil thethe “We used to sit with the homehome waswas burgledburgled andand allall thethe physiotherapists at lunchtime. Like furniturefurniture fromfrom thethe groundground floorfloor waswas us they belonged to an isolated strippedstripped out.”out.” team. The sisters had their own OtherOther clinicalclinical professionsprofessions dining table, as did the staff nurses. suchsuch asas physiotherapistsphysiotherapists andand If the students were allowed in, they radiographersradiographers werewere presentpresent inin mostmost would be at the back of the queue. hospitalshospitals inin 19481948 butbut inin relativelyrelatively Until matron had served everybody smallsmall numbers.numbers. ConsideredConsidered and said it was all right, nobody supplementarysupplementary byby some,some, theythey thought of starting their meal.” ● ON YER BIKE: MEMORIES OF A 1948 MIDWIFE Having worked as a general nurse for without complications, I would several years, Mona Williams began deliver the baby on my own and only midwifery training in 1948. As a called the doctor for abnormal county midwife for Cheshire council, presentations.” she attended Ms Williams lived with thousands of home her mother in a house with births in the a door plaque so district of everyone knew Hoylake where the midwife on the Wirral. lived and was on call 24 hours a “I helped day, six-and-a-half days a week, with mothers who had one weekend off a month. chosen a home “I cycled everywhere for birth to prepare the first few years,” she says, and themselves and during a labour she would “send their home. When the husband to our house to collect the time came and the gas and air because I couldn’t labour progressed carry it”.

Medical transport, the old way. GETTY, HULTON ARCHIVE HULTON GETTY,

hsj.co.uk 3 July 2008 HSJ NHS60 anniversary supplement 47

46-47_1948 hierarchy-jm/as/JW.indd 2 24/6/08 10:32:19 A DAY IN OUR LIFE t is easy to see the changes of something utterly mundane. the past six decades in terms of But this ritual would go on the big political shifts. But there for an hour, after which the I is another story to tell about the director would jump to his small changes to daily life. feet and announce that he Managers of the early decades of had to rush to a meeting. the NHS describe a world that is “I thought that if almost unrecognisable today. I ever got to a position Almost no one drove to work, of authority, I would not everyone wore a collar and tie and run an office in that addressed seniors as Sir or Mr – way,” adds Mr Brown. there were no senior women to address. Formally speaking “Ties were a must,” says John Forms of address Roberts, who started work as a remained formal until national trainee in the service in quite recently: no one 1962. “I remember one trainee would have dreamt of The daily life of an NHS turned up in a black jacket and calling a senior by their first striped trousers, but it was still name before the 1980s. manager has changed common to be wearing stiff collars, As Mr Roberts says: “It was double cuffs and cuff-links.” usual to address the chairman hugely since 1948, As a trainee, he attended as Sir well into the 1980s, but says Daloni Carlisle Thursday evening dinners at the then where I worked, most of King’s Fund, where “they them were knights. In 1978 some complained at the cost of passing were shocked when the new the port round twice”. regional chief medical officer Mike Brown, who joined the breezed in, telling everyone on management training scheme in his staff to address him by his 1967, recalls a daily ritual at a forename.” infection regional hospital board where he Even as recently as the 1990s, control worked for one of the directors. etiquette was very different from the saw this “He would get the post in the way it is today. Lyn Darby, who change within my morning and have his whole team joined the NHS on its 50th first year and female gather for the post meeting,” says anniversary in 1998, says: “The managers were asked to wear Mr Brown. Eight to 10 staff would relationship with senior managers skirts, as trousers were felt to be watch as the director took the first and particularly the senior medical untidy. Before my first day in one was promptly sent to town to buy a letter from the pile and ritually staff was quite formal, though this trust, I received a phone call tipping skirt and not to return till I had opened it, before discussing its may just have been because I was a me off about the no-trouser dress done so. Embarrassing at the time contents with the room. management trainee. code. But as I didn’t even own a to be sent away on your first day, As the pile was not sorted “Some nurses still wore belts skirt, I went to work on my first day but both incredible and funny to beforehand, this might be with ornate buckles, although in a smart black trouser suit and think of it now.” ●

LORDS, LADIES AND FREEMASONS: LIFE ON THE STAFF OF AN ASYLUM IN THE 1970S Former manager Alan his title, he fell well Also on the committee to me that this was a Negotiating the temp did not know what Randall recalls his first down the hierarchy. His was Caroline Bond, a compliment in that it asylum’s hierarchies OT stood for, but she job at Herrison Hospital first handicap was that wonderful person who put me on a par with also provided Mr decided to take an (the county asylum) in he was a mere pig later on became chair of their butlers. Randall with “one of the inspired guess. Oh how Dorset in the 1970s with farmer, while other Great Ormond Street “There was also most embarrassing I wish I had checked it! tales that could have members of the hospital Hospital. When I a second hierarchy at moments of my 33-year When invited by the come from the pages of management committee tentatively tried to find work, as many of the NHS career”. chairman to speak to her an Edwardian novel. were landed gentry. out where she fitted senior staff and “I tabled one of Lady tabled report, Lady “Nothing on the two- “Of the committee into the pecking order, members were Williams’ reports of Williams announced in year national training members, Sir Joe Weld I was left in no doubt by freemasons. All big a departmental visit she her fearsome, deep, course helped me to was the Lord Lieutenant her comment that her decisions had to be had made,” he explains. resonant voice that fathom the hospital of Dorset, lived at family gave its name to referred to the head “She had handed me her ‘contrary to the report, power structure,” he Lulworth Castle and Bond Street.” gardener, who was grand handwritten report just I did not visit the says. “I naively assumed seemed to own much of He goes on: “I was master of the lodge and before the meeting and outside toilets and find that the chairman was East Dorset. Lady taken aback to be spent his days smoking a I passed it to a temporary morale high’. the most important Williams lived at Port addressed by the pipe in a rather grand secretary to type copies “For the rest of my member of the Bredy and appeared to members as ‘Randall’. building out in the for the members. career, I could never committee. But despite own all of West Dorset. It had to be explained magnificent grounds.” Unbeknown to me, the take OTs seriously.”

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48 day in life/jm/jw/JW.indd 1 24/6/08 12:57:07 IT WAS THE TOUGHEST TWO YEARS OF MY LIFE Being in the top job at the Department of Health means overseeing the biggest political football of all. Peter Davies and ‘Daloni Carlisle hear six former health secretaries’ memories

hsj.co.uk

50-54 ministers-jmas/JW.indd 1 24/6/08 13:00:26

24/6/08 13:00:28 24/6/08 2 ministers-jmas/JW.indd 50-54 hsj.co.uk hsj.co.uk TWO YEARS OF MY LIFE MY OF YEARS TWO

‘ TOUGHEST THE WAS IT Norman Fowler: “Whatever you did, there was a massive row”.

ascinating, fulfilling and not to have been in the same job worthwhile. Many agree that for so long. being secretary of state for Mrs Thatcher regarded him as “a F health is one of the biggest – good defensive player” but not one and most difficult – jobs in to transform the NHS. “I believed in government. With so much at stake evolution,” explains Lord Fowler, it is characterised by battles with who says that behind the scenes he the prime minister (particularly repeatedly opposed “batty” Margaret Thatcher) and the ever- alternative funding proposals. present influence of organisations “Those putting forward these such as the British Medical ideas had no concept of the Association. But past incumbents upheaval involved and the politics largely look back with pride, as would have been totally disastrous. reforms introduced as far back as People didn’t want a privatised the 1980s continue to shape policy health service.” Kenneth and old foes forget their grievances. His long service at the DHSS was Clarke: “We As Alan Milburn observes: “They all invaluable in launching the had ferocious love you when you’re dead.” groundbreaking AIDS awareness meetings”. campaign of 1986. “If I’d been new I wouldn’t likely to return me. She thought the NORMAN FOWLER remotely have been able to spend NHS should be a service of last ‘The department September 1981 to June 1987 the time I did on it.” Initially resort for people who couldn’t Norman Fowler was social services planned as conventional public afford to insure themselves. I was wasn’t at all keen on secretary, running the gargantuan health advertising “with dense text”, strongly opposed to that.” Department of Health and Social even this took months to get past The review of the service, says Mr reforming. It wanted Security during six of the most ministers. Clarke, “had really got nowhere in minimum trouble turbulent years of Margaret Only after persuading Mrs particular” other than to suggest tax Thatcher’s premiership. Assailed Thatcher to “stand to one side” and relief for those taking out private from the unions’ from the right by colleagues who let a cabinet committee take charge insurance, an idea the then thought the NHS a costly folly and did policy develop. “We made more chancellor Nigel Lawson was from the left by opponents and quicker progress on that issue resisting. Mr Clarke set about working. It was very good if you convinced the government wanted than any other issue I can reviving proposals for a purchaser- could stand the hassle. She’d to privatise it, he recollects: “We remember in government,” he says. provider divide that had been challenge everything you said. It forget just how hysterical the health looked at but had not progressed. made you do the work and go away service debate was in the 1980s. “The department wasn’t at all and think. Whatever you did, there was a KENNETH CLARKE keen on reforming. It wanted a “Early on I tried to bury her massive row about it.” July 1988 to November 1990 quiet life with a minimum of trouble under detail, which was a complete He says his key to survival was to Kenneth Clarke became health from the trade unions. It thought waste of time. All she wanted was build the best possible team. secretary in the middle of Mrs there was nothing wrong except more detail. You could deliver it late “It sounds obvious but it’s not Thatcher’s NHS review, when she we’d got to do better in next year’s the night before and she’d have read what every secretary of state did. decided to split health and social public spending round. I remember it by next morning and be ready to Some didn’t want the best ministers security into two separate the permanent secretary explaining continue the battle. around them because they felt it departments. The review – to me he couldn’t spare any staff to “We had lots of these meetings, might detract from their star quality. prompted by a funding crisis and help me on the review. tortuously thrashing out the details The one thing I did insist on with conducted behind closed doors – “I left the Department of Health and getting them into the shape she Margaret Thatcher was that I contemplated replacing the NHS as I arrived – wondering what on wanted. We all enjoyed a good row.” should pick my own people.” with private medical insurance. earth these 6,000 people I Eventually a paper was put to the Among his team were future Mr Clarke had previously been supposedly employed were doing. It cabinet. “People think Margaret’s prime minister John Major, future health minister for three years took quite a struggle to get a team cabinet was like Spitting Image, but health secretary Kenneth Clarke and until 1985. together that I wanted.” she usually ran genuine cabinet health minister Edwina Currie. “I was rather surprised to be The work meant making regular government. We could sometimes Lord Fowler says heading such a given the post of secretary of state progress reports to Mrs Thatcher, have long policy discussions. But vast and diverse department meant because she must have realised I with the chancellor and the then one of her classic techniques he avoided getting stale and enjoyed was a supporter of the NHS as it Treasury chief secretary John Major. worked: instead of letting me significant fire-power in the cabinet, stood and I didn’t think it was a “These were ferocious meetings. present my paper, which she should although he would have preferred department to which Margaret was This was Margaret’s way of have done, she presented it herself

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50-54 ministers-jmas/JW.indd 3 24/6/08 13:00:35 managers and told them: “‘You’ll never get me to say this on a public platform but you’ll be thinking about how you’re going to live under a change of government. I can’t be part of that process, but the reality is there’s a shared agenda between myself and most Labour Stephen health ministers, in particular about Dorrell: pathways of care and focusing on surprising responsiveness to patients.’ I told consensus. them this was their opportunity to put their priorities on paper. glazier. Ken Clarke was definitely a “There’s very little that comes out window-breaker and I’m much of the DH now that couldn’t – with Virginia Bottomley: more a glazier.” some changes – be reconciled with “A fearful battle”. She remembers the BMA giving what we were doing in the mid to her a standing ovation, such was late 1990s.” from the chair. She went through it her commitment to cutting junior He sees “big improvements” in and made it clear she agreed with it. ‘My colleagues were doctors’ hours. “I thought – rather today’s NHS but bemoans the “over- Frankly, she bounced it through. vainly – ‘perhaps this will be in the centralising managerial dead ends” Here was this fundamental reform constantly calling newspaper’. But it wasn’t because I represented by too many targets of the NHS, which the present was naive about how the press and too little respect for healthcare government is still having difficulty me Nanny Bottomley operates. I never rang journalists, professionals. completing and getting right, which but I’m quite stoical ever. In today’s age of spin, that’s “If we’d followed through the went through with five minutes’ extraordinary.” consensus that was emerging I discussion.” and resilient’ Her style was “earnest”, she says. think we’d have made a lot more The subsequent white paper, “I laugh at myself looking back now. progress in the last 11 years with the Working for Patients, was launched I was always criticised for using too money that was provided.” amid “very daring and slightly off VIRGINIA BOTTOMLEY many statistics. Now brilliant the wall PR razzmatazz”, with TV April 1992 to July 1995 politicians are people who paint big presenters hosting simultaneous Becoming health secretary after pictures and I don’t think I’m good ALAN MILBURN video-linked roadshows. “I’ve still three years as a health minister at that. Having that lightness of October 1999 to June 2003 got the souvenir photographs. It realised a long-held ambition for touch is a skill I certainly don’t have Ask current senior NHS managers looks very corny now.” Virginia Bottomley. and I rate it a lot.” to name their top three health Exhausted, the next day Mr “Until I die I’m sure this will be secretaries and Alan Milburn is Clarke went to a cricket match at the job that has most marked my nearly always among them. Lord’s, only to be summoned to take career,” she says. STEPHEN DORRELL Mr Milburn himself laughs at a phone call from Mrs Thatcher Educated in the social sciences, July 1995 to May 1997 this. “They all love you when you’re congratulating him on her Ms Bottomley had been a social “If you take office for the last two dead,” he jokes. “That’s not my perceived triumph of the white worker and Lambeth magistrate years of an 18-year spell, the memory of how it was but it is very paper’s launch, which had got a before entering the Commons. She chances of your leaving great nice people feel like that.” good press. felt ideally suited to a role she found monuments are relatively remote,” He came to the job of secretary of “I told her all hell would let loose “with all its pressures, totally says Stephen Dorrell, who was state for health from the Treasury in and not to be deceived by the first absorbing; completely fascinating, health secretary in the last days of October 1999, having previously 24 hours. I warned her the BMA fulfilling, demanding and John Major’s government. been a health minister for a year would go berserk and they did.” worthwhile”. He says: “By 1995 most of the under Frank Dobson. Almost 20 years later, Mr Clarke Her unusual pedigree for a heavy lifting had been done. I’d like Almost immediately he ran into says that the present government Conservative MP gave her a to think in my time we gave the one of the worst winters the NHS “is following exactly the same different outlook from most of her reform programme a chance to had experienced. Trolleys were principles as I did”. party colleagues, “those who used breathe. We drew some of the stacked up in accident departments “They’ve gone much further than the Thatcherite language of the political venom out of the and the press was full of pictures of I could possibly have contemplated, market to antagonise the old argument.” the patients on them. using the private sector. I envy their Fabians”. Many felt she was “too And despite lingering opposition “It was a dreadful winter, one of freedom of action because they much of a Guardian woman for “there was a developing willingness the worst on record,” he recalls. “It haven’t got a political opposition. I their liking”. to see the point of what we were was tough for the health service and had one for whom this was the Ms Bottomley pushed through a trying to do. People were relatively tough politically. Getting through biggest topic.” public health white paper, The weary of the arguments of principle that was one of the most difficult He now deplores the “explosion Health of the Nation. “I had a fearful and more interested in making it times.” of staffing and pay, reduced battle and was nearly kneecapped work. I tried to focus on solving The 2000 NHS Plan was already workloads and contractual by all my colleagues, who hated it. practical problems rather than being worked on and it fell to Mr obligations and declining They were constantly calling me having great ideological debates.” Milburn to implement it. productivity” in today’s NHS, ‘Nanny Bottomley’ but I’m quite In fact, Mr Dorrell achieved “That was the second most noting that “ministers left to stoical and resilient.” surprising consensus. His white difficult period: pushing through themselves tend to want a quiet life Regarding the job as custodial, paper, A Service with Ambitions, can some of the reforms that are now on the industrial relations front”. not party political, she tried to be seen as the precursor of much broadly accepted as the right The service’s “huge surge” in recruit as her special adviser Philip Labour health policy, and his direction of travel.” spending was “very badly planned”. (now Lord) Hunt, then director of Primary Care Act was passed with He did it by setting himself up as But the NHS has, he says, the NHS Confederation; he later all-party support. Some colleagues the patient’s champion. “My “improved in every way and always became a Labour health minister. questioned why the Conservative number one job as secretary of state has ever since 1948, not least After the 1992 general election government was “giving political was to look after the NHS patient,” because of clinical advance but also the heat had been taken out of the oxygen” to the NHS so near to what he says. He remains convinced the because it’s always had ever more reforms as a political issue and her was clearly going to be a difficult NHS Plan set the health service in resources put into it. Most citizens’ main role was to bed them in. “In election. the right direction. experience of the NHS varies from politics you sometimes want a Drawing up the white paper, Mr “We redesigned the health service

good to excellent.” window-breaker and sometimes a Dorrell says he gathered senior around the needs of patients. Ë54 PA REX,

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50-54 ministers-jmas/JW.indd 4 24/6/08 13:00:42 53Á I am very proud of that and making progress in the right Patricia Hewitt: “Everybody was very pleased with the progress that’s direction. The question now is shocked that we had a deficit”. been made on a lot of the changes I whether the journey will be was responsible for.” completed or truncated. There is, in He lists these as choice, standards my view, no third way.” and inspection regimes, the creation of foundation trusts and primary care trusts and introducing diversity PATRICIA HEWITT in provision. May 2005 to June 2007 “These are all now part of the Patricia Hewitt is remarkably frank accepted architecture of the modern about her time as secretary of state health service.” for health. Mr Milburn is sometimes “It was the toughest two years of accused of “throwing mud at the my life but it was also the most walls in hope that some of it would rewarding.” stick” rather than having an overall Perhaps that is no big surprise. strategy in place. Ms Hewitt arrived in post a few He admits the NHS has been weeks before news of the NHS through a period of unprecedented deficit broke and forced the health change in the last 20-30 years, service to address this in a period which certainly accelerated in the she acknowledges was “incredibly the NHS deals with life or death we last 10 years. But a lack of overall difficult and painful” for everyone. have to get the money right. Every strategy? No. And although she successfully penny being wasted is a penny “When I became secretary of wooed doctors at the 2006 BMA being denied to a patient who state, there were lots of good things conference, she was booed at the needs care.” about the NHS but lots of things Royal College of Nursing congress, She felt the old NHS system of wrong as well, such as a lack of a first for a Labour health secretary. balancing the books by taking away responsiveness and poor waiting Ms Hewitt also oversaw the from those that had made a surplus times. People often look for a magic legislation that banned smoking in to pay off the debts of those with a silver bullet but the truth is that in public places. deficit was grossly unfair and no an organisation as large and “That is the really big change that incentive to improve. complex as the NHS you have to fire is already making more difference And the fact that the NHS was a lot of bullets. to people’s health, as distinct from wasting vast sums was apparent in “You have to have national how we look after them when they the wide variation in performance Alan standards, local autonomy, that, thanks to Alan Milburn’s Milburn: inspection, a system of rewards and ‘It’s one of those reforms, was becoming transparent. no “magic incentives for individual members “There was no longer any hiding bullet”. of staff and organisations. Then you mistakes you place for poor performance,” she get some progress.” says. “But I never had any doubt Her excuse? “That’s one of those And there has been progress, he can make when that it had to be done.” mistakes you can make when you emphasises. “Now I have heard so many are very new as a minister, and we “I think back 10 years and what you are very new people say ‘God, it was tough but had to spend several months was then regarded as the core now we have freedom and can do unwinding that and reassuring problem in the NHS was a woeful as a minister’ what we want to do’.” people they were not going to be infrastructure and capacity, leading Ms Hewitt also admits to one cast off.” to long waiting times. It’s not been are ill, than anything in the last major regret. “The mistake we The separation of purchaser and solved completely but we are in a decade.” made with Commissioning a Patient- provider remains a live issue and different position and that’s as She adds: “It’s one of those areas led NHS in creating terrible Ms Hewitt’s feeling is that it will much about reform as investment.” where you really have to think uncertainty for health visitors, evolve according to local need. Mr Milburn remains the through how you reconcile district nurses and primary care “But I think [current NHS chief politician and won’t admit to individual freedom with protecting trust staff.” executive] David Nicholson is difficult relationships with any of people, especially for a government Commissioning a Patient-led NHS, absolutely committed to what we the key players with whom he that’s always being taunted with concerned with realigning PCTs so were trying to do to devolve power engaged. He prefers to accentuate being the nanny state.” that they could become efficient to the service within a framework the positive. But she admits that what really commissioners, came out in July that puts the focus on the patient. “The joy of being health secretary made her time in the post so 2005. Meanwhile the DH’s And I am confident the Darzi review is you meet [such a] wonderful and difficult were the NHS’s financial commercial directorate issued a will take that forward.” diverse range of committed people problems. “Everybody was shocked tender document which seemed to She also dismisses as “absurd who want to make the system that, given the tens of billions of open the way for tendering all PCT rhetoric” accusations of privatising work.” pounds we had invested, it could provider functions. the NHS by bringing in the He attributes some of his reforms end up with a deficit.” There are various versions of independent sector. Patients want to these meetings. “The idea for It was not so much the size of the these events and here is Ms choice and trusts respond by upping foundation trusts basically came deficit – which compared to the Hewitt’s: “My focus had simply their game, she says. from discussions with NHS overall NHS budget was small – but been the issue of the PCTs,” she Ms Hewitt was not a popular managers from some of the best the fact that it was doubling every says. “It was very clear we needed to health secretary but has been organisations in the country.” year. There were several underlying allow at least some of them to praised for improving policy His only reservation today is problems contributing to this, says merge and I was clear this should making and engaging professions whether the NHS will finish its Ms Hewitt, the biggest of which was be a genuinely bottom-up process. in the reform process. journey. a culture in which the NHS was said “While I was focused on that, the “I think it is true I spent more “I talk to people in the NHS to be dealing with life and death department had been pursuing the time than any health secretary for almost on a daily basis and [the and therefore money did not matter. idea of a complete separation of the a long time just listening to staff NHS Plan] is still regarded as the “I was constantly being criticised purchaser-provider roles, which and engaging with the professions,” bedrock of what people are trying to for putting money before patients,” understandably caused immense she says. do. The NHS is on a journey. It was she says. “What I kept trying to say distress. When I realised what was “I feel very lucky to have had the

a 10-year plan and we are broadly to people was that it was because going on I just stopped it.” chance to do the job.” ● REX

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50-54 ministers-jmas/JW.indd 5 24/6/08 13:00:55 Manager bashing is a national sport – but try not to believe your own bad press. Ken Jarrold asks why administrators have become unpopular and argues that it is still worth taking a few knocks DON’T BEAT

YOURSELFome advice for those in the 60, manager bashing has become brought higher salaries, lease UPBut the bashing can be limited and dating game: if you want the steadily worse, for four reasons. cars – and many more managers. managers can increase appreciation object of your desire to First, cash limiting came to In a reverse of combat history, red of their role, using four simple rules. S swoon at the mention of your public services in the late 1970s. coats have replaced battle fatigues. First, remember managers exist job, do not be a health service This new discipline reinforced the Managers are visible and often to support doctors, nurses and manager. However, if you are restrictions of annual budgets and resented by the press, most of public everyone else in the main business content to impress with who you are administrators policed the regime. opinion and even many colleagues. of treatment and care delivery. rather than what you do and want Second, the 1983 Griffiths report Second, demonstrate your to be useful in a good cause, then it transformed us from administrators Need for questions commitment to patient care and could be the career for you. who were equal members of Administrators in early years did your interest in and knowledge of Management is not a caring or management teams with doctors not have high status or salary. They the real work of the NHS. glamorous profession. In fact, it is not into general managers in charge. It were members of a triumvirate of Any challenge or change must be a profession of any kind. However, it separated us from colleagues. doctor, nurse and administrator, and because it improves patient is a necessary and – done well – a Third, governments in the late belonged to a management team. experience. So third, show by your very useful occupation in which I 1980s began to realise they could They administered a low-cost system words and actions that you value was proud to spend 36 years. make the NHS do things, and so the undisciplined by cash limits and and respect the people of the NHS. Manager bashing has long been a review system and targets were were not expected to do a great deal. Fourth, be one of management popular sport. Just as people of a introduced. Managers were forced When I became a deputy guru Robert Greenleaf’s “servant minority race or nationality are to interfere in the real work of superintendent in 1971, no one leaders”: listen, heal, persuade, often blamed for social problems by the NHS. expected me to cut waiting times or conceptualise and build community; those unwilling to deal with the Fourth, the coming of trusts even know how long patients waited. and show empathy, awareness, complexities of migration, so and the chief executive role To do so would have been regarded foresight, stewardship and managers are often blamed by as a gross invasion of clinical commitment to people’s growth. those unwilling or unable to ‘No one expected me freedom. It is no wonder manager If I were 21 again, I would still grapple with the “wicked issue” bashing has increased when apply to enter the NHS. It has been of providing comprehensive to cut waiting times – managers today are high profile and a privilege and has used all I had to healthcare in a world of scientific well paid and have to question offer. I felt useful in a good cause and advance, an ageing population, that would have been clinical practice and change process. valued – worth a little bashing. ● increasing demand and cash- Much of this cannot and should Ken Jarrold is a senior consultant at limited budgets. seen as an invasion not be changed. A modern health Dearden Consulting and a former I joined the NHS in 1969 when we of clinical freedom’ system needs effective and strategic health authority chief

had both just turned 21. As we reach appropriately rewarded managers. executive. WELLS KEVIN

hsj.co.uk 3 July 2008 HSJ NHS60 anniversary supplement 55

55 manager bashing/jm/as/SJ/JW.indd 55 24/6/08 13:02:09 STEPHEN THORNTON healthcare, that has come at the cost managers, which he suggests was “It used to be said that you could Every NHS chief executive lives of a top-down approach to most evident during the rapid do anything in management as long with the knowledge that they could managing health services.” expansion of primary care trusts. as you did not take the credit for it,” one day face a drubbing in the Daily Mr Thornton believes managers “We have some real capacity he says. Before the days of Mail. Stephen Thornton was one of also have multiple accountability problems in finance and in HR and management, administrators in the first NHS managers to face they did not have before – to in those people who are hospitals were meant to be first heavy media attention, when, as regulatory bodies, local authorities, knowledgeable and adept at among equals but in reality Mr Wall chief executive of a health the media and above all upwards to continuous quality improvement. believes the clinicians were so busy authority, he was caught up in a the Department of Health. This has That is what the ethos of NHS that the administrators actually controversy over whether a child contributed to a tougher climate for management should be about.” were in charge, although careful not should be given an unproven managers. He adds that working with to boast about it. treatment for cancer. He left the NHS 11 years ago, clinicians and others through the This discretion, which he believes Now he believes the mid 1990s became chief executive of the NHS Health Foundation has convinced has now vanished from the service, marked a sea change for NHS Confederation for five years and him there is an enormous vitality allowed him to make improvements managers. now runs the Health Foundation. and energy in the NHS – although to services which would probably “In the past, media interest had “There is a very heavy political some of this is lost as staff struggle not have been possible in today’s either been political or clinical; pressure group overlay on the NHS with its inherent bureaucracy. target-ridden culture. there was rarely any public which tends to be very fraught, very “I am a bit critical of today’s understanding that the NHS was negative, with a lot of pressure ANDREW WALL managers,” says Mr Wall. “I was managed in some way,” he says. “I groups able to say no to things.” Andrew Wall spent 50 years known for being one who had got to the Appeal Court before I But NHS managers also learn to working in the health service – or challenged ministers and asked: put in a call to Alan Langlands be adept at looking upwards and lecturing about it – after initially “Do you know what it is like to [then chief executive of the NHS]. spotting the next political move. joining as a nursing auxiliary in implement that policy?”. I was used That would not happen now “That kind of political adroitness 1955. After working as a porter to speaking my mind. There were because accountability kicks in at is really important in any line of during his university degree, he certain things you did not do and such an early stage.” business but NHS management joined the NHS as a junior one of those was overspending but He says: “It is the whole spends so much time on it that it administrator and then worked his now overspending seems to be collection of accountabilities that is neglects to look inwards and way up to become chief executive of something everyone does. The debilitating, particularly when the downwards and takes its eye off the the Royal United Hospital in Bath. main accountability line up to quality ball.” After retiring from Bath he spent 13 government is so managed. While He believes top NHS managers years lecturing at the health the last 10 years have been stand comparison with those in services management centre at tremendous in terms of seeing a other sectors, but is concerned there Birmingham University before government keen on investing in is a “long tail” of less able finally retiring to Somerset. Y M A L A RETROSPECTIVE 56 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk money that is available now is BRIAN EDWARDS than it used to be and the phenomenal compared with what NHS managers today have a ‘NHS managers environment in which managers we had. But a lot of it is being tougher job than in the past, with a work is much more controlled.” wasted. The amount of money that plethora of targets and central learn to be adept He says that while it would be has been poured into the health interference, says Brian Edwards. impossible to have an NHS totally services with little result is a scandal.” Mr Edwards spent 10 years as at looking upwards independent of government, Mr Wall admits to being chief executive of the Trent regional and spotting the ministers should step back surprised at the numbers of health authority and three years as from operational details and managers in NHS organisations regional director of the West next political move’ concentrate on the bigger picture. now, compared with when he Midlands before leaving the service started in managerial jobs in the in 1997. He says he is “immensely TIM MATTHEWS 1960s. But this reflects the number proud and privileged” to have Once one of the highest paid chief of things they are being asked to do worked in the NHS and is still chair executives in the NHS, Tim now, he adds. of a consultancy firm specialising in Matthews was the one who famously “I don’t believe things were much healthcare. guided Guy’s and St Thomas’ better in the past – they weren’t – He says a major difference through their merger. but there has been a big shift, and between the NHS now and then is But after 20 years in the health not only in healthcare, towards the the amount of direction from central service, he left and has spent the rise and rise of managers.” government. past eight working at first the Mr Wall’s own more recent “The regions had a chance to Highways Agency and then US- experience of the NHS has been work out their priorities and get on based engineering firm Parsons pretty positive. He says he was with it,” he says. Brinckerhoff. amazed how quickly his “There was an acceptance from “I learned a huge amount about notes were available when he the centre that they did not try to managing large organisations, attended casualty at his run the NHS – it was a job for the complexity and change, all of which old hospital in Bath – something authorities in the field. The other are as relevant in non-NHS he believes would not have been sharp difference is that managers government agencies and in the possible in his day. are much more involved in clinical private sector. processes now because that is where “There are a lot of differences in the targets are.” working between the public and Professor Edwards thinks life is private sectors but when you are “certainly different and probably running large complex tougher” for managers now. organisations, there are a lot of “It’s certainly more complicated similarities,” he says. One of the complexities Mr Matthews encountered in the health service was managing change in a very public environment with lots of stakeholders, a situation which is not mirrored in the private sector. But working for a company with substantial government contracts still involves “handling the politics”. “The NHS was a fantastic place to work. It was always complex, always going through change. But personally, I have to say there are only so many bouts of reorganisation that you want to go through and they come round with wearying frequency,” Mr Matthews says. Although he believes that for all its frustrations and slow pace of change the NHS is an enormously rewarding environment, he says it has become increasingly tough. “Being a chief executive in a big city has been a tough road for the past 15 years. Ë58

Former chief executives and health authority leaders compare their challenges and ambitions with the picture they see emerging for managers today. By Alison Moore hsj.co.uk 3 July 2008 HSJ NHS60 anniversary supplement 57 STEPHEN THORNTON healthcare, that has come at the cost managers, which he suggests was “It used to be said that you could Every NHS chief executive lives of a top-down approach to most evident during the rapid do anything in management as long with the knowledge that they could managing health services.” expansion of primary care trusts. as you did not take the credit for it,” one day face a drubbing in the Daily Mr Thornton believes managers “We have some real capacity he says. Before the days of Mail. Stephen Thornton was one of also have multiple accountability problems in finance and in HR and management, administrators in the first NHS managers to face they did not have before – to in those people who are hospitals were meant to be first heavy media attention, when, as regulatory bodies, local authorities, knowledgeable and adept at among equals but in reality Mr Wall chief executive of a health the media and above all upwards to continuous quality improvement. believes the clinicians were so busy authority, he was caught up in a the Department of Health. This has That is what the ethos of NHS that the administrators actually controversy over whether a child contributed to a tougher climate for management should be about.” were in charge, although careful not should be given an unproven managers. He adds that working with to boast about it. treatment for cancer. He left the NHS 11 years ago, clinicians and others through the This discretion, which he believes Now he believes the mid 1990s became chief executive of the NHS Health Foundation has convinced has now vanished from the service, marked a sea change for NHS Confederation for five years and him there is an enormous vitality allowed him to make improvements managers. now runs the Health Foundation. and energy in the NHS – although to services which would probably “In the past, media interest had “There is a very heavy political some of this is lost as staff struggle not have been possible in today’s either been political or clinical; pressure group overlay on the NHS with its inherent bureaucracy. target-ridden culture. there was rarely any public which tends to be very fraught, very “I am a bit critical of today’s understanding that the NHS was negative, with a lot of pressure ANDREW WALL managers,” says Mr Wall. “I was managed in some way,” he says. “I groups able to say no to things.” Andrew Wall spent 50 years known for being one who had got to the Appeal Court before I But NHS managers also learn to working in the health service – or challenged ministers and asked: put in a call to Alan Langlands be adept at looking upwards and lecturing about it – after initially “Do you know what it is like to [then chief executive of the NHS]. spotting the next political move. joining as a nursing auxiliary in implement that policy?”. I was used That would not happen now “That kind of political adroitness 1955. After working as a porter to speaking my mind. There were because accountability kicks in at is really important in any line of during his university degree, he certain things you did not do and such an early stage.” business but NHS management joined the NHS as a junior one of those was overspending but He says: “It is the whole spends so much time on it that it administrator and then worked his now overspending seems to be collection of accountabilities that is neglects to look inwards and way up to become chief executive of something everyone does. The debilitating, particularly when the downwards and takes its eye off the the Royal United Hospital in Bath. main accountability line up to quality ball.” After retiring from Bath he spent 13 government is so managed. While He believes top NHS managers years lecturing at the health the last 10 years have been stand comparison with those in services management centre at tremendous in terms of seeing a other sectors, but is concerned there Birmingham University before government keen on investing in is a “long tail” of less able finally retiring to Somerset. ALAMY

Former chief executives and health authority leaders compare their challenges and ambitions with the picture they see emerging for managers today. By Alison Moore RETROSPECTIVE 56 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk

56-58 chiefs/jm/JW.indd 64 24/6/08 13:13:14 money that is available now is BRIAN EDWARDS than it used to be and the phenomenal compared with what NHS managers today have a ‘NHS managers environment in which managers we had. But a lot of it is being tougher job than in the past, with a work is much more controlled.” wasted. The amount of money that plethora of targets and central learn to be adept He says that while it would be has been poured into the health interference, says Brian Edwards. impossible to have an NHS totally services with little result is a scandal.” Mr Edwards spent 10 years as at looking upwards independent of government, Mr Wall admits to being chief executive of the Trent regional and spotting the ministers should step back surprised at the numbers of health authority and three years as from operational details and managers in NHS organisations regional director of the West next political move’ concentrate on the bigger picture. now, compared with when he Midlands before leaving the service started in managerial jobs in the in 1997. He says he is “immensely TIM MATTHEWS 1960s. But this reflects the number proud and privileged” to have Once one of the highest paid chief of things they are being asked to do worked in the NHS and is still chair executives in the NHS, Tim now, he adds. of a consultancy firm specialising in Matthews was the one who famously “I don’t believe things were much healthcare. guided Guy’s and St Thomas’ better in the past – they weren’t – He says a major difference through their merger. but there has been a big shift, and between the NHS now and then is But after 20 years in the health not only in healthcare, towards the the amount of direction from central service, he left and has spent the rise and rise of managers.” government. past eight working at first the Mr Wall’s own more recent “The regions had a chance to Highways Agency and then US- experience of the NHS has been work out their priorities and get on based engineering firm Parsons pretty positive. He says he was with it,” he says. Brinckerhoff. amazed how quickly his “There was an acceptance from “I learned a huge amount about notes were available when he the centre that they did not try to managing large organisations, attended casualty at his run the NHS – it was a job for the complexity and change, all of which old hospital in Bath – something authorities in the field. The other are as relevant in non-NHS he believes would not have been sharp difference is that managers government agencies and in the possible in his day. are much more involved in clinical private sector. processes now because that is where “There are a lot of differences in the targets are.” working between the public and Professor Edwards thinks life is private sectors but when you are “certainly different and probably running large complex tougher” for managers now. organisations, there are a lot of “It’s certainly more complicated similarities,” he says. One of the complexities Mr Matthews encountered in the health service was managing change in a very public environment with lots of stakeholders, a situation which is not mirrored in the private sector. But working for a company with substantial government contracts still involves “handling the politics”. “The NHS was a fantastic place to work. It was always complex, always going through change. But personally, I have to say there are only so many bouts of reorganisation that you want to go through and they come round with wearying frequency,” Mr Matthews says. Although he believes that for all its frustrations and slow pace of change the NHS is an enormously rewarding environment, he says it has become increasingly tough. “Being a chief executive in a big city has been a tough road for the past 15 years. Ë58 RETROSPECTIVE hsj.co.uk 3 July 2008 HSJ NHS60 anniversary supplement 57

56-58 chiefs/jm/JW.indd 65 24/6/08 13:13:16 57Á Expectations are very high most difficult periods was in the and your ability as a chief executive early years of Labour’s first to deliver is always going to be administration. “It felt tougher and limited. tougher,” she says. “The real failure “You have an impact and you lead was that expectations were set out and direct change but there are so to the public as if they could be many forces in the NHS that can delivered tomorrow. That caused slow you down or stop you. That is huge tensions at the front line.” But one of the differences between the she adds going out to the front line NHS and the private sector; in the and seeing what was being done latter once you decide to do was always “a joy”. something the imperative is to get on She has no plans to and do it. In the NHS the decision is return, however: “I felt I just the start of the debate.” had done what I could.” After several years in New York Mr Matthews is now returning to MAURICE NAYLOR the UK. At 56, he is not ready for Now 87, Maurice Naylor retirement and does not rule out started his career in another NHS role. local government before the Second World War but moved to BARBARA STOCKING the NHS seven years after its birth. Barbara Stocking had a meteoric He spent the next 26 years rise in the service. After running the working at regional level, first in King’s Fund she was appointed as Manchester and later in Sheffield, general manager of the Oxford and then became chief executive of regional health authority, before the National Association of Health heading Anglia and Oxford and Authorities – forerunner of the NHS finally the entire South East region. Confederation – when he retired But in 2001 Ms Stocking left to from the NHS in 1981. run the UK arm of international “The regional level was development charity Oxfam. It was responsible for building new a change of direction that surprised hospitals, training of staff and so on. many – especially as she had been I would not say that it was all tipped for the top job – but one different from today. It may be more where she says there are complicated now,” he says. tremendous similarities. Mr Naylor also notes the changes “People in the NHS are not there in the relationship between the NHS to make lots of money. They are and central government. there because they believe they have “The government now is much a vocation and they believe in the more hands on, NHS,” she says. wanting “People in Oxfam are passionate targets to about ending poverty. So it is very be met. We hard to tell people what to do. You were not know what consultants are like, well micro- it is the same here. You have to managed in my day. really explain to people why they One of the main should do things or go in a certain differences is that until direction.” 1980 there were regional She adds that the main difference authorities which were a between the two organisations is the regional level interposed between highly political environment in central government and the which the NHS operates – this coalface. Managers and senior civil made it hard to lead towards long- servants were not involved in quite term objectives. “Certainly at the the same way. I regret the loss of level I was working at, where the that.” government not only sets priorities Mr Naylor now lives in Leicester but wants to intervene and change and several of his family have priorities. followed him into the NHS. His “At Oxfam I really do lead the nephew Sir Robert Naylor is chief organisation. I have a board but it is executive of University College not the same as having ministers London Hospitals foundation trust. who are involved in the day-to-day “From the patient’s perspective, I running of the health service. don’t think things are very much Although in a way Oxfam is a public better now,” he says. “Although institution it is not so publicly medical science means that all sorts challenged as the NHS. In the NHS of things can be done, I don’t feel you can’t hide anything – everyone there was a great difference lying in experiences it.” a ward now to having my appendix She believes one of the service’s out in 1956.” ●

458 H HSJealth NHS60 Service anniversary Journal 00 supplement Month 2008 3 July 2008 hsj.co.uk

56-58 chiefs/jm/JW.indd 4 24/6/08 13:13:32 FLASH OUTFIT The light pulsing on top of a modern NHS emergency vehicle signals a mobile unit packed with staff expertise and impressive technology, says Airwave’s David Sangster

mergency services pre-date very people they need to treat can the NHS, with a direct present a danger to them. To keep evolutionary path from the them safe, the emergency services E stretchers and wheeled litters have evolved a number of used on ancient battlefields to the techniques. modern “blues and twos” we have Radio communications have been today. But it was Aneurin Bevan’s central to these changes and in legislation that made it compulsory recent years we have seen a vast for ambulances to be available to all improvement in the quality, who needed them. Before then, the coverage and usability of the radios provision of emergency care was employed. The introduction of solely the responsibility of charitable Airwave, a nationwide, digital organisations. Emergency services communications system for the became, in a stroke, egalitarian. emergency services, has changed The role of the emergency how they can communicate with services was at first clear cut: the each other. carriage of persons in need of Following the 2005 Bradley medical attention but unable to Report Taking Healthcare to the proceed to a doctor unaided. This Patient: transforming NHS original role remains, but the ambulance services, ambulance trusts paramedics of today have in are now moving to treat more addition a raft of new duties and patients at home or at the roadside. responsibilities. They are now the This can only be achieved with front door of the NHS, giving initial advances in technology. The (and often life saving) treatment to Airwave service facilitates this those in need of medical attention approach and is working to deliver and taking the lead in dealing with more benefits. These include giving accidents and emergencies. access to electronic patient records Recognised as a healthcare in the mobile environment and professional on a par with nurses enabling tests and procedures and physiotherapists, today’s traditionally done in hospital to be paramedics have come a long way done closer to home, and linked to from their original role as porters the national Care Records Service. for the sick. These can range from blood tests to respiratory function. Dangerous conditions Advances in technology will also Paramedics have engaged in a make the workforce more efficient. corresponding change in their If communication at the touch of a professional practices. The modern button also allows the transfer of paramedic needs to master a range data records, it negates the need for of technologies. The proficient use community nurses to return to the of medical equipment, from hospital so frequently, enabling defibrillators to heart monitors, is them to give care where they are obviously important, but there are needed. less well-known technologies that Looking forward, mobile data will paramedics have grown to rely on. play a major role in the day-to-day Paramedics can work in workings of all out-of-hospital dangerous conditions and often the health and social care staff. The

62 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk

62-63 airwavesponsor-jmas/JW.indd 1 24/6/08 13:32:58 62-63 airwavesponsor-jmas/JW.indd 2 hsj.co.uk set to change as ambulance trusts worked in teams of two but this is a panic button. and so their Airwave handsets have may not have time to radio for help possible. In some cases paramedics assistance. But this is not always paramedics may call in police increased productivity of NHS staff. more timely information flow and are fewer handoffs, improved and lead to a reduced error rate as there and refer to specialty doctors will patient notes, prescribe medication ability, among others, to update hospital, because many treatments can carry out while on route to the been limited in the procedures they help can be sent. pinpointing their whereabouts, so room about an incident, also health workers to alert a control duties. safety when carrying out their handsets, to improve their personal buttons similar to those on radio provide all such workers with panic a government-backed plan to employee working alone, leading to however, a duty of care to the NHS one paramedic is sufficient. There is, at the site. Previously, ambulance staff In a troublesome situation, Paramedics have traditionally The solution would allow mobile For such small-scale treatments are always looking for new methods to enhance patient care and reduce inappropriate admissions to A&E a patient and treat them departments, while for a paramedic to visit guaranteeing the safety of a better patient experience better use of resources and their workers. hospital, it is both a authorise risky treatments remotely’ to do this is by changing non life-threatening accident is known to be situations. If the provided in a range of the way healthcare is not require a visit to and the treatment does One way they intend instant data could allow doctors to ‘In the future live video feeds and 3 July 2008

for health, Airwave. David Sangster is general manager deliver a world class service. pace with the NHS and help it to years is for the technology to keep for the doctor’s expert opinion. doctor and the patient and a conduit becoming a bridge between the than ever before and is increasingly risky treatments remotely. information to authorise potentially could allow doctors enough feeds and instant data on a patient development in this area. Live video The future could see much the provision of life-saving drugs. doctors over the radio to speed up costly hospital bed. while keeping the patient out of a treatment plan can be commenced prepare or to ensure the correct either to give staff plenty of time to hospital well in advance of arrival, patient can be radioed to the information on the health of a Radio telemetry means vital now being bridged with technology. emergency care practitioner, a gap needed is of great benefit to the varied medical conditions. assessing patients with complex and drug and treatment regimes, often levels of patient assessment and individuals specialise in far greater highly trained and skilled emergency care practitioners. These evolving with the advent of However, paramedic training is Specialist skills needed. the sheer numbers that would be obviously impossible because of to a doctor in every ambulance: problem would be solved by having treatments more quickly. Ideally the was a way to deliver these more lives could be saved if there avoiding misdiagnoses. and has saved countless lives by undertaken. This decision is sound consulted before they are can be risky and doctors need to be The challenge for the next 60 The paramedic is doing far more Paramedics can consult with The ability to access a doctor if But the flip-side is that arguably HSJ NHS60 anniversary

supplement ● 24/6/08 13:32:59 63

KELLY DYSON he NHS may the biggest awareness – in which employees “The trouble with large employer in Europe, but in How does the NHS not only address the issue of stress organisations with a public profile global terms it only comes in match up to the at work, but also have the chance to is that there is a lot of external T at number three. The NHS’s understand and reduce the stress of comment about targets and 1.3 million strong workforce is other biggest bringing up children at home. performance and this is the last dwarfed by the People’s Liberation Employees are invited to embark on thing that people doing the actual Army of China, which has around employers in the a “journey of togetherness” in job want to hear,” he says. 2.3 million troops and can call on a “enlightened parenthood”. For Ashridge Business School reserve of 1.2-1.5 million, not to world? Sally O’Reilly However, perhaps the most public leadership centre director mention an armed police service of reports significant cultural change brought Mark Pegg, the besetting sin of a 1.1 million. Less alarming but in by the railway in recent years is huge organisation is that staff can equally mind-boggling in scale is the philosophical change from lose their sense of personal the Indian state railway, which politicised decision-making to responsibility. employs some 1.4 million staff, pay compared with other segments business-oriented decision-making. “It’s about taking pride in what transports 16 million passengers of Chinese society is a big factor. For instance, it has had to respond you do and being passionate about every day, covers a total length of Professor of Chinese business to competition from the aviation it. And that includes people in back 63,140km and runs 14,444 trains. and management at the School of sector with improved information office roles as well.” Does the NHS have anything to Oriental and African Studies for passengers via call centres and It is vital that the people who fill learn from these enormous Laixiang Sun points out money improved passenger information. such roles understand the priorities organisations when it comes to is a more powerful motivator in Can the NHS learn from such of frontline staff. productivity, motivation and morale? the UK. “There is more of an examples? According to Cary “Bureaucracy grows and grows For China’s army, recruitment is a Americanisation of Chinese society Cooper, professor of organisational and you need to get back to what simpler matter than for large-scale than Europeanisation. People are psychology and health at Lancaster the organisation actually does,” organisations operating in a prepared put in a 10 or 14-hour day University Management School, the warns Mr Pegg. democracy. All Chinese adults are and a seven-day week if that is what essential point the NHS needs to “But the great thing about working required to do at least two years’ it takes to be successful,” he says. take on board is that being a for the NHS is this – if you can’t feel military service and joining the “Maybe when they get richer, people monolithic organisation can only passionate about health, what can army is seen by many as a way of will get lazier!” work if its component parts are you feel passionate about?” ● acquiring essential skills for a later Working life at the Indian state given a measure of autonomy. civilian career. railway may be a little less arduous “One hospital trust or PCT may But it does have issues when it and is certainly likely to be better have problems that are very comes to getting the best quality paid in the near future. Railway candidates. More than 2,000 style- minister Laloo Prasad Yadav is ‘The Chinese army conscious Chinese youths have credited with engineering a dramatic recently been ruled out of the financial turnaround, changing the turns away recruits military because they have tattoos: railway from being a notorious loss- any over 2cm long are a no-no, say maker to making an annual surplus who are overweight military chiefs. The PLA turns away equivalent to over £1bn. recruits who are overweight or who An Indian government pay or who test test positive for drugs or HIV. Even commission is reviewing the pay chronic snorers are given their structure of public sector staff. Its positive for HIV’ marching orders because their recommendations are due out by “nasal sound... disturbs collective the end of 2008. Based on its different from any other. The life”, according to official guidance. findings, the salaries of all railways comparison with China’s army or Once in post any recruit to officers and staff are expected to be the Indian railway is accurate, in China’s army can expect to be part increased, including back pay until 1 that all these large organisations of a fast-changing organisation January, 2006. But pay is not are state-controlled and there is increasingly putting an emphasis on everything. a political agenda.” high-tech warfare. Stress is an issue in India as it is Chartered Institute of Since the early 1990s the in the UK. According to the VV Giri Personnel and Chinese army has focused on National Labour Institute, nearly Development adviser modernising and streamlining its three in 10 employees will have a on employee troops. But problems with mental health problem in any one engagement desertion, declining relations year. Now some divisions of the Mike Emmott between officers and troops, Indian Railway are combating says employees reluctance to train with obsolete workplace stress with health of any large equipment, high spending by promotion policies. organisation need to feel a officers, anti-corruption audits One example is Konkan Railways sense of identity with a smaller which restrict outside earnings and in western India, which has piloted unit within that whole and are food shortages have all been a project called Chaitanya – likely to be engaged and inspired reported in the Chinese press. Low Sanskrit for awakening or by managers they can relate to.

MANAGING64 HSJ NHS60 anniversary supplement 3 July 2008 hsj.co.uk A MULTITUDE FACTS AND FIGURES The People’s Liberation Army of China ● Established in 1927 as the military wing of the Communist Party of China, it was known as the Red Army until 1946 and has a standing army of 2.3 million. ● China recently announced extra spending: military salaries will be increased, training updated and the quality and variety of the military diet improved. Soldiers stationed in remote areas are also entitled to special subsidies for winter clothing. ● Soldiers usually undergo two years of selective service before choosing between returning to civilian life or continuing military service. They are usually given many preferential policies on employment after they are transferred to civilian life. ● Job security is not what it was. The military has seen a 45 per cent reduction since 1987 and recent years have seen protests by uniformed and retired military personnel over pay and pensions. Last year the army announced improved support for demobilised troops, including help with food and housing.

Indian Railways ● The number of the railway’s employees, which peaked at 1.65 million in 1991, was reduced to 1.47 million by 2003 and to 1.41 million by 2006. ● Railway workers in India have their benefits linked to those of civil servants, with a living allowance linked to the cost of inflation. The pension scheme was reformed in January 2004. Benefits include help with education costs, subsidised accommodation, healthcare and free rail passes across India. ● Some families have worked on the railway for generations.

The NHS ● The NHS is the biggest employer in Europe. Over 10,000 NHS employers employ around 1.3 million staff. ● Every year the NHS recruits around 35,000 people to healthcare professional courses and the number is increasing. At least this number are also recruited to other NHS jobs. ● The NHS runs a “key workers living scheme” in London, the south-east and east of England. This helps staff to buy or rent a home. All employees should have access to a childcare co-ordinator and some have creche facilities and/or childcare vouchers.vouchers. OOtherther pperkserks iincludenclude eenhancednhanced mmaternityaternity and paternity leave, adoption leave, career break schemes and occupational health support. MAGNUM

MANAGING A hsj.co.ukMULTITUDE 3 July 2008 HSJ NHS60 anniversary supplement 65 Diamond sixty

‘Nye Bevan was determined the new health service would “universalise the best”, not just be a safety net for the poor’

66-73 DIAMOND60-asas/JW.indd 1 24/6/08 14:05:25 Who are the most influential people in the history of the National Health Service? HSJ invited a panel of prestigious judges to pick 60 people who have been central in shaping today’s NHS. The list includes politicians, managers, Diamond professionals, campaigners, civil servants, historians and designers. Is anyone missing? Send your thoughts to hsjfeedback@ emap.com. By Peter Davies sixty and Alison Moore NYE BEVAN

When the NHS came the best”, not just be a safety net for post-war housing programme. Yet eight and his younger sister when into being on 5 July the poor, and that it would be free to support for him in cabinet was she was a teenager. His father died 1948, an astonishing all, funded from taxation. always fragile, not least because he of pneumoconiosis, a lung disease 94 per cent of the First, Mr Bevan had to convince was identified with Labour’s left. As caused by inhalation of dust. public were enrolled sceptical colleagues keener to the service ran into financial Unsuccessful at school and with it and more than channel spending towards re- problems – its funding had been suffering with a stammer, Mr Bevan 2,500 hospitals were armament rather than healthcare. based on wartime estimates – he too joined the local colliery at 13. nationalised. It had taken Then he faced 18 months of bitter proved unable to secure a flow of As a union activist he won a health minister Aneurin resistance from the British Medical adequate resources. scholarship to study in London. In Bevan just three years to Association, which still intended to the 1926 general strike he was a get his proposals for the wreck the plan by boycotting the Impassioned protest leader of the South Wales miners, service up and running, to NHS as late as February 1948. When cabinet voted in 1951 to later becoming a Monmouthshire popular acclaim. The scheme Mr Bevan’s strategy was to split introduce charges for dentures, county councillor and in 1929 MP was implemented almost as he the profession. He won over the spectacles and prescriptions, Bevan – for Ebbw Vale. In his first Commons had conceived it, but until hospital consultants by agreeing now labour or employment minister speech he attacked Lloyd George close to the appointed first day they could use NHS “pay-beds” for – resigned in protest. He wrote to and Churchill. By the second world of the new service, its future private care. In hindsight he said he prime minister Clement Attlee: “It war Bevan was a figurehead of the often seemed uncertain. Mr had “stuffed their mouths with is the beginning of the destruction left and edited its newspaper, Bevan had to deploy political skill gold”. Then he withdrew proposals of those social services in which Tribune, from 1941 to 1945, and determination that would to force GPs into a salaried service. Labour has taken a special pride recruiting George Orwell to its staff. have been beyond most. At the time these appeared minor and which were giving to Britain Despite his cabinet resignation Inheriting a ramshackle structure compromises that left the essentials the moral leadership of the world.” and leadership of the left-wing and only vague ideas for reform of the NHS intact, although they Mr Bevan was born the sixth of Bevanites during the 1950s, Mr from his wartime Conservative stored up problems for the future. 10 children to a mining family in Bevan was elected Labour’s deputy predecessor, he was Mr Bevan might have expected Tredegar, South Wales, which gave leader at the end of the decade. But determined the new promotion to chancellor or foreign him first-hand experience of poverty he already had cancer. Twelve years health service secretary, such was his achievement. and disease. Two of his five brothers and one day after the beginning of would “universalise At this time he was also heading the died in infancy, a third at the age of the NHS, he died.

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66-73 DIAMOND60-asas/JW.indd 2 24/6/08 14:05:25 ARCHIE COCHRANE RICHARD ASHER Archie Cochrane was an Richard Asher was an epidemiologist whose work gave outstanding essayist who great impetus to the concept of challenged prevailing medical evidence-based medicine. In his practice. His famous 1947 article 1972 book, Effectiveness and in the British Medical Journal on Efficiency: Random Reflections on “the dangers of going to bed” Health Services, he suggested that argued against confining patients because resources would always to bed and called for day rooms to be limited, they should be used to be attached to every ward. “Get provide healthcare shown to be people up and we may save our effective in properly designed patients from an early grave,” he evaluations. His thinking was shaped wrote. He also listed the “seven by his experiences in the Spanish sins of medicine” as obscurity, civil war and as a prisoner in Greece cruelty, bad manners, over- and Germany during the Second specialisation, love of the rare, World War. Support for his views led common stupidity and sloth. to the opening of the first Cochrane A physician at the Central centre in Oxford in 1992 and the Middlesex Hospital in London, Dr founding of the Cochrane Asher coined the term Collaboration in 1993. Munchausen’s syndrome.3

GEORGE GODBER Sir George Godber was chief RICHARD DOLL/AUSTIN medical officer from 1960 to BRADFORD HILL 1973. As a doctor he had disliked taking fees from Sir Richard Doll (right) and Sir patients so went into public Austin Bradford Hill were the health and joined the first to demonstrate that Ministry of Health in 1939, smoking was linked to lung where he was closely cancer and heart disease. Doll 5 involved in setting up the was a doctor working on a NHS. He strove to rectify Medical Research Council pre-war deficiencies in project on asthma when he met healthcare, arguing for Hill, an outstanding medical specialists to be evenly statistician and epidemiologist distributed in district who introduced the principle hospitals, GPs to work in of randomisation in clinical teams in health centres and trials. Studying lung cancer for doctors to keep up to patients in 20 London date. His other initiatives hospitals, they initially included making the suspected tarmac or car fumes contraceptive pill available were to blame before on prescription and several discovering tobacco was the public health campaigns, sole factor in common. Doll particularly against and Hill published their first smoking. He famously wore paper in 1950 and went on to a monocle and slept on a carry out a long-term study of camp bed in his office two or the smoking habits and health three nights a week. of 30,000 British doctors.

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66-73 DIAMOND60-asas/JW.indd 3 24/6/08 14:05:47 CLEMENT ATTLEE After public school and Oxford Mr Attlee became a barrister, but developed an interest 7 in social problems 6 while working as a volunteer in a boys’ club in Stepney. Labour leader for 20 years from 1935, he was also deputy prime minister in the Second World War, responsible for domestic policy. Quiet and unassuming, Churchill described him as “a modest man who has much to be modest about”, although in 2005 academics voted him the best prime minister WILLIAM BEVERIDGE of the 20th century. As well as creating the Mr Beveridge’s 1942 report on post-war reconstruction NHS, his government provided the blueprint for the welfare state, identifying its nationalised a fifth of task as overcoming the “five giants” of want, disease, the economy. He lost ignorance, squalor and idleness in order to take care of the 1951 election 3 citizens from “the cradle to the grave”. It proposed: “Medical despite winning more treatment covering all requirements will be provided for all votes than the citizens by a national health service.” An economist, Conservatives. Beveridge had been a leading authority on unemployment insurance. He helped organise a national system of labour exchanges and his ideas had influenced the 1911 National KENNETH CLARKE Insurance Act. He later became leader of the Liberals in the House of Lords. First as health minister and later as health secretary, Kenneth Clarke forged a reputation for being forthright, fearless and TONY BLAIR argumentative, not least in his legendary 9 confrontations with doctors over the limited No prime minister has list, GP contract and internal market. He ever tied their dissuaded the then prime minister Margaret government’s Thatcher and right-wing colleagues from reputation – or their scrapping the NHS in favour of an insurance 8 own – so closely to the system during her 1988 review and was an NHS as Tony Blair. He unequivocal advocate for the health service portrayed the election when it was unfashionable in Tory circles. He that brought him to was a favourite of managers, who felt he gave power as a “last them reliable support and trusted them to get chance to save the on with the job without interference. NHS”. Yet despite rhetoric about modernisation, he had ENOCH POWELL been in office for three years before conceding Enoch Powell’s stint as health – on Breakfast with minister from 1960-63 has been 10 Frost – that the service overshadowed – like the rest of his was chronically career – by his later “rivers of underfunded and blood” speech opposing spending should immigration, but he pioneered two match “the European measures that had lasting effects. Union average”. With his “water tower” speech of Spending on health 1961, Powell began the process of had almost doubled by closing long-stay mental hospitals, the time he left while his Hospital Plan of 1962 Downing Street – launched a 10-year building although the private programme to make district general sector’s role had hospitals the backbone of the NHS, expanded beyond the although it was never completed. As wildest dreams of the a former Treasury minister, Mr Conservatives, whom Powell was convinced the NHS was Labour once scorned a legitimate target for cuts in public for “commercialising” spending – possibly the last health the NHS. minister to think so.

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11 CICELY SAUNDERS her lamp through the corridors of NHS and other health systems famous assertion that it was “safe in Dame Cicely Saunders founded the the NHS today she would almost abroad, as well as acting as a our hands”. hospice movement in the UK when certainly be searching for the people consultant to the World Health But there is no doubt that Lady she set up St Christopher’s Hospice, in charge”, his proposals included Organisation. Thatcher’s influence persists in the the world’s first purpose-built general managers, management purchaser-provider split, the hospice, in London in 1967. Her budgets, emphasis on value for ‘Alan Milburn was internal market and the idea that concentration on providing both money and a greater emphasis on giving GPs the “right” to influence effective palliative and holistic care training for management. the health secretary hospital services through holding has led to a better experience of This led to the end of consensus their own budget can lead to better, death for thousands of people and management and increasing who surprised the more responsive care. their families. professionalism in the management She had a strong Christian faith, of the NHS. However the reforms left by introducing 15 ALAN MILBURN opposed euthanasia and believed contributed to the “them and us” Alan Milburn was the health dying was as natural a phenomenon attitude which still persists between policies that might secretary who surprised many on as being born. While her views were managers and clinical staff and to have come from the the left by introducing policies that opposed by some doctors, she the demonisation of NHS managers might have come from the influenced the care of the terminally in the media. Conservatives’ Conservatives. Foundation ill across the NHS and worldwide. hospitals, a concordat with the The Cancer Plan in 2000 13 BRIAN ABEL-SMITH private sector and a blunt star acknowledged the NHS should fund Professor Brian Abel-Smith’s work 14 MARGARET THATCHER ratings system were hated by many specialist palliative care and now influenced understanding of the Margaret Thatcher still provokes a within the political and NHS many hospices receive some embryonic NHS and of the lives of range of passionate views among establishment and came as a shock element of NHS funding. the poorest in the UK. A special HSJ readers. On one hand, she after the more conventional adviser to the Labour governments emphasised proper management of approach of Frank Dobson. 12 ROY GRIFFITHS of 1964 to 1970 and 1970 to 1979, the NHS and did much to break the But Mr Milburn’s reign from Sir Roy Griffiths is often credited as his work was already influential by doctors’ near-monopoly of power in 1999 to 2003 included massive being the father of modern NHS the time the NHS was established hospitals. But opponents will point improvements in NHS planning management. As part-time adviser after he wrote a seminal study of to her lack of interest in health and delivery, including the NHS to Margaret Thatcher, Sir Roy voluntary hospitals which showed inequalities, her support for private Plan of 2000. No one could deny Mr proposed radical changes to the way how they were no longer financially healthcare and insurance and the Milburn had vision and enthusiasm in which the NHS was managed. viable. He went on to produce an financial strictures of the late 1980s for reform and managers sometimes Famously remarking that “if analysis of the young NHS’s costs as evidence that she did little to still miss his honest approach. But Florence Nightingale were carrying and later wrote widely on both the promote the NHS, despite her there remains a question over

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66-73 DIAMOND60-asas/JW.indd 5 24/6/08 14:06:45 THE JUDGES 20 ● Jessica Allen, head of health and social care, Institute for Public Policy Research ● John Appleby, chief economist, King’s Fund ● Virginia Berridge, Professor of History, Centre for History in Public Health, London School of Hygiene and Tropical Medicine ● Dame Yves Buckland, chair, NHS Institute for Innovation and Improvement ● Andrew Corbett-Nolan, head of governance, Humana Europe ● Deirdre Doogan, director of government relations and NHS services, Lloydspharmacy ● Nigel Edwards, director of policy, NHS Confederation ● Tim Keenan, chair, Tribal health services group ● Noel Plumridge, consultant and HSJ columnist ● Geoffrey Rivett, former GP and civil servant and NHS historian ● Dominic Robertson, client director, Airwave ● Paul White, chief executive London NHS Programme, BT ● Richard Vize, HSJ editor ‘There is no doubt Thatcher’s influence persists in the purchaser-provider split, and letting GPs hold their own budgets’

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whether he did enough to ensure new Labour government and as possible. Many elderly sick As CMO he had to deal with the the extra money that started to flow included the Bristol inquiry, the rise patients had been discharged BSE crisis and initially gave into the NHS was used to the of concern about healthcare- during the Second World War, assurances about the safety of greatest benefit. acquired infections and pressure for exposing the inadequacies of the eating beef. He remains an changes in working practices in the care available to them in important government adviser in 16 JULIAN TUDOR HART NHS. He also oversaw the setting communities. Dr Wallace was Scotland. Julian Tudor Hart has spent his up of bodies such as the National highly critical of the lack of medical working life as a GP and researcher, Institute for Clinical Excellence and leadership, inadequate diagnostics, 20 DOUGLAS BLACK often approaching the NHS from a the Commission for Health lack of rehabilitation and absence of Professor Sir Douglas Black was an rigorous Marxist-socialist Improvement, which drove a multi-disciplinary approach in the able medical researcher – helping perspective. Much of this time was improvement and consistency field. She advocated a focus on our understanding of the spent as a GP in the South Wales across the NHS. But for many in the rehabilitation and discharge from importance of fluid balance in the coalfields, where his observations of NHS his time at the top was marked hospital only after assessment. body – and popular president of the poverty and ill health led to much of by structural upheaval – notably the Royal College of Physicians. his research work, but he also abolition of regional health 19 KENNETH CALMAN His name is writ large in NHS challenges doctors and others to authorities and the establishment of Professor Sir Kenneth Calman was history because of his chairmanship think about the wider picture of primary care trusts – and financial chief medical officer for Scotland of a committee into health how the NHS can be a civilising restrictions. before becoming the Department of inequalities which was commissioned influence on society. Health chief medical by a Labour government but only A passionate advocate of high- 18 MARJORIE officer for seven years. reported after Margaret Thatcher quality primary care and general WARREN YOUR CHOICE A prominent took power. The controversial practice, he is best known for Marjorie Warren’s We also asked readers oncologist, he was co- conclusions of the committee – that propagating the inverse care law – work laid the to name their top five author of the Calman- poverty was behind many that the availability of good medical foundation for the most influential Hine review in 1995 inequalities (it found the death rate and social care varies inversely with modern specialty of people, from a list of which led to for the poorest men in society was the need of the population served. geriatrics and changed over 20 names. Here restructuring of cancer twice that of the richest) and that the emphasis of care are the results. services with an changes to the NHS could reduce 17 ALAN LANGLANDS for older people from 1 Aneurin Bevan emphasis on specialist this – were anathema to the new Sir Alan Langlands was chief maintenance of the 2 William Beveridge multi-disciplinary Conservative government. executive of the NHS in England chronic sick to 3 David Lloyd George teams. Much of the The report was eventually during a period of rapid change. His rehabilitation and 4 Roy Griffiths philosophy of this released on a bank holiday Monday six years at the top, from 1994 to enhancing their ability 5 Kenneth Clarke review underpinned with only a limited number of 2000, spanned the election of the to live as normal a life the later Cancer Plan. copies made available.

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21 DAVID STEEL has most recently been involved in and asked his patients if he could years in the top job have seen Sir David Steel, the former Liberal the introduction of a cervical cancer have their hips back after they died increasing emphasis on public party leader, steered the 1968 vaccine for young girls. His previous for examination. health issues and patient safety, but Abortion Act through the House of battle honours include defending he was criticised over the 2007 Commons, ushering in an era where the MMR vaccine and the 32 DAVID CARTER debacle over reforms in the way abortion moved from the back government’s record on pandemic Professor Sir David Carter led a key junior doctors were appointed. streets to clinics and hospitals. flu preparation. review of NHS commissioning arrangements and was also 37 SIMON STEVENS 22 JOHN SMITH 27 KENNETH ROBINSON Scotland’s chief medical officer until Simon Stevens was an influential A senior civil servant, John Smith Kenneth Robinson was health 2000, where he highlighted many health adviser to both Alan Milburn chaired the Resource Allocation minister under Harold Wilson. His key risks to public health. He is also and Tony Blair but now works for Working Party whose 1976 report time in office saw TV cigarette chairman of the Health Foundation. US firm UnitedHealth. Mr Stevens backed the use of population and advertising banned, prescription is often thought to be a prime mover mortality as the basis for charges reintroduced and an accord 33 BRUCE KEOGH in opening up the NHS to outside distributing NHS money, rather with GPs on a GP’s charter. An eminent cardiac surgeon, competition. than historical spending. Professor Sir Bruce Keogh was 28 JERRY MORRIS appointed NHS medical director in 38 ANDREW DILLON 23 BRIAN JARMAN Professor Jerry Morris carried out 2007. He has played a leading role Andrew Dillon has the unenviable Professor Sir Brian Jarman pioneering work on heart disease in in opening up surgeons to scrutiny task of leading the National developed an important index the 1950s and proved conclusively through the publication of mortality Institute for Clinical Excellence. As showing the effect of social and the link between exercise and good and survival rates for individual chief executive since it was set up in economic factors on health status – health, particularly to a lower heart surgeons and units. 1999, he is often called upon to and the consequent demand for incidence of heart attacks. justify decisions that appear to primary care services – and worked 34 GODFREY HOUNSFIELD ration or deny care – and to explain on mortality rates in hospitals. 29 SHEILA SHERLOCK Godfrey Hounsfield was a Nobel the delicate balance of clinical Sheila Sherlock put hepatology on Prize-winning electrical engineer evidence and cost considerations 24 IAIN CHALMERS the map in the 1960s and 1970s, who developed the first practical that underlie these. Sir Iain Chalmers is a former with a renowned unit at London’s computed tomography device in director of the UK Cochrane Centre Royal Free Hospital, where she was 1972. CT scanners allowed doctors 39 GORDON BROWN and leading researcher into medical professor of medicine. to see a detailed image of cross- The prime minister has had trials and their evaluation. His work sections of the human body for the incredible influence over the NHS has helped the public and clinicians 30 JOHN WEEKS first time. since 1997, controlling the purse make informed decisions about Architect John Weeks worked on strings as chancellor for 10 years. healthcare interventions. modern hospital design for the 35 MAGDI YACOUB Many people thought that he would Nuffield Trust. Many of his ideas Professor Sir Magdi Yacoub has roll back some of the reforms from 25 JEAN MCFARLANE were influential from the 1960s carried out more heart transplants the Blair/Milburn years but, Baroness McFarlane of Llanduff onwards, including the belief that than anyone else in the world. He although approval of new projects was the holder of the first chair of design should reflect the central developed Harefield Hospital as a involving the private sector have nursing in an English University position of patients in hospital care. leading transplant centre and in been slow, there is little sign so far when she was appointed at 2002 was appointed an NHS special of a major change in policy. Manchester in 1974. 31 JOHN CHARNLEY envoy. Professor Sir John Charnley carried 40 RICHARD TITMUSS 26 DAVID SALISBURY out the first full hip replacement in 36 LIAM DONALDSON The first professor of social Professor Salisbury is the long- England in the Wrightington Sir Liam Donaldson is the chief administration at the LSE, Richard standing head of immunisation at Hospital in Wigan in 1962. He medical officer for England and the Titmuss did much to bring the Department of Health, where he tested the material on his own leg UK’s chief medical adviser. His nine contemporary social policy into the

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academic mainstream. A fierce surgery, based on observations of at the Bristol Royal Infirmary and campaigner for better defender of the NHS, his work wartime airmen with eye injuries. chairs the Healthcare Commission. understanding and care for mentally included health inequalities and an The technique has saved the sight of handicapped people. His daughter analysis of the cost of the service. 200 million people worldwide. 51 DAVID LLOYD GEORGE Shelley was born with Down’s As chancellor, Lloyd George laid the syndrome in the 1950s, after which 41 EDITH KÖRNER 46 JOHN YATES groundwork for a welfare state in the family were told they should Dame Edith Körner led a steering Dr John Yates’ research on NHS his 1909 budget which provided “put her away and forget about her”. group on health services consultants’ private work caused a tax-funded welfare schemes. information. Its report in the early furore in the 1990s and may have 57 BARBARA ROBB 1980s led to the development of helped to shape tighter controls on 52 PETER TOWNSEND Barbara Robb’s groundbreaking better statistical information which how they work. He also advised the Professor Peter Townsend wrote book, Sans everything; a case to has aided health service planning. government on waiting lists. seminal works on poverty in the answer, brought the issues of the 1960s and 1970s dispelled the myth treatment of elderly people in long- 42 JOHN AND 47 DONALD IRVINE that the welfare state had eliminated stay wards to a wider audience. She ROSEMARY COX Sir Donald Irvine was president of poverty. founded the Aid to the Elderly in John and Rosemary Cox (on right of the General Medical Council in the Government Institutions pressure picture above left) set up the NHS turbulent 1990s. In the face of 53 BRUCE ARCHER group to campaign for better organ donor register after their son public criticism of the institution, he Professor Bruce Archer was a treatment. died in his 20s and his organs were supported self-regulation, but designer and engineer who worked transplanted. They argued for warned doctors that this needed to on solving practical hospital 58 THOMAS MCKEOWN legislation presuming consent to be earned. problems. He designed a Thomas McKeown’s work raises the organ donation, unless stated standardised hospital bed in the question of how much healthcare otherwise. 48 TREVOR CLAY 1960s for the King’s Fund which is contributes to population health, or Trevor Clay was RCN general now used throughout the country. whether other factors, such as 43 ALAN WILLIAMS secretary for much of the 1980s and income, nutrition and social A professor at York University for clashed with the government over 54 JILL PITKEATHLEY conditions, are important in 40 years, he applied economics to health policy. He did much to forge Baroness Jill Pitkeathley has been a reducing mortality. funding and providing healthcare nursing as a profession with an tireless campaigner for the and did much to clarify the identity and role of its own rather voluntary sector, especially in her 59 HELEN BEVAN economic thinking behind decisions than one subservient to doctors. role as chief executive of the Carers’ Helen Bevan is a leading innovator on NHS resource allocation, such as National Association, where she put in service delivery. Currently the use of quality-adjusted life years. 49 RUDOLF KLEIN the needs of Britain’s six million director of service transformation at Professor Rudolf Klein is a leading carers on the political agenda. the NHS Institute, she developed 44 MURIEL POWELL social policy researcher and the 10 “high-impact” changes to Dame Muriel Powell was an commentator on the NHS who has 55 MARJORIE WALLACE transform patient care. exemplary matron in the 1950s and written widely on “rationing” of Journalist Marjorie Wallace set up 1960s who believed changes in services and the politics of the NHS. mental health charity SANE after 60 MICHAEL MARMOT hospital practice could benefit writing about the lives of people Professor Sir Michael Marmot is a patients and who championed 50 IAN KENNEDY with schizophrenia. She was critical leading epidemiologist and graduate nurses. She went on to Professor Sir Ian Kennedy is a of the discharge of patients into the researcher on inequalities in health. serve as chief nursing officer of leading academic lawyer who has community without sufficient He set up Whitehall II, the Scotland. specialised in the law and ethics of support in the 1980s. long-term study of civil servants, healthcare and has consistently which has led to a better 45 HAROLD RIDLEY advocated a patient-centred 56 BRIAN RIX understanding of how social class, Sir Harold Ridley pioneered the use healthcare system. He chaired the Brian Rix, the master of the psychosocial factors and lifestyle of artificial lenses in cataract inquiry into children’s heart surgery bedroom farce, has been a tireless contribute to health. ●

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74-76 popcultureAS-tj/JW.indd 2 24/6/08 15:55:12 Suave doctors, flirtatious nurses and evil managers. Nick Samuels looks at popular images of health professionals as portrayed in television and film

n 1948 the NHS had little to film and television have evolved fear or gain from television. with the service. Undeniably people The BBC had relaunched its are influenced by what they see, but I fledgling service from London’s little or no research has been done Alexandra Palace just two years on how what we see affects how we earlier, broadcasting three hours a behave when using or seeking day, to the handful of people with a healthcare. Depending on which set in the 25-mile radius of the programme you watch, you might transmitter. have very different expectations of Nowadays daily broadcasting services: whether they work, programmes are packed with medical whether you will die waiting for dramas. We have our own domestic them and whether the staff are dramas and even more from the US. competent to deliver them. Medical storylines and characters feature in every soap, thriller and Viewers’ expectations comedy. If the drama is not dramatic Casualty viewers might well be the enough, reality television picks up easiest for accident and emergency the slack with fly-on-the-wall staff to deal with. The popular soap documentaries about every aspect of first aired in 1986 and its early days the service and its professions. were characterised by an underlying Then there are the science theme of valiant clinical staff programmes, with Lord Robert struggling against decay, Winston wandering around your bureaucratic challenge and the reproductive system, portraying indifference of a Conservative breakthroughs in DNA, imaging government. Battle lines between technology and the like. One other frontline staff and everything above genre scoops up the rest of the them were clearly drawn. viewing: news and documentaries, Viewers’ expectations of the NHS invariably focusing on the less must have been significantly successful bits of the healthcare depressed by Casualty, perhaps system, exposing and excoriating helping them to accept long waits, everything in their path. broken vending machines and an

Representations of the NHS in apparently pedestrian pace of Ë76 BBC AMARANG, AQUARIUS, GRANT, RONALD

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74-76 popcultureAS-tj/JW.indd 3 24/6/08 15:55:36 75Á activity. This is a recipe for surgery was no Carry on Matron. So, according to success, for broadcasters at least. problem, the most British film, doctors are smooth and Despite all the misery Casualty obscure of diseases seductive, nurses flirtatious and viewers may have experienced in were diagnosed with patients cheeky. All authority figures real A&Es, the programme has ease and 10 are either fearsome or a bit hapless. remained hugely popular: it is the convoluted personal By contrast, Britannia Hospital in longest-running emergency emotional 1982 was anarchic. Every public medical drama in the world. It has circumstances could sector institutional and professional also spawned spin-offs as the BBC be dealt with in a malaise was satirised. Its plot is finds more ways to eke life out of single episode. Yet, summarised by the British Film the formula. Holby City takes us to though Casualty and Institute as: “A strike at a hospital the surgical wards of the hospital ER were trailblazers, on the eve of a royal visit results in and there have been special medical drama did mayhem, while a mad doctor uses crossover episodes not begin with them national health funds to create (Casualty@Holby and has moved on Frankenstein-type creatures.” The City). significantly since they first film allows the imagination to run But it was appeared. riot about running the NHS. This is American import ER, probably where No Angels and arriving almost a decade No sex please Green Wing picked up three later, that broke the mould The biggest popular portrayals of decades later. of medical dramas and made the NHS on film were the comedy No mention of managers so far – previous shows seem rather Doctor and Carry On films, creating they don’t appear to make great cosy and old-fashioned. ER was a uniquely British, saucy postcard drama except when you want a one- fast, very fast. The characters tone for depictions of doctors and dimensional villain. spoke in clauses, not nurses that still lingers. They do pop up in supporting sentences, because Doctor in the House came first in roles, including a management everything happened 1954, with a group of students consultant character who spent an so quickly. But of coming to grips with consultants, episode of ER annoying staff with course ER was nurses, matrons and patients in his clipboard and time-and-motion American so, in the their first year of medical school. study, only to be revealed at the end context of the NHS, The dashing male medical students so what? played by Dirk Bogarde, Leslie Well, it came Phillips, Kenneth Moore and ‘Nowhere is there along at a time when Donald Sinden fitted in study dramatic or comedic the NHS was between being terrorised by inwardly focused on irascible chief surgeon James representation of management Robertson Justice and pursuing reforms and 1990s romance (not sex, it was 1954 after managers that we prime minister John all) with simpering young nurses Major had launched whose sole career aim was to marry would recognise a major policy a doctor. How many stereotypes initiative, the does that make in 87 minutes of as sympathetic’ Patients’ Charter, celluloid? alongside the cones Doctor in the House, which was of the episode as an escaped hotline. The programme offered the biggest box-office hit of 1954, psychiatric patient. They also thrive viewers a very different take on made Dirk Bogarde the housewife’s in darker dramas such as Cardiac what emergency care should look choice and typecast Joans Arrest and Bodies as malign forces like. It also introduced a flurry of Sim and Hickson as stern of evil. medical jargon that was hard to matrons with meltable In fact, nowhere is there dramatic understand but did sound hearts for the next four or comedic representation of impressive. And there was a huge decades. But they were management that any of us would amount of expensive kit and tests soon overshadowed by the recognise as either sympathetic involved – something which never most famous comedy (a ratings loser surely), heroic or seemed to clutter Casualty – and matron, Hattie Jacques. even tragic. some very good-looking doctors and She Jacques cornered the It is left to Yes Minister to come nurses. Casualty did try to respond matron market in the 1959 closest to NHS management, circa to that last development. film Carry on Nurse, the 1981, when minister Jim Hacker is biggest grosser in the UK appalled to learn one of the most High drama that year. In the very loose efficient NHS hospitals owes its ER showed public healthcare need script, patients on a male success to a crucial factor – it has no not be drab and could look effective, surgical ward revolt with doctors, nurses or patients. The responsive and exciting. Much of the support of junior nurses dialogue is instructive: the excitement in Casualty comes in against the size-45 matron. Minister (slowly and carefully): the first five minutes of the show, Matron was not to be Humphrey, there are no patients! when viewers have to guess which messed with and definitely That is what a hospital is for! of the anonymous extras is about to not a sex symbol. Patients! Ill people! Healing the sick! become a patient. ER decided the But female characters in the Sir Humphrey (calmly): Minister. drama was not about how you came Carry On films tended to play totty. We don’t measure our success by to A&E, but what happened after Doctor and Carry On both spawned results, but by activity. ● you crashed through the doors. several series, with Doctor at Sea, Nick Samuels is director of What the shows have in common, ...at Large, ...in Love, ...in Distress, communications at Imperial College however, is the dramatic licence to ...in Clover and ...in Trouble jostling Healthcare trust and chair of the provide amazing healthcare in an for screen space with Carry on Association of Healthcare A&E department. Quaternary-level Doctor, Carry on Again Doctor and Communicators.

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