Professor Lord Darzi

Minister 2007–2009

Profesor Lord Darzi

Interview at Wharton April 2009

Professor Lord Darzi  was born in Iraq, to Armenian parents displaced by the 1915 genocide. The family later emigrated to Ireland. He came to Britain for a year's medical training, never left, and is now married with two children.  In 2003 he became a British citizen. Professor Darzi was knighted by the Queen as a Knight Commander of the most excellent Order of the British Empire (KBE) in December 2002  for his 'services to medicine and surgery'. In June 2007 he was appointed Parliamentary Under-Secretary at the Department of Health by  Gordon Brown.  He was created  a life peer in June 2007 as Baron Darzi of Denham, of Gerrards Cross.  Two years later, in July 2009, he resigned his post.

He studied medicine in Ireland and qualified from the Royal College of Surgeons. He obtained his fellowship in Surgery from the Royal College of Surgeons in Ireland and a M.D.from Trinity College, Dublin. He was subsequently granted the fellowships of the Royal College of Surgeons of England, The American College of Surgeons, the Royal College of Surgeons and Physicians of Glasgow and of the Royal College of Surgeons of Edinburgh. More recently he was awarded fellowship of the Academy of Medical Sciences and City and Guilds of London Institute and an honorary fellowship of the Royal Academy of Engineering.

Professor Darzi made rapid progress in the profession. He worked at the Central Middlesex Hospital and was involved in the development of its pioneering ambulatory care centre.  He holds the Chair of Surgery Imperial College London where he is head of the Division of Surgery, Oncology, Reproductive Biology and Anaesthetics.  Professor Darzi's main clinical and academic interest is in minimal invasive therapy, including imaging and biological research together with investigating methods to measure core competencies of surgery. He has published widely in the field of minimally invasive therapy. In the past he has been a Hunterian Professor of the Royal College of Surgeons of England and the James the IV travelling fellow for 1999/2000.

Professor Darzi and his team are internationally known for their work in the advancement of minimal invasive surgery and in the development and use of allied technologies including surgical robots and image-guided surgery. Professor Darzi actively pursues the need for improved inter-disciplinary research with a closer integration of information technology, biotechnology and physical sciences. He leads a team of researchers engaged in a number of fundamental research issues related to the future development of minimally invasive surgery as well as covering a wide spectrum of engineering and basic sciences research topics encompassing Medical Image Computing, Biomedical Engineering, Clinical Safety, Robotics, Man-Machine Interfacing, Virtual/Augmented Reality and Bio-Medical Simulation.

Professor Darzi's politics are to the left and he has long established contacts with Labour. Long before becoming a Labour minister, he was on the NHS Modernisation Board, advised the government on Modernising the NHS and became advisor in surgery to the Department of Health. He chaired the London NHS Modernisation Review and was asked to examine the reconfiguration of  health services in London,. NHS London (The Strategic Health Authority) having asked him to develop a strategy called A Framework For Action to meet Londoners’ health needs over the next five to ten years.  He published the national guidelines for day care surgery and in his role as Chair of the National Centre for Innovations in Elective Care was involved in setting the future model of Diagnostic Treatment Centres.

This c.v. is based upon material from the Imperial College website, the Department of Health site, and Wikipedia.

Ara Darzi and the British National Health Service: Changing the Mindset

Published: April 27, 2009 in Knowledge@Wharton

During a visit to the University of Pennsylvania in 2009, Ara Darzi, Lord Darzi of Denham, spoke with Wharton management professor Michael Useem about the National Health Service and how it plans to meet the challengs of delivering quality health care in England over the next decade.

An edited transcript of the conversation follows.

Knowledge@Wharton: Welcome to Philadelphia. Based on almost two years in office as Health Minister, are there general guidelines for the structuring and operating of national health systems that you can offer?

Darzi: Thank you. It's nice to be in Philadelphia. May I just add that first, I am a clinician academic and continue to be a clinician, working two and a half days a week. But at the same time, the Prime Minister very kindly asked me to serve, and it's been my privilege to do so for two years. Working in the National Health Service (NHS) and also being part of policy making for the NHS, I'm a great fan. Last year, we celebrated its 60th anniversary. It has stood its test of time.

What really attracts me about the NHS is one of its principal values: Everyone has access to care, irrespective of their ability to pay. For free. That is a very unique value. We have a universal health care system. I think that value actually is more relevant 60 years down the line than it's ever been. As you know, it's a tax-funded system. The government has significantly increased the expenditure in the NHS from somewhere around 42 billion pounds in the year 2002 to somewhere approaching 110 billion pounds next year. That's massive growth. We've done many reforms in the NHS over the last seven or eight years. I had the privilege of designing where we are heading for the next phase of our reform, which I articulated in my report last July. [It contains] a very clear statement: "Quality will be the organizing principle of the NHS."

Knowledge@Wharton: Let me ask about the last six months which, with the financial crisis, have been very difficult on major economies just about everywhere in the world. It has now morphed into an economic crisis for many countries, certainly the U.S. and the UK. Given the fact that GDP in the coming 12 months may actually be negative, certainly in the U.S. -- and also, I believe, in the UK -- talk through some of the implications for providing health care given the downward pressure that comes from fewer taxes, fewer pounds coming in from the tax rolls, and other consequences of the economic crisis. What is being done to cope with the fact that this is going to be a very difficult 12-month stretch?

Darzi: I think most of us have grave concerns about the economy, and I think all governments across the globe are working very hard dealing with the causation of this problem. As far as health goes, certainly within the NHS, I made the point earlier, we've increased the expenditure to about 110 billion pounds. That's more than doubling the expenditure in the health system. What drove my report at the time was [that] quality was an organizing principle. There are two things that the NHS has as unique advantages during these difficult economic times.

First, because it's a health care system that looks after you from cradle to the grave, it should start with -- and we are investing in -- prevention. Prevention is better than cure. Prevention is cheaper than treating illness. Many of our interventions are: "How do we introduce evidence-based measures in prevention?" -- whether these happen to be lifestyle-based diseases or [others]. I'll give you obesity as a good example. We look at obesity as seriously as climate change, because we believe, from a health perspective, that it could have the biggest impact on the health of our population.

The second thing is quality. It's like many other sectors. Let's not forget that quality may be cheaper in health care. Quality's not more expensive. It may be cheaper. Doing things right the first time, giving patients access at an earlier stage of their disease -- that in itself will make health care costs cheaper. So on the one hand, I'm reassured because we have a universal health care, which is tax-funded.

Knowledge@Wharton: One of the central thrusts in your report, which is going to guide your actions in the next several years, is to focus on developing ownership and leadership on the part of all players, all participants, in the health system: patients, physicians, nurses, administrators, pharmacists. It's a difficult goal to achieve, especially on the massive scale that you have proposed. If you could say a couple words about how you're going to go about developing that sense of identity as a leader on the part of all of the players, so that they indeed feel that they own the system, that the problems are theirs, and that they have an obligation to address the problems and solve them.

Darzi: I couldn't agree more. I think one of our biggest opportunities is to invest in the tremendous leadership pool we have in the NHS. The question is, how do you activate that? How do you promote that leadership gene that exists in the system? That, in itself, requires more than just saying, "Go out there and be a leader." Leadership has to have a purpose. It's leadership for quality that I'm looking for from the Health Service, from those who work in the Health Service.

To do that requires a mindset change, a behavioral change, across the system. That is the type of transformational change that we are thinking of at the moment. More importantly is what we've learned from the next stage review, which I led. There were 10 regional reports. Clinicians felt that they were actually involved, challenging themselves with evidence-based care, and designing the pathways of care. So there was ownership in that process.

Besides the ownership, we need to move on to the next phase, in which they feel empowered to make that change happen. I think what's important for us, as clinicians -- and I will say "us," me, too -- is that when you are empowered, accountability comes with it. I think, for the first time, and certainly in this phase of reform, it's not just individual accountability; it's a collective accountability around the team looking after a patient.

I'll give you an example. If you look at a patient pathway, from the day they are referred from their primary care physician into a hospital setting -- treatment is done in hospitals by multiple teams -- then back to the primary care physician, we need a way in which there is a collective accountability across the pathway of care. That is what we need to work on and develop within the NHS, and that's exactly what we're doing. I announced in my report what I call the National Leadership Council, which is the opportunity for the NHS itself to develop and promote leadership skills within that accountability framework that I described.

Knowledge@Wharton: Let me ask several personal questions. As a surgeon, you are in control of the surgical theater. As a member of the House of Lords and a Minister, that control is shared with many other individuals. There are forces over which you, indeed, can exercise very little control. Guide us through your own experience in moving from a clinician, a researcher, to a person responsible for a national health system.

Darzi: It was a fairly steep learning curve. [As for] my role in the House of Lords, I'm a member of a team of five. We are five ministers in total, and the Secretary of State for Health, who is in the House of Commons, is Alan Johnson. I've benefited a lot from his mentorship and the mentorship of many other colleagues in the House of Lords who welcomed me and mentored me for my initial introduction there. You started by describing me as a clinician and an academic. I'm a professional. I talk about what I know. My role in the House of Lords is to bring that clinical flavor to what I do in health care policy. That, in itself, the support that I have received from many noble Lords in the House, [means that] I've been very fortunate in having some fascinating debates, very interesting debates. The chamber itself is full of exceptional people with all sorts of different backgrounds. So, when you take a bill through, as I did -- my first bill was the Human Fertilization and Embryology bill -- I can't remember having heard any debates of that quality ever in my life before. So it was a great privilege to be part of that, and be personally responsible for leading that bill through.

Knowledge@Wharton: Let's go back a little bit on your career. To do it over again, would you pick a career in medicine, and in particular, would you pick a career in surgery?

Darzi: Absolutely. There's no doubt in my mind. It's not just picking it. There are two privileges in life. One is to serve your patients, and that is the most gratifying thing you can ever do. In surgery, you tend to see the benefits of that more quickly, because you will see the outcome of the interventions you've been involved in with your colleagues from a patient's perspective. The second privilege is to serve in public service itself. I've been fortunate enough to do both. But ultimately, I'm a clinician, I'm a surgeon, and when I'm finished with this job, I'll [return to practicing surgery]. Let's not forget, as I said, that I do this two days, or two and a half days a week.

Knowledge@Wharton: Let me ask about that. You wear two hats, you have two jobs, you're in senior administrative roles and you are part of, in effect, politics in Great Britain. But you also are in surgery several days a week. How do you balance the two very different worlds in the same week, in the same day?

Darzi: It is tough. I do work very hard. But it's enjoyable. And let's not forget the reason I'm doing the two jobs. That is exactly the purpose of my appointment. The Prime Minister and the government were very keen that [they have] someone who was an active clinician, who could come in and be part of a bigger team of five other colleagues in which I led a major review, where clinicians were very active players in that review, designing the future of the NHS. So I don't see [the two different worlds] in any way opposing each other. I think they are very much aligned, and, as I always remind my civil service colleagues in the department, it's not uncommon that I do my four days in Whitehall, and then I go to my operating theater. I am constantly asking what some of my colleagues will think of this policy or that policy. It's my "testing bed," as I call it. And that, in itself, has been very, very powerful for me.

Knowledge@Wharton: As I recall, the Prime Minister called you to 10 Downing Street and offered you the position you hold now. It did come as a surprise. If there's been one surprise since then, something you have had to master that you didn't appreciate, or didn't really anticipate, what would that be? What is the biggest surprise you have faced since the initial offer itself?

Darzi: How long do you have? You know, when you go into a new job like this, you have many, many anxieties. In relation to that, I was tremendously surprised by the amount of positive welcome that I had from everyone, and the support I've received from, not just government, but people within the House of Lords and others. Everyone has this passion in our country about the NHS. That is fascinating. It's part of our social culture now. Those positive things weren't just within the NHS: When I went outside the NHS, that was very obvious to me as well. So, as I said, it's been a tremendous experience for me, and I very much hope one day I can look back at it and say I had the privilege of making a contribution in the NHS.

Knowledge@Wharton: Professor Darzi, that takes me to my final question. The day will come when you do step out of your position, and as you anticipate that day sometime in the future, what do you hope will be said about your legacy in this role on behalf of the British people?

Darzi: Time will tell. Another person will have to answer that question rather than me. I believe what I would like to be said is [that I] focused our minds on what matters most - -with quality being the organizing principle of any health care system. It is quality that wakes me up in the morning to come to work, it is quality that my patients expect from me.

Knowledge@Wharton: Professor Darzi, thank you for taking time to talk with us.

The Main Darzi Reports

This lists the main reports and provides access to them by hyperlink.  The reports are many and some may have been missed out.  Many are on this server and are secure, but some are by hyperlinks to other sites and may be removed.

Date

London Reports

Nationwide reports

March 2007

The case for change

April 2007

Saws and Scalpels  (by Darzi – one of the series below)

‘Clinical Case for Change’ is a series of papers published by the National Clinical Directors in late 2006 and early 2007, and relevant to the future of local hospitals. They included
Emergency access: clinical case for change – report by Sir George Alberti, the National Director for Emergency Access
Mending hearts and brains: clinical case for change – report by Professor Roger Boyle, National Director for heart disease and stroke
Breaking down barriers: the clinical case for change
Making it better – For mother and baby: Clinical case for change – report by Sheila Shribman, National Clinical Director for Children, Young People and Maternity Services

July 2007

A Framework for Action

October 2007

Our NHS, Our Future (interim report)

May 2008

Leading Local Change – Our NHS  Our Future

June 2008

Next Stage Review – High quality care for all

November 2008

A local hospital model for London

February 2009

London consultation on Stroke and Trauma

Sir George Godber KCB

1908–2009

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Sir George Godber pursued a distinguished career in health planning and education, and was closely involved in the establishment of the National Health Service (NHS). As a child he lost the sight of one eye, as a result of an accident. After training at the London Hospital and the London School of Hygiene & Tropical Medicine, he became a Medical Officer at the Ministry of Health (MoH) in 1939. He felt certain that there would be a National Health Service, and entered public health medicine later, being recruited to the MoH by Wilson Jameson – then Chief Medical Officer (CMO) who had known him at the London School of Hygiene &  Tropical Medicine. In the early 1940s Godber was part of one of the teams that undertook a national survey of hospitals, his report covering the Sheffield and Midlands area. The concepts he developed, similar to those of the London team supported by his colleague John Pater, influenced his future thinking. When I was in the Department of Health, George advised me to gain experience on the regional side of the Department, the NHS being central to the Department’s concerns.

In 1950 he became Deputy CMO, MoH, and from 1960 to 1973 he was CMO at the MoH’s successor departments, the Department of Health and Social Security, the Department of Education and Science, and the Home Office. Because of office politics, his appointment was by no means certain. It was not widely known that on two occasions he privately told Ministers that if they persisted with particular policies, which he thought damaging to the service, he would resign while keeping his views to himself. On both occasions Ministers had second thoughts.

George was always on the look out for young people with talent. He would identify people with good ideas and ensure that they were placed on committees normally inhabited by very senior people. “You do not get tomorrow’s policies”, he said, “by speaking to yesterday’s people.” He held evening meetings with the newest recruited doctors in his division to help them to see the broader picture. “This is not a place,” he said, “where you can say ‘this is so and I tell you it is so because I am a doctor.’” He believed you could achieve anything in the Department as long as you did not insist on claiming credit for it. He was a quick and often an accurate judge of people, had a personal ‘promotion’ list, but could take quick decisions if people did not deliver. He served many Ministers and, on one occasion, greeted a new arrival by saying something along the lines of “you are the 10th Minister it has been my honour to serve”. He was an early believer in the need to involve doctors in management (The Cogwheel Report), and strove for many years to improve medical manpower planning.

Without his work, the NHS would be very different. Godber aimed to put the deficiencies of pre-war health care right, ensuring that specialists were evenly distributed, that general practitioners worked in good premises and that all doctors kept up to date through postgraduate education. His Cogwheel Report was an early attempt to involve doctors more deeply in management, and he worked hard at medical manpower problems to overcome the shortages in some specialties. His other important initiatives included support for Powell in the policy of closing large mental illness hospitals, putting the contraceptive pill on prescription, and public health campaigns, particularly against tobacco smoking (he was instrumental in the initiation of work at the Royal College of Physicians that led to its landmark report).

I had the privilege of being appointed by George to a post in the Department in 1972, and working for him as secretary to one of his committees (on general practice). George Godber in later years assisted in the correction of the first three chapters of my book, From Cradle to Grave; I kept in regular touch, and was invited to pay tribute to him at his memorial service.

Modesty was George Godber’s main feature: he refused to be called “the best CMO the country ever had” or “one of the architects of the National Health Service”. Yet, to many, he is the gold standard by which CMOs are judged. He was appointed Knight Commander Order of the Bath in 1962, and Knight Grand Cross of the Bath in 1971. He married Norma Hathorne Rainey in 1935. There were tragedies in his private life and he paid great tribute to the way in which his wife kept things going through times when his civil service work was near overwhelming. He died in his sleep in January 2009.

A fine review of the first 40 years of the NHS by Sir George Godber appears in the BMJ for 1988 a very large pdf file. Sir Douglas Black’s obituary in the Guardian.

Geoffrey Rivett’s tribute at his memorial service.

Tribute to Sir George Godber

Dr Geoffrey Rivett

I am honoured to be asked to speak today.  George was great.  He was a giant, and you do not find many giants around the place these days.

I first met him in January 1974.  I needed a new job and he was on the interview panel.  The following morning I found a thick envelope in the post.  It was a note from George who had obviously returned from the interview and written to me.  It was pure George, a brief note – eleven words – but it said everything - and more - that one wanted to hear.  George could inspire loyalty. 

Subsequently, in the couple of years that I was in the Department of Health before he retired, he selected me to be secretary of a committee he had established between the Department and British Medical Association and the Royal College of General Practitioners.  It was a new task for me, but he taught me how to do it, encouraging me when necessary.  Before he left he counselled me on my career.  I did not see him again for some years, by which time I was writing a history of the NHS.  He went through the first three chapters that covered the time he had been in the Department, added to my knowledge and picked up some errors.  He and his wife entertained me in Cambridge, and we continued to keep in touch. 

George had a habit of selecting young people, helping them in their career, and using their talents.  ‘You do not mould the future by listening to the voices of the past’ he said, and many of the people he selected outside and within the Department went on to greater things.  He was loyal to Ministers and Government, and simultaneously to the medical profession, not an easy task.  However he felt deeply that people were best served by a health service in which the professions were willing partners.  He covered the water front – he was not a single issue guy.  He had the knack of spotting what was going wrong, like his good friend Gordon McLachlan at the Nuffield Provincial Hospitals Trust, and acting fast.  He had a regular meetings with new doctors in the Department and told them “you can achieve anything in this place if you do not insist on claiming the credit for it.” 

As I came to write the history of the NHS I repeatedly found his finger prints on things. There were many and these are just a few.  In 1942/3, early in his time in the then Ministry, it was decided to survey all hospitals in England and Wales to help the planning of a future hospital service.  He was one of the two people, an administrator and a clinician, who surveyed what became the Sheffield region.  The deep knowledge of the hospitals and their problems helped him to form a conceptual model of how things ought to be, how they might be. 

In 1947 as Bevan was developing his plans, he secretaried a group of senior consultants who were trying to define the specialists needed in a district hospital.  It covered all fields from thoracic surgery to mental deficiency.  Now long outdated, it then provided the young health service with an invaluable guide at a time when everyone was new to the job of creating an equitable system. 

In the late 1950s, appalled at the inexorable rise in the number of deaths from cancer of the lung, and the desultory response of the Ministry, he undertook what would now be called a piece of skunk work.  He went outside the Department and with Charles Fletcher influenced the Royal College of Physicians to publish its iconic report that became the key to subsequent action on smoking. 

In the mid 1960s the morale of general practitioners was at rock bottom and that part of the profession was in crisis.  George understood that primary care was the rock on which the service was built, and with Kenneth Robinson and Sir James Cameron from the BMA a new contract was put together that led to a renaissance in general practice.  When there were doubts about its funding, he quietly made this a resignation issue. 

Always a believer that doctors should be involved in the management of the service, in 1966 he created the Cogwheel committees, the very name implying the need to work together.

When, in 1968, the first heart transplants were taking place with 100% mortality, he gathered together the great and the good in heart surgery, as a result of which the profession placed an informal embargo on further operations until the techniques, the immunology and the animal work had been sorted out.  Some years later when the success rate in the USA was high, Papworth and Harefield began work. 

A good friend and colleague who knew George well, Dr John Ball, said that there was a unit of measurement of the quality of CMOs.  It was the godber.  He said that no other CMO had ever exceeded 0.5 godbers.

Sir George Godber's Guardian obituary by Sir Douglas Black

George Godber, who has died aged 100, was a medical lay saint. The three terms may be separately incompatible, but together they form the ideal description of a man whose name still recalls, more than 35 years after his retirement as Chief Medical Officer (CMO), a nostalgic recollection of the halcyon days of the NHS - an epoch to which he himself had contributed so much.

As the last surviving member of the 1940s planning group at the Ministry of Health that gave rise to the NHS, Godber had worked alongside Aneurin Bevan, its chief architect, and William Beveridge, the father of the modern welfare state. As deputy CMO from 1950 to 1960, and CMO from 1960 to 1973, he exercised an influence over health policy that remains unmatched by any holder of those posts.

Brought up in Bedford and educated at Bedford School, New College, Oxford (where he was a rowing Blue), and the London Hospital, he chose to enter public health medicine. He did his post-graduate training at the London School of Hygiene, obtaining the diploma in Public Health in 1936, three years after medical qualification. The same year, he joined the then Department of Health, where he spent the next 37 years, becoming Deputy Chief Medical Officer in 1950. More or less at the time when health was conglomerated with social security, he became Chief Medical Officer to the DHSS, likewise to the Home Office and the Department of Education and Science. What he thought of the merger at the time is not recorded, but it is a fair surmise that its undoing was one of the few changes of later years which he would have welcomed.

The part which he himself played in the planning and implementation of the NHS can be well gauged from Rudolf Klein's classic 1983 book The Politics of the National Health Service, and from his own account in The National Health Service: Past, Present and Future, written in 1974 after he retired.

As early as 1948, when still a Medical Officer, he was the architect of the plan to improve the distribution of consultants throughout Britain. This was one of the early achievements of the NHS, even though Godber himself came to regret the tardiness with which certain of the more deprived regions applied for additional consultants for which finance was at that time available. He was also influential in welcoming and implementing the proposal for a confidential inquiry into maternal deaths, which was set up in 1952, and did much to improve matters in that area. Indeed, it became the model for later confidential inquiries into deaths associated with anaesthesia and surgical operations.

When Enoch Powell was appointed minister of health in 1960, it marked, in Klein's phrase, "the end of the Ministry of Health as a political backwater". Ministers come and go, so perhaps it was still more important that the new permanent secretary, Sir Bruce Fraser, not only came from the Treasury but was also not "scarred by the experience of setting up the NHS". Most vital of all was the promotion of Godber as CMO, for he had a rare understanding of the genesis of medical advances, and of how these may be applied to the health of a nation.

In Godber's own words, "The NHS is comprised of very many services rendered daily by physicians, nurses, dentists, pharmacists and others. The content of these services is defined, not by planners, but by essential professional knowledge and skills. Change in method and practice is brought about by intra-professional exchanges; it may be abrupt because of a scientific development such as the advent of a new drug, or it may occur gradually with experience." Such an analysis of how a service should be promoted leads naturally to the encouragement of dialogue with the health professions, and of a consensus style of management, both of which Godber fostered in his term of office, and in which he greatly welcomed the support, always acknowledged in later years, of Fraser.

As CMO he provided advice to other departments of state, including that of education. This brought Godber an early insight into the cavalier attitude of Margaret Thatcher, then Secretary of State for Education and Science, to scientific advice transmitted from experts by way of the civil service. Within the DHSS, as it then was, there was a group of expert committees on medical aspects of various matters, each abbreviated somewhat infelicitously as Coma. There was a Coma on nutrition, which should at least have been informed of, and preferably consulted on, a decision to withdraw free milk from school children aged eight to 11. But I have it from Godber that he was given no time even to notify members of his Coma in advance of a public announcement that the milk was to go.

Even ordinary politicians, with their bias of "illogical positivism", find it hard to understand that science is probabilistic, not categorical; and that their quest for certainty can rarely be met to their satisfaction. Not the least of Godber's qualities was the honesty and self-confidence that allowed him to deny a politically plausible claim, or - more difficult still - to say the balance of evidence on a particular matter was inconclusive.

The shape of the NHS in the mid-1970s was very materially determined by Godber's influence, acting of course within the constraints of what was medically, politically and economically possible. Among the qualities which enabled him to exercise such influence were, as I have said, honesty and self-confidence. But there was much more. He had within his range the capacity to be at one time endlessly patient, at another time magisterial; and the discernment to know what behaviour was appropriate to what occasion. He deployed such skills not as exercises in manipulation, but in untiring pursuit of a hope earlier enunciated by Nye Bevan, of "universalising the best". In this he had largely succeeded when he retired in 1973, a date coincident with the first of many attempts to substitute administrative devices for adequate funding of the NHS. Athough a civil servant is debarred from public criticism of government policy, as a private man in retirement he made no secret of his regret at the policies which were transforming a service into a business.

Physically, he was a commanding figure. Tall and well built, he played a regular round of golf well into his nineties. He neither drank nor smoked. He continued to drive until the age of 97, but was irked in recent years by the signs of his decline, and hoped that medical opinion might change to take greater account of patients' wishes in deciding when their life might end.

To an interesting extent, he was both aloof and approachable. No amiable chatterbox could have attained the influence which he enjoyed in the formative period of the NHS; but "off-duty", and at times when "on duty", he could and would speak at length, formally or informally, but always to the point. His wealth and variety of experience made him an interesting companion; but while he was in his post, he was economical of his leisure. In his weekly staff meeting as CMO, he could be formidable. Although he never paraded benevolence, he not only wanted to do good but actually did it. In an age clamorous of rights, he saw and pursued his duty in promoting the rights of others.

Like anyone who had the privilege of working with him, I recognised him as a great man, and as a friend to be proud of.

He was appointed CB in 1958, advanced KCB in 1962 and GCB in 1971. In 1935 he had married Norma Rainey and her support was crucial to him, particularly in the period in the 1940s when they endured the death of a son and daughter within six months of each other. She predeceased him in 1999. He is survived by two sons, Colin and Steve, and a daughter, Bridget.

Guillebaud Report – National Health Service

HC Deb 08 February 1961 vol 634 cc65-7W 65W

Dr. Stross asked the Minister of Health

(1) whether he will extend Table 4 in the Report of the Guillebaud Committee, which demonstrates the cost of the National Health Service in relation to national income for England and Wales, so that comparison may be made for each full year since 1948–49;

(2) Whether he will publish in HANSARD an extension of Tables 6 and 7 of the Guillebaud Committee's Report to cover each year from 1948–49 to the last available year;

1949–50

1950–51

1951–52

1952–53

1953–54

1954–55

Gross National Product at factor cost (£m.)

10,036

10,502

11,752

12,709

13,532

14,333

Gross Cost of health services (£m.)

381.2

392.8

401.2

452.3

434.8

455.2

Gross Cost as percentage of Gross National Product

3.8

3.7

3.4

3.6

3.2

3.2

Gross Cost at 1949–50 Prices (£m.)

381.2

358.3

343.3

383.1

360.9

366.8

Gross Cost per head of population at 1949–50 Prices

£8 14s.

£8 3s.

£7 17s.

£8 14s.

£8 4s.

£6 8s.

Net Cost of health services to Exchequer (£m.)

298.8

330.3

334.5

370.8

351.9

370.9

Net Cost as percentage of Gross National Product

2.98

3.15

2.85

2.92

2.60

2.59

Net Cost at 1949–50 Prices (£m.)

298.8

301.3

286.2

314.0

292.1

298.9

Net Cost per head of population at 1949–50 Prices

£6 16s.

£6 17s.

£6 11s.

£7 3s.

£6 12s.

£6 15s.

1955–56

1956–57

1957–58

1958–59

1959–60

Gross National Product at factor cost (£m.)

15,384

17,021

17,466

17,978

19,010

Gross Cost of health services (£m.)

508.5

575.9

602.4

641.7

689.0

Gross Cost as percentage of Gross National Product

3.3

3.4

3.4

3.6

3.6

Gross Cost at 1949–50 Prices (£m.)

390.8

430.6

438.6

467.2

501.6

Gross Cost per head of population at 1949–50 Prices

£8 16s.

£9 13s.

£9 15s.

£10 7s.

£11 1s.

Net Cost of health services to Exchequer (£m.)

407.4

482.0

481.8

484.4

521.2

Net Cost as percentage of Gross National Product

2.65

2.83

2.76

2.69

2.74

Net Cost at 1949–50 Prices (£m.)

313.1

360.4

350.8

352.7

379.5

Net Cost per head of population at 1949–50 Prices

£7 1s.

£8 1s.

£7 16s.

£7 16s.

£8 7s.

Note: 

1. All figures are for England and Wales.

2. The Gross National Product figures have been arrived at by taking 89 per cent. of the total for the United Kingdom.

3. The cost figures include both capital and current expenditure. No adjustment has been made for certain changes in the content of the services.

4. The adjustment to 1949–50 prices is based on the price index of consumers' expenditure.

(3) Whether he will publish in HANSARD a completion of Table 5 of the Guillebaud Committee's Report on the National Health Service up to the last available year; and what would have been the gross cost of the service in that year in terms of prices ruling in 1949–50.

 Mr. Powell:

The cost of the National Health Service as defined in the Guillebaud Committee's Report cannot readily be calculated for later years. The figures in the following table are in terms of the cost of the National Health Service in England and Wales and the Ministry of Health as shown in the Appropriation Accounts. They exclude local health authority services.

King’s Fund analysis on polyclinics

Under One Roof

Text from the Fund press release in June 2008

The report draws on original research into facilities similar to the polyclinic models developed both in the UK and abroad. The proposals, which have been discussed as part of Lord Darzi’s NHS Next Stage Review, could bring together family doctors and specialists alongside other services, such as diagnostic testing, minor surgery, blood tests and X-rays.

The term polyclinic has been used to describe a variety of different approaches from very large super surgeries, which involve closing current GP practices and moving their services into the new unit, to the so-called hub-and-spoke model where most existing practices continue but share access to a set of new services in one facility. The King’s Fund report concentrates on the ‘big building’ model and examines the impact they would have on patient care.

It welcomes the government’s ambition to develop more patient focused and integrated models of care but warns that poor implementation of this model could create significant risks for patient care. Its key findings are:

  • Quality of care – polyclinics could help to redesign services around the needs of patients and deliver integrated care, particularly for people with long term conditions. However, the evidence suggests that in practice these opportunities are often lost – bringing together multiple services does not always result in better working practices between professionals, and there is no evidence that larger GP practices deliver higher quality care than smaller ones although they may be able to offer a wider range of services.
  • Accessibility of services – for some patients access to diagnostic and other services would improve and the impact would vary depending on how large and centralised the polyclinic would be. However, a major centralisation of GP services into polyclinics would make it more difficult for patients to visit their GP, especially those living in rural areas. This would be a major sacrifice given that primary care visits account for 90 per cent of all patient contact with the NHS, and that patients are less prepared to travel further to see their family doctor than they are to use outpatient and hospital services.
  • Costs – while there is a strong case for providing more support in the community to prevent hospital admission there is substantial evidence that shifting some specialist services out of hospital can prove more expensive. In these cases services can be less efficient and often fail to reduce demand on hospitals, so that the costs of new services supplement rather than substitute for hospital costs.
  • Workforce – the successful examples of integrated care delivered in polyclinics abroad may not transfer easily to the NHS in England due to important differences in the medical workforce. Here most specialists are based in hospitals not the community as they often are abroad. The European Working Time Directive and changes to postgraduate medical training will place further demands on specialists’ time. Some of the polyclinic models of care therefore present significant workforce challenges.

Report co-author Candace Imison said: ‘There is a strong case for challenging the way we organise health care in England. For some health communities the development of polyclinic-type facilities could offer great opportunities to establish more integrated care that delivers real benefits to patients. But these benefits will only be realised if the focus is on changing the way we deliver care, not just changing where care is delivered.’

King’s Fund Chief Executive Niall Dickson added: ‘Our model of health care has changed little since the NHS began 60 years ago – advances in technology, changes in the composition and working hours of staff, as well as patient expectations and evidence about what is effective, all signal the need to review how and where care is delivered. The polyclinic approach could be one way to redesign services around the needs of patients but we must not underestimate the amount of time, energy, and resources that would be needed to make it work.

‘We welcome the government’s assurance that there will be no national blueprint but that needs to be spelt out in unequivocal terms. Above all we appeal to ministers to make it abundantly clear that there will be no compulsion on local NHS organisations to erect buildings or follow this or any other centrally dictated model of care. Polyclinics may be the right answer in some areas, they will not be right for others. That should be a matter to be decided locally on a case-by-case basis using the best clinical evidence available together with a full assessment of the costs and the impact on patient access.’ 

The report’s analysis of polyclinics suggests that local planners should be careful to assess the benefits and costs of the polyclinic approach. Its recommendations aim to provide guidance for local NHS services and commissioners on realising the opportunities and avoiding the risks of introducing these new models of care:

  • Primary care trusts (PCTs) should proceed with polyclinics only where benefits to local communities in terms of quality, access and costs are clear. The primary focus should be on developing new care pathways, using technologies to improve patient care and better joint working across teams and professions. Developing new facilities may form a part of the strategy, but buildings should be a means to an end, not an end in themselves.
  • PCTs should consider alternative polyclinic models which do not require mass centralisation of family doctor services, such as the hub-and-spoke or federated model where most GPs remain in their premises and draw on resources in a central polyclinic or resource centre.
  • Strong clinical and managerial leadership supported by clear governance structures will be necessary. Polyclinics will also require workforce planners at the national and local level to explore and address the workforce implications as a matter of priority.

Aneurin Bevan

1897–1960

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Aneurin Bevan was one of the most important ministers of the post-war Labour government and the chief architect of the National Health Service.  He was born on 15 November 1897 in Tredegar in Wales. His father was a miner and the poor working class family in which Bevan grew up gave him first-hand experience of the problems of poverty and disease.

Bevan left school at 13 and began working in a local colliery. He became a trades union activist and won a scholarship to study in London. It was during this period that he became convinced by the ideas of socialism. During the 1926 General Strike Bevan emerged as one of the leaders of the South Wales miners. In 1929 Bevan was elected as the Labour MP for Ebbw Vale. In 1934 he married another Labour MP, Jennie Lee.

During World War Two, Bevan was one of the leaders of the left in the House of Commons. After the landslide Labour victory in the 1945 general election, Bevan was appointed Minister of Health.  He inherited complex plans assembled by the previous Conservative administration, which were the result of many compromises.  He took a fresh look at the possibilities and the many power groups and decided that instead of giving local authorities a lead role, all hospitals should be taken into public ownership as they would need so much public money.  In doing to he alienated members of his own cabinet, such as Herbert Morrison who was a strong supporter of the London County Council. Firmly on the left, he distrusted some in his own party as unlikely to build a socialist Jerusalem. He felt that where medical need existed, medical care should follow and that budgets should be of secondary importance.

In 1951 Bevan was moved to become minister of labour. Shortly afterwards he resigned from the government in protest at the public expenditure on the military and the  introduction of prescription charges for dental care and spectacles. Bevan led the left wing of the Labour Party, known as the 'Bevanites', for the next five years. In 1955 he stood as one of the candidates for party leader but was defeated by Hugh Gaitskell. He agreed to serve as shadow foreign secretary under Gaitskell.

In 1959 Bevan was elected deputy leader of the Labour Party, although he was already suffering from terminal cancer. He died on 6 July 1960. A BMJ editorial described him as the most brilliant Minister of Health the country had ever had, much less doctrinaire in his approach than many of his Labour colleagues, and conceiving the NHS on more liberal lines than his Conservative predecessor. He towered over a long line of Ministers of Health and attracted in the medical profession profound admiration on one side and the sharpest antagonism on the other. The editorial proceeded to claim that the medical profession, rather than Bevan, was the principal architect of the NHS!

Much material on Bevan is to be found in Wikipedia and on the web more generally, including the BBC website, partly used above.

Sir Wilson Jameson

(from the BMJ May 1950)

Sir Wilson Jameson on reaching the age limit retired this week from the post of Chief Medical Officer to the Ministry of Health. He has held office at the Ministry for ten years, years of unprecedented strain and anxiety. Sir Wilson Jameson had by 1939 already made his name as Dean of the London School of Hygiene and Tropical Medicine, having been appointed to this post in 1931. It seemed likely to those who knew him and his work that he would remain attached to this institution until retirement. He was asked to become Chief Medical Officer of the Ministry of Health in 1940, and it must have been difficult for him to decide to leave an institution he loved and had served so well. Among the many motives that influenced him a strong sense of duty undoubtedly was one, and a powerful one. Sir Wilson assumed office at a time when many feared that bombing would bring in its train widespread outbreaks of infectious disease, when the hospital services of this country and especially of the big towns were being disrupted and had to be reorganized, when, in fact, central decisions affecting the life and health of the people had to be reached and acted on from week to week. Then after the publication of the Beveridge Report the Ministry had the task of drawing up plans for a national health service. Few men in the medical profession can have been subjected over the past ten years to such a continuous strain, a strain made not less in Sir Wilson's case when by virtue of his position he found the Ministry he served at times very much out of favour with the medical profession. That he has come through the past ten years with his reputation for fair-mindedness and professional loyalty enhanced is a tribute to a great public servant and an eminent doctor. His services to the profession and the public have been recognized by fitting honours and awards. In his retirement from the Ministry of Health the profession will add to these its own good wishes in the work Sir Wilson has agreed to do for the King Edward's Hospital Fund.

Bevan's view

At a private dinner party after the launching of the NHS, Aneurin Bevan paid personal tribute to Wilson Jameson as having made an outstanding contribution to the formation of the NHS.

Dr. John (Jack) E. Wennberg

For more than 40 years, Wennberg has studied and documented striking variations in health care delivery across the United States, concluding that where a patient lives determines the amount of medical care he or she receives. His work is frequently cited as evidence of the lack of a scientific basis for most medical practice. His recent research has focused on ways to document the outcomes, or results, of various medical practices and communicate this information to patients. With his Harvard colleague Dr. Al Mulley he founded the Foundation for Informed Medical Decision Making, an organization that works to promote patient involvement in medical care decisions.  Donald Berwick, cofounder of the Institute for Healthcare Improvement, recently called the CECS work "the most important health service research of the century."

His early work on hysterectomy rates, in the mid-1970s, showed that in the city of Lewiston, an unusually large number of women were having hysterectomies. He projected that if the rate of surgeries continued in Lewiston, 70 percent of its women would have a hysterectomy by age 70.  He decided to collect information about every medical transaction of every person in every town in the whole state of Vermont.  "We needed to know what was going on in home health agencies, what was going on in nursing homes, hospitals, doctors offices," Wennberg says. "And for each patient, what their diagnosis was, what their treatment was, how much money was spent, and what the outcomes were in as far as we could measure them."

To collect these records, Wennberg hired researchers, people dubbed "the pit crew" who year after year were sent out to medical record rooms to collect records. It was a truly massive undertaking to gather every medical transaction in the state of Vermont. It took two years of road trips just to collect the records for 1969.  Wennberg discovered Lewiston's high hysterectomy rate, but he did much more than that. Over the past 40 years, he has completely transformed our understanding of what's going on in health care systems.  He started in Vermont, then moved to Maine, until eventually he studied communities throughout America. Wennberg led us to a clearer understanding of what doctors and hospitals are doing with their patients all across the United States  [www.dartmouthatlas.org]  It was clear that it wasn't that patients were different between regions, so it wasn't the illness that was driving this, this must be coming from the provider side."

His insight:  It was doctors, not patients, who drove medical consumption, and all kinds of things influenced the decisions a doctor makes when a patient enters his office. Sickness and patient preference play an important role, but a much smaller role than patients and the health care community had originally thought.

Historical UK spend (£m)

Year

Gross UK Expenditure 

Charges

Net UK Expenditure

1948–49

282.4

2.4

280.0

1949–50

459.9

3.0

456.9

1950–51

477.1

3.4

473.7

1951–52

493.9

7.9

486.0

1952–53

525.7

20.0

505.7

1953–54

532.8

24.3

508.5

1954–55

548.6

25.0

523.6

1955–56

595.6

26.7

568.9

1956–57

651.2

28.6

622.6

1957–58

692.5

32.7

659.8

1958–59

744.1

33.0

711.1

1959–60

804.0

35.0

769.0

1960–61

898.1

36.7

861.4

1961–62

932.3

48.3

884.0

1962–63

988.2

49.7

938.5

1963–64

1,121

52.0

1,069

1964–65

1,216

53

1,163

1965–66

1,451

28

1,423

1966–67

1,467

30

1,437

1967–68

1,619

31

1,588

1968–69

1,755

46

1,709

1969–70

1,820

58

1,762

1970–71

2,132

61

2,071

1971–72

2,440

78

2,362

1972–73

2,486

90

2,396

1973–74

2,967

100

2,867

1974–75

4,207

112

4,095

1975–76

5,580

110

5,470

1976–77

6,381

132

6,249

1977–78

7,044

148

6,896

1978–79

7,992

157

7,835

1979–80

9,557

195

9,362

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Acknowledgements