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Public health and bureaucracy. The beauty and the beast
- Ioannis M Vlastos (24 November 2005)
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Asking the wrong questions
- Andrew Al-Adwani (1 December 2005)
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Ioannis M Vlastos, resident in pediatric otorhinolaryngology-head and neck surgery Aghia Sophia Children's Hospital, Athens PO BOX 11527
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Dear editor Reading the editorial of Judith Smith and Nicholas Mays on the role of PCTs, I would like to mention some thoughts on the conflicting role of Strategic Health Authorities and generally on public health organizations that were created by my short stay in a SHA as a foreign observer. There is a satirical expression: “if you don’t want to solve a problem organize a committee to solve it” querying the value of organizations consisting of groups, teams, committees etc with complex interactions and bureaucratic processes. North Central London Strategic Health Authority looks like this, probably for the majority of people and even for some of its employees. Teams with promising but not so meaningful names, members with unknown roles, processes with complex determinants feed thoughts for useless money spending. Various networks with a total of hundreds of components and thousands participants seem meaningless or unacceptably slow. So what do we actually have here? Bureaucracy or essential mechanism? Resource drain or the inevitable cost of development? Artificial or real need? Having spent several months in surgery as a surgical trainee in a foreign country and feeling that public health is underrepresented in my curricula I decided to use my annual leave to do an attachment and get a better idea on public health’s principles. Finally after the exchange of several letters with advisors of the Faculty of Public Health and PCTs’ directors I was accepted at NCLSHA. The director of public health there organized a few sessions for me and let me attend lectures, meetings and workshops. And all of a sudden one day while attending one of the extreme time consuming meetings listening to everybody views with the confidence of a doctor who had taken tough decisions, as tough as letting on old man “die with dignity” or persuading people accepting the high risk of an operation, I realised that clinical decision making differs from policy making. Yes they are the simple, basic principles of our clinical decisions, the same that should determine the acts at the higher level of hierarchy. Transparency, ethical use of evidence, equal participation of both doctor and patient are the requested in our days and these also are some of the principles of a health impact assessment or some of the general determinants of a political process. But values based commissioning remains a complex issue. It is a balancing process, which requires not only the evidence but also the incorporation and implementation of principles and facts in a way that ensures the maximum benefit. It is a corporation which increase the input of data, ensures feedback mechanisms and proper analyses and aims at better, long lasting and cost effective health promotion. Not all the countries have the resources and the structure to do this. So the answer is clear: if Britain wants to lead health development, the need of financing such kind of mechanisms is inevitable and “some” bureaucracy an acceptable cost. The real problem we should focus on is to manage those structural changes that will improve the performance of the mechanisms. The recent networks review and the evaluation of their maturity, operational structure and general performance can be regarded as an example of this consolidation and rationalization process. Doctors who have the willingness and the capacity to move from the evidence based decisions of the clinical setting to values based processes of policy making are and should be welcomed and offered the appropriate help. Well-organized public health specialization programs, which only few countries in the world have developed, can contribute the most of it. Yours sincerely,
Acknowledgements: I would like to thank Dr Catherine Brogan, an inspiring leader who offered me the chance to stay with public health team of NCLSHA for a month and Andrew Harris, a very kind and educated director of clinical governance for his willingness to introduce me into his amazing speciality Competing interests: None declared |
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Andrew Al-Adwani, Consultant Psychiatrist Great Oaks, Ashby High Street, Scunthorpe, DN15 7QL
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Sir: The government in it's perception of a mismanaged NHS resulting from
awkward and intransigent doctors and nurses developed a management
structure which it belived would force health workers to tow the party line.
Having started this being it rapidly metamorphosed, like Frankenstein's monster, into an even less manageable beast that has grown and grown creating ever more nebulous jobs, titles, roles and functions neccessitating endless meetings where the most difficult decisions made are which flavour of vol-a-vent to choose. Even where dubiously valuable decisions are made these are inevitably reversed within days due to a lack of consultation with those who actually do the real wiork of the NHS. The layers of bureaucracy created by manament protect those at the top from the consequnces of thier decision making and from dismissal - to abbreviate the famous quote 'first they came for the communists ..... then they came for me', Having created this now uncontrollable, criminally wasteful and ultimately purposeless monster whose motto appears to be that the job of a manager is to keep his job the government is at a loss as to what to do so it hopes to hive the problem off to the private sector pretending it's proposed public private mix is in patients interests. Hiring unappraised doctors from eastern Europe at great cost, apart from the other issues this raises, can hardly be sold as an innovative policy and is part of the slippery slope to total privitisation. The correct question is not whether primary care trusts, and the rest of NHS management, have a future but whether they are needed at all. Competing interests: None declared |
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