Staff cuts would leave CMO stranded in a crisis

Dramatic cuts in staff reporting to the chief medical officer (CMO) for England over the past decade have undermined the role to such an extent that effective action in a health crisis--such as occurred over bovine spongiform encephalopathy (BSE)--would now be almost impossible, a senior health administrator said last week. The warning came just before the announcement that Professor Liam Donaldson is to be the next CMO for England (see p 233).

Presenting evidence to the BSE inquiry, Dr Hilary Pickles, who was lead principal medical officer on BSE from 1988 to 1990, said that the past 10 years had seen senior and middle ranking medical staff dramatically reduced, promotion prospects for senior staff disappear, and direct reporting to the CMO largely removed.

“Most doctors and all administrative staff now report through the permanent secretary or the NHS chief executive. It would be impossible now for the Department of Health to field someone with the experience and seniority that I had who also had undivided loyalties to the CMO,” said Dr Pickles.

Dr Pickles, who is now director of public health and health strategy at Hillingdon Health Authority, London, told the BMJ that the number of senior medical staff had been halved since the 1980s. Only the deputy CMO, Dr Jeremy Metters, now directly reports to the CMO, and the current incumbent, Sir Kenneth Calman, has been reported as saying that his staff consists of a secretary and a mobile phone.

Sir Kenneth's predecessor, Sir Donald Acheson, led some four deputy CMOs and 14 senior principal medical officers in a completely separate hierarchy from the Department of Health's permanent secretary. He says that the cuts and integration have made the CMO's role difficult. “Can you imagine being editor of the Guardian without having anybody accountable to you? Can you imagine being secretary of the BMA without having anyone accountable to you? In the CMO's case, it means that he may be limited in the extent to which he can call on the help of colleagues.” Sir Donald said: “If the government now wanted the CMO to lead a response in a public health emergency such as AIDS, I do not know how it could be easily done with no one accountable to him. One would depend on someone else to lend you people. With good will on both sides this might work, but the key issue is why should someone with the heavy responsibility of the CMO be put in such a position?”

One explanation for the cuts has been that the Treasury was eager to save money. But this does not explain why the number of senior medical staff has been drastically reduced compared with the minor reductions in senior administrative staff, said Dr Pickles. “In theory … it looks as if it would be all right; in practice … it is the medics who have lost out.” Other observers suggest that civil servants have long wanted to weaken the clout of the CMO, who benefits from a powerful public persona, pointing to the weighting of the balance towards administrative staff, who are more likely to err on the side of caution and put the public purse before the impact on public health.

“I would say that for a new chief medical officer coming in from outside, the job is virtually impossible to do without more senior staff,” says Dr Pickles. “And we need to strengthen Liam Donaldson's hand to enable him to argue for that.”