Decision making in the National Health Service.

Abstract

One of the complaints made by clinicians since reorganisation of the National Health Service is the failure of the administration to make decisions. They contrast this with the comparative ease with which decisions were made before the reorganisation and still are made in private practice. The answer to this is twofold. Firstly, it is much easier to make decisions in private practice, where you can define the type of work you intend doing and can restrict the patients coming to see you on the assumption that somebody else will deal with those you do not wish to see. This ability to choose which patient to treat and which to reject does not apply in countries where private patients form a larger part of the whole than they do here, and where the costs are paid by some insurance body which will lay down complicated rules about who is eligible for treatment. In other words the freedom of the doctor to make decisions even in private practice is conditional on alternative facilities being available for those patients who are rejected. So the reason why decisions are more difficult in the National Health Service (NHS) than in private practice is because the NHS cannot turn patients away. Secondly, the reason why reorganisation is seen as a particular bogey is because each reorganisation usually has as one of its main aims to increase specific pressures on the clinician. Thus the Lloyd George Act of 1911 establishing the panel1 meant that any family doctor who accepted panel patients had a continuing obligation to them, an obligation that had not previously existed. The Act which led to the introduction of the NHS in 1948 extended this to the whole family and every citizen of Britain when they need medical treatment.2 The 1973 Act extended the service to in? clude the former local health authority services so that the district health authority of today has a responsibility also for preventive medicine.3 The 1982 reorganisation was different in that it did not extend the responsibilities of the service so much as change and, I believe, improve the organisational structure,4 but it is still too early to evaluate this. It is worth noting that the obligations laid on the general dental practitioner are appreciably different from those laid on the general medical practitioner in that the dentists do not have continuing re? sponsibility for a patient who has completed a course of treat? ment, and therefore they do not suffer from the same sort of pressure. Clearly there are different types of pressure on different clinicians. I want to consider primarily the way in which decisions are made within and concerning the NHS, starting at Cabinet level, because it is here that the major decisions are made?decisions that are the outcome of discussions with other members of the cabinet in the light of political pressures from the whole popula? tion. The sorts of decisions include, for example, the proportion of the gross national product to be spent on the NHS and the proportion likely to be spent on health in the private sector. Figure 1 shows that the proportion of the gross national product