Medical advice to the NHS: a simpler structure.
Authors: M Burrows
Journal: BMJ (1981)

Like Gaul, the National Health Service is not one but three entities. While essentially similar, each part has quite different demands and offers varied services. The rural service has scattered populations with stretched lines of communications, the conurbation service has concentrated resources stretched to cope with inner city deprivations, while London, as all agree, has unique difficulties. Thus it is probably beyond the wit of men or women sitting around a table to devise a rigid medical advisory machinery that is ideal for all the NHS's varied circumstances. So the Chief Medical Officer's Joint Working Group, of which I am a member, set its sights on a simple, flexible structure for providing medical advice in the NHS, tackling first advice at district level (p 239). I see any medical advisory machinery having three essential features : (a) It must be readily available to health authorities and to clinical members of district management teams as well as being able to offer advice on its own initiative. (b) the practical arrangements must contain some flexibility while maintaining a balance between the representational and expert elements; (c) the machinery must have the confidence of the profession at large so that health authorities can be confident that the views expressed represent the general views of the profession locally. Furthermore, any machinery must be as simple as possible and use doctors' time efficiently?the present structure has proved too cumbersome and wasteful of doctors' time to work effectively. The 1974 reorganisation of the NHS has been widely criticised?though some of its failings may have been caused as much by worsening economic circumstances and changed industrial attitudes in the NHS during the last six years as by the structure itself. The praiseworthy intention of widening participation in decision making has been lost in less than clear lines of command and obscure channels of communications. Many hospital doctors have found the relations between the hospital staff committee (with or without specialist divisions), its medical executive committee, and the district medical committee (DMC) with the medical members of the district management team (DMT) difficult to elucidate. Further confusion has occurred when a multi-district area also had its area medical committee (AMC) and area team of officers (ATOs) above the district structures. In general practice it has not always been clear how the local medical committees have related to these various groups. There have been demands for changes from all sides. Clinicians do not want to waste time in sterile discussions around committee tables but they do want to participate in giving expert advice with the expectation that the advice reaches the proper quarter and without delay. The medical profession face a particular difficulty in organising representative machinery for providing advice to employing authorities. As members of a profession of high ideals and strong independence, doctors do not readily hand over decision making to any one person or group of persons. It is important that authorities recognise that unanimity in the medical pro? fession is rare?and thus especially important when it does