Acheson and the General Manager

Received: 17th August, 1989

Margaret Goose

Margaret Goose has been District General Manager in North Bedfordshire Health Authority since 1985 following a career in health service administration in and around London. She was President of the Institute of Health Services Management 1989-90 and also serves on the Ambu­lance Staff Training Committee of the NHSTA.

O Keywords Acheson — general management — public health — community medicine — skills

O Abstract A District General Manager offers some

thoughts on the implementation of the Acheson Report and challenges community medicine specialists to he realistic about deployment of their scarce skills.

O Introduction

Relationships between community medi­cine specialists and general managers in the UK have not always been easy, mainly because of different perceptions of key objectives and lack of clarity of rela­tionships rather than because of issues relating to status. The publication in December 1988 of HC(88)64, 'Health of the Population: Responsibilities of Health Authorities',1 does not of itself resolve the differences and tensions, but working through the issues should produce greater clarity and understanding.

It is worth remembering that the Acheson Report2 arose from concern at ministerial level that communicable disease control was not effective following food poisoning at Stanley Royd Hospital, Wake­field, in August 1984 and Legionnaires' Disease at Stafford Hospital in April 1985. A report was finally published in January 1988 and covered public health issues of a wider nature. For many it read as a justifi­cation for community medicine specialists to revert to their local authority role. Some people were very disappointed that the contribution that community medicine could make to the wider management of health care was mentioned only in passing:

'5.3.1 to provide epidemiological advice to the D.G.M. and the D.H.A. on the setting of priorities, planning of services and evaluation of outcomes.' This state­ment was not developed much further in the report.

The independence of opinion of the doctor charged with the responsibility of assessing the health needs of a population has never been questioned although the forum and manner in which points have been made have.

With the publication of the circular the particular responsibilities of District Health Authorities (DHAs) and District General Managers (DGMs) are clearly spelt out and proposals were to have been submitted to the Regional Health Authorities by the end of June 1989. They had to review their access to public health advice, and how they are going to discharge their respon­sibilities in this field, including surveillance and control of communicable diseases.

195

Journal of Management in Medicine Volume 4 Number 3 • Goose

The proposals must in particular cover: (1) the appointment of a Director of Public

Health (DPH); (2) arrangements for an annual report by

the DPH on the health of the popula­tion;

(3) revised arrangements on the preven­tion and control of communicable diseases and infection; and

(4) collaboration with local authorities, family practitioner committees (FPCs) and other relevant agencies.

The subsequent publication of the NHS Review 'Working for Patients'3 necessitates reassessment of the patterns which were emerging, particularly with respect to the DHA's role as a procurer of services which requires assessment of the health needs of its population. The Government's response to the Griffiths' Report on Community Care also has implications necessitating further reassessment.4

O A changing world The British National Health Service, like

society as a whole, is subject to change at an ever-increasing pace and no one arrangement should be expected to meet these changing needs without subsequent adjustment. Thus arrangements will con­tinue to evolve as both environment and individuals change.

It is clear that the role of the DPH will be increasingly vital in a health service where health authorities will be specifying contracts for service on the basis of quan­tity, quality and outcome for its local popu­lation — they will have particular responsibilities for advising on priorities in relation to the health needs of the popula­tion as well as helping to assess health out­comes and advise on the evalution of different services.

A crucial question therefore remains — whether there are sufficient community medicine specialists available throughout the country to take on these new respon­sibilities. The survey done for the Acheson Report and by the Faculty of Community Medicine showed that the specialty had declining numbers; there are not enough people of consultant rank or with the requisite training to fulfil these new responsibilities. It is therefore important to

make the best use of those that are avail­able and to ensure that there are other per­sonnel to cover those aspects of the work which do not require medical qualifica­tions, such as data analysis information and other research, in order to allow com­munity medicine specialists to concentrate on key areas. It should not be that the whole of the public health function con­sists of public health specialists alone, although medical leadership is essential.

For many districts the issues in imple­menting the new role of public health medicine are straightforward. For others a more radical approach will be required before their proposals could be submitted.

(1) Appointment of DPHs General managers will be recommending

whether or not their current District Medi­cal Officers (DMOs) or their equivalent are appointed as DPH. They are expected to discuss this with their regional public health colleagues. But how many people are clear about what will be expected of the role, how it will operate and how perform­ance will be measured?

(2) Production of an annual report EL(89)P/13,5 published before the NHS

Review in January, states that it expected that most health authorities would produce a report before December 1989 and prob­ably by October. General managers will be deciding whether this report is to be part of a wider coverage including finance, activities and other issues facing the health authority. I for one, have no intention of interfering with the independent nature of the content of the report in my authority nor with the views expressed in it, but I do not see why it should necessarily be assumed that it should form a separate document when there are other major features involving the statutory responsi­bilities of a health authority which should similarly be brought to the health authority's attention at this stage in the planning cycle. It needs to be capable of standing alone so that it can be distributed to other bodies for information and as a background to their decision-making, as well as being available to the general public. One suggestion I have heard is that it should be an important appendix to the

196

Journal of Management in Medicine Volume 4 Number 3 • Goose

Short Term Programme which generally encompasses a review of past activities and proposals for future action.

(3) Prevention and control of com­municable diseases and infection

This area has been highlighted as an extremely important part of the role of public health medicine and one which had potentially been 'downgraded' due to the changing roles of community medicine specialists following the introduction of general management and to an apparent lack of interest among trainees. The review of arrangements to discharge this function will need to take account of the implica­tions of the NHS Review. It is stated that self-governing hospitals will continue to be held responsible but the arrangements for each district must take into account the fact that some hospitals may no longer be directly managed by health authorities.

Since the prevention and control of com­municable diseases and infection was the major reason for establishing the Acheson Committee, it is imperative not only to ensure that mechanisms exist to fulfil the function properly and that appropriately trained staff are available to carry out the duties, but also that they have time to do so properly with support staff available. The formal relationship with consultant microbiologists and control of infection nurses will also require clarification.

Prevention of communicable diseases and infection involves links with many agencies and with a large number of indi­vidual practitioners; control, when a major outbreak occurs, not only relies upon those relationships but also is of itself extremely time-consuming because of the detailed nature of the work. My earlier comment on the need for other personnel to be available to assist public health medicine specialists is particularly pertinent in this regard.

(4) Collaboration with local authorities, FPCs and other relevant agencies

Local arrangements will vary according to whether they are district-specific or based on a consortium approach, particu­larly where boundaries are not co-termi­nus. It is important that each district works out how its Director of Public Health will fulfil its function in this respect, since there

are many other senior staff who also carry responsibilities for such collaboration. Fol­lowing the NHS Review it is essential that there is clarification of the roles of DGM, UGM (Community), FPC General Manager not to mention Directors of Planning and Information as well as the DPH. When the White paper is published in autumn 1989 following the Government's response to the Griffiths' Report on Community Care, much detailed work will be required. How many Directors of Public Health will be the person appointed by the FPCs to provide independent medical advice?

Community medicine specialists' skills will be in much demand, as clarification is sought between medical care and social care; discussions take place on philoso­phies of service; and strategies are drawn up for the transition, as well as the even­tual pattern, of all non-acute hospital ser­vices. Again it will be important to be clear about who is doing what among the health authority's senior staff.

These are the main areas outlined in the circular to be implemented in 1989. What happens to the other roles both advisory and managerial in which community medi­cine specialists have traditionally been involved, eg medical manpower, general planning, management of health promo­tion, management of child surveillance as well as evaluating clinical outcomes in the changing nature of medical practice? It is to be hoped that the experience and advice available from community medicine col­leagues will not be lost in some of these areas.

However, if the skills and experience of this particular specialty are needed first and foremost for public health, we should not diminish that resource by asking them to take a leading role in other areas where other staff could provide an alternative and are sometimes better equipped to do so.

With a more flexible approach to under­taking different tasks and the expectation under the Government's proposals for pri­mary health care that general practitioners will be undertaking a more major role in health promotion, child and other surveil­lance, the time is ripe for all health authorities, when addressing their respon­sibilities with respect to public health, to scrutinise critically the expectations they have of how their community medicine department may contribute in other areas.

197

Journal of Management in Medicine Volume 4 Number 3 • Goose

It is good to see that the public health function has emerged at this time as a key area which health authorities are to ensure is being handled effectively; this will mean resourcing properly. However, it is to be hoped that the Faculty of Community Medicine and the individual practitioners will not retreat to their former stance as medical officers of health and forget that they are now operating in a more dynamic management environment which in future will be more pluralistic in its approach. It is imperative that DGMs are clear about their expectations and that DPHs are realistic about what they can deliver; a fully fledged department of public health for each district is obviously not viable in the fore­

seeable future and various short-term measures will therefore be necessary. I trust that, by working through the issues together, community medicine specialists and general managers will ensure that the nation's public health is improved.

References 1 HC(88)64. 'Health of the Population: Responsibili­

ties of Health Authorities' (1988). 2 'Public Health in England'. The Report of the Com­

mittee of Inquiry into the future development of the Public Health Function.

3 'Working for Patients: The Health Service Caring for the 1990s'. HMSO (January 1989).

4 HN(89)18. 'Government's Response to Griffiths Report on Community Care'.

5 EL(89)P/13. 'Annual Reports on the Health of the Population'.

198