Reflections of an ex-AHA member

Abstract

Now that area health authorities are part of the history of the National Health Service, there may be a case for reflecting on what we can learn from their experience before completing the final burial rites. In my study stand three crammed box files: memorials to the three years I spent as a member of an AHA. What did I learn from this experience? And what are the implications for the future ? This paper attempts to draw some cautious conclusions about the role of authority members in the running of the NHS on the basis of my own three-year stint. It is, self-evidently, dangerous to extrapolate too recklessly from limited experience of one AHA. In particular, it is important to emphasise the special characteristics of my own AHA : Wiltshire. It lacked the sort of acute social and economic problems that afflict some inner cities; it did not mirror the political tensions generated by such problems; it had been fortunate enough to attract a highly competent team of chief officers who commanded the support and confidence of the members. authority's style reflected these characteristics. emphasis was on achieving consensus; at times the chairman had to make quite deliberate efforts to ensure that important issues were given a more than perfunctory discussion. Only rarely did the members vote, and then usually on matters that did not affect the AHA directly. For example, the question of whether or not the AHA should back legislation to make the wearing of seat belts compulsory aroused strong passions. But such passion was exceptional. To the extent that members felt strongly, it was usually about issues that united them: in particular, about what they saw as the region's insensitivity to the area's claims to extra resources and its rigidity in seeking to impose regional policies and plans. Overall, it would be difficult to conclude?on the basis of my short experience?that authority members played a large part in either formulating or executing policies. With some ex? ceptions, discussed below, their role tended to be reactive and concerned with the small print of local implementation rather than grand strategy. Nor can this be explained by Wiltshire's special characteristics: my experience was in line with other studies.1-3 Instead, my experience suggests that the relatively recessive role of authority members may be explained by some of the problems built into the role itself. And it is these problems that I shall explore. For, though AH As may now have disappeared, their abolition has not automatically solved the difficulties faced by the members of health authorities. And the experience of AHA members may, therefore, still have implications for the new district health authority members. first discovery I made as an AHA member, no doubt like all other new recruits, was the extraordinary difficulty of my role?even for someone like myself, with a professional interest in the NHS, who should in theory have come reasonably well equipped for the task. difficulties had little to do with the organisational structure of the NHS?the number of tiers and their relation to each other?but reflected the peculiar nature of health services. Being an authority member is a never-ending, often frustrating battle against history, ambiguity, and uncertainty in an environment of exceptional complexity. 1972 Grey Book on the management of the NHS4 defined the role of AHA members in ambitiously, and optimistically, comprehensive terms: The AHA will itself take all decisions on planning, and resource and control the performance of its officers. main role of the member turned out to be, however, to judge by my own experience, the ratification of decisions imposed by the logic of history and the organisational dynamic of the Service itself. In practice, most decisions about policy, planning, and resource allocation have been pre-empted by the past. At any one point in time the scope for taking strategic decisions is constrained. Becoming an authority member is rather like boarding a train: the passengers can decide where to get off, but they have no say in its destination. Specifically, most developments flow from decisions about the capital investment programme: so, inevitably, given the long lead time, authority members are the prisoners of past planning policies now embodied in concrete.