💾 Archived View for gemini.spam.works › mirrors › textfiles › politics › SPUNK › sp000026.txt captured on 2022-03-01 at 16:02:57.
-=-=-=-=-=-=-
AN INTERNAL EXAMINATION OF THE NHS REFORMS
Despite its much-publicised opposition, in reality it seems as if the Labour
Party will not be too drastic in its attempts to reverse the NHS reforms.
Perhaps this explains the reluctance of Shadow Health Spokesman Robin Cook to
face questioning about future heath policy from health workers in Leeds. The
hysteria with which his minder, local left-wing MP John Battle, sought to
protect him belies an anxiety not to be pinned down on anything more than
vague sentiment and rehearsed outrage.
For the changes are not ones that threaten Labour's current constituency.
Whereas a few personnel changes might be in order, not least to reflect the
eighties tendency towards the placing of political friends in apparently
"neutral" posts, the changes themselves bolster up the professional class
Labour seeks to represent - and in fact provide room for its extension. The
rhetoric of empowerment, "consumer sovereignty" and "quality" camouflage
re-arrangement of authority relations. As Alex Richards in H&N no. 6 ("The
Eclipse and Re-Emergence of the Economic Movement") put it:
"Power is re-fragmented in ways which would have seemed unthinkable to the
Left of a previous generation, who saw only the prospect of a steady growth
in monolithic power. And this fragmentation proclaims a new freedom for all,
confident that, in each of its moments, with each transaction, Capital, as
the principal social relation, is being renewed."
With the ideology of "post-Fordism", this necessity is being recycled as a
virtue, intensification is recast as deliverance, escalating interference
translated as a release of creativiity. For the public will be no more free
to change their hospital, question their doctor, or contest treatment from
the basis of informed consent than before. Nor will workers in the health
service be edlivered from the constraints of bureaucracy. The reforms
constitute a "re-commodification" - a penetration of Capital's necessity
deeper into the conduct of social relations.
The Invasion of Exchange
In H&N no.4, the article "The Invasion of Exchange" attempted to show how
de-regulation and the "Enterprise Culture" were essentially new forms of
labour discipline emerging from the failure of the corporatist / job
enrichment schemes of the 70s. "Working for Patients", the White Paper on
which the NHS reforms are based, is essentially a blueprint for introducing
these techniques into the health service. What is envisaged is an internal
market. Instead of having resources allocated to District Health Authorities
responsible for the provision, nature and supply of health services, the DHAs
are separated from their provider role and instead become purchasers of
health care from a variety of surces: Self-Governing Trust hospitals
(opted-out hospitals), directly-managed units (still under nominal DHA
control but providing service on the basis of a contract with the DHA) and
private hospitals. Nor is the DHA the only purchasing authority. Family
Practitioner Committees and budget-holding General Practises are also
empowered to buy the health services they require for their patients.
Despite claims to the contrary from Regional Authority members (who seem to
be trying to carve out a new role for themselves as arbiters within the new
market), some element of competition between hospitals has been introduced
into the system. The hospital which cannot attract the attention of the
purchasing authority either by its cheapness, its speed of delivery or,
possible, its quality, will not receive the patients and therefore the money
which it needs to survive. At the same time, political appointees on the DHAs
have been removed, and "self-governing" hospitals will be able to set wages
and conditions independant of national agreements. In fact, Eric Caines, the
NHS Personnel Officer, has said that he expects the national agreement system
(the Whitley Councils) to unravel for all health staff soon after the reforms
start to bite.
Instead of the bureaucratic regulation of both staff wages and the provision
of care, re-commodification is to be instituted as an unanswerable incentive.
Demand, mediated by panels of businessmen and experts on the various
purchasing authorities, will determine not only the level of provision
(albeit still cash-limited by central government) but in the end the wages
and conditions of staff. As a management discussion document on Trust status
for the Leeds General Infirmary frankly puts it, in the event of financial
difficulties, viability "will be achieved by increases in
efficiency,reduction in service levels or the availability of additional
funds." Unhampered by national agreements on wages, etc., local managers have
been handed the capacity to pass on problems of finance, demand or crumbling
plant directly to the health service worker. In fact, the Act of Parliament
which instituted the reform is only part of an overall process of
strengthening management's hand in the cost-conscious nineties.
Re-commodification simply underlines the necessity of efficiency and of
maximizing labour output. It highlights and enhances the development of
managerialism in the NHS.
Managerialism
It's been a useful myth that commodification and the existence of
bureaucracies are somehow incompatible. In fact the two have a symbiotic
relationship, as the development of Western Capitalism has revealed. One
ofthe key boom areas this century has been in the management of measurement,
and developments in the NHS give an insight into the connections between the
commodity and the bureaucrat.
The Management of Measurement
One central problem in setting-up the internal market will be the pricing of
health care. Previously, the system worked without a lot of attention to the
price of resources. Rationing took place through the use of waiting lists and
assessing the urgency of the need for treatment. Regular overspending
occurred, as doctors and nurses got on with the job without excessive
attention to resources. Balancing the books took place at a general level,
with pricing based on last year's expenditure plus inflation, without too
much breakdown of the cost of particular resources, still less cost per
patient.
This is in marked contrast to working in the private sector, where each item
used has a detachable label for sticking onto a patient's chart, so that
everything can be accounted in his or her bill. It is this which explains why
the bill for administration in health care is 5.3% on the overall US health
budget while it is ony 2.6% on the overall UK health budget.
However, for the internal market to function, pricing systems will have to be
established. Behind the jargon of Resource Management Initiative and
Diagnostic Related Groupings is the establishment of information technology
systems designed to provide "accurate" pricings for different kinds of
patients. Again, unlike what theorists of "post-Fordism" allege, this means
an intensification of Taylorism, a closer scrutiny of what is being done as
work in order to measure it. Although still in its infancy, the kind of
practises occurring give some idea of what measurement in health care will
mean. For example, time-and-motion experts have been on the wards timing how
much of a qualified nurse's jobs is taken up doing tasks that only a
qualified nurse can do, compared with those any nurse could do. Other
measures include setting-up databases to catalogue all resources used on a
patient. Such measurement, howver, impells the manager to take a closer look
at what his or her workers do, and how what they do can conform to managerial
goals.
The Management of Human Resources
Anyone thinking that these changes simply confirm that techniques of
management are repressive, authoritarian and de-humanising has missed the
point. Perhaps absorbing Cardan better than the working class ever did,
today's management are all too aware of the need to involve the worker in the
process of work organisation.
Modern managerialism involves the devolution of managerial goals throughout
the organisation. In a Science as Culture article on Post-Fordism, a
description of the various techniques of labour control reveal a move towards
team work in General Motors factories. Here all grades of employees come
together in teams to discuss improving quality and maximising efficiency. The
team leaders are elected by the workers themselves and an ethos of loyalty is
inscribed, so that such autonomous activities as knowing the job so well that
a worker can secure a bit of time for him/herself becomes the property of the
company itself, and a key piece of knowledge is gained in order to speed-up
particular tasks and gain efficiency.
Similarly, the NHS has introduced Quality Circles (often using ex-Trade
Unionists as organisers) so that the problems of service delivery are aired
in a convivial atmosphere where a nursing asistant can enlighten a general
manager of the problems of work. At the same time, there has been an attempt
to change the nomenclature of the organisation - in particular, to change the
title of Ward Sister or Charge Nurse to that of Ward Manager, thereby not
only devolving managerial goals to a non-managerial level, but also enhancing
the legitimacy of management by extending that description down to those who
work. This process is enhanced by actually devolving tasks with the name, so
that each ward is given a budget to work within, so that staff hours are
balanced against ward supplies.
The aim is to ensure widespread understanding and enforcement of managerial
goals. Further loyalty to management aims is gained in team briefings,
councelling by management (as distinct from disciplinaries) Individual
Performance Reviews (in which the employee confesses various weaknesses and
ambitions to their superior) and the use of in-house staff training to impact
the organisation's aims and principles. Knowing what their employess do not
only improves the process of measurement, it enables management to locate
both weaknesses and strengths in the system, exposes areas of autonomy where
workers have managed both to do their jobs and not drive themselves to an
early grave.
The Managament of Marketing
Marketing is seen both as an external and internal need. Internally, morale
is managed by a proliferation of house magazines, all using the advice of the
American management theorist Tom Peters of including the names and faces of
employees - although in fact their crass enthusiasm and absolute
unwillingness to countenance any unpleasant reality in their pages marks them
for comparison with Stalinist newspapers of the "Record Beetroot Harvest in
the Ukraine" variety! Such Stalino-Capitalism extends to the fascination with
symbols and logos. The Leeds General Infirmary was recently kitted out with a
whole new corporate image, down to new uniforms for all staff, LGI colours
and LGI logo.
Again to achieve both internal and external marketing (and external marketing
has barely begun), new posts are created: Quality Assurance Manager.
Commercial Manager, etc. The sheer mendacity of managerial "positivism"
ensures their hold on defining the institution's character. Nobody provides,
or expects to see revealed, the unpalatable truths that need airing. The
corporate image demands a corporate mentality which sanitises potential
criticism and conflict by demanding their referral through the interminable
machinery of procedural participation policed by staffs of loyal cadres.
Quality Control
The growth of dissatisfaction within the NHS in the 70s and 80s was reflected
in both Left and Right critiques of the welfare state. The NHS reforms
attempt to head off this dissatisfaction through the ideology of consumer
sovereignty. By attaching the health of the hospital to the numbers of
patients it attracts, the government believes that "bad" practises will be
worked out of the system. As a result, a veritable industry of quality
control mechanisms has developed.
Including the appointment of Quality Assurance Managers and the development
of quality consciousness, perhaps the most significant product of the new
"awareness" is Monitor - An Index of the Quality of Nursing Care. Not only
is this the most sophisticated managerial device for work study that I have
ever come across, it has the added value of being a method of comparison
between wards (and, who knows, perhaps in the future between staff?) It's
worth quoting some of the propaganda used to sell it to the staff. Conceived
in Newcastle Polytechnic, it is described as a "systematic indicator", it is
"not as accurate or as simple as a ruler, but can be compared to a barometer
because it distinguishes nursing care of a high quality from care of an
average or lower quality". Pains are taken to reassure staff that it will not
judge them individually but as a team, and lip-service is paid to the problem
of staff shortages, although it is unclear how this will be taken into
account.
Monitor consists of some 450-500 questions answerable on a YES/NO basis. Some
of the questions are put to nurses, some to patients and some are gathered
from nursing records. An outside assessor is appointed to undertake the
questionairres and a score is arrived at by the number of YES answers. It is
reckonded to take 1-3 hours to do a Monitor on an individual patient. This
gives management a crucial measurement with which to make comparisons. The
tortured syntax of this piece of management publicity exposes their anxiety
to obtain staff compliance:
"MONITOR also includes questions which relate to the second list (i.e.
caring, rapport, attitudes) - because they, too, are important for quality
care; but they are not assessed comprehensively - mainly because they are so
subjective. It is believed though, that 'TO MEASURE SOMETHING WELL IS BETTER
THAN NOT MEASURING ANYTHING AT ALL'
Wouldn't you agree?"
The results of Monitor will be made known only to Ward Sisters / Charge
Nurses and Senior Nurse Managers, for whom, no doubt, perusal of the ward
league tables will be incentive enough to crack the whip over their
subordinates. However, it is unlikely that, once knowledge of such a
measurement becomes even more widespread, it will remain the property of such
select company.
A Discomforting Episode
To explain and expose the development of modern managerial techniques should
not, although it often does, imply adherence to a universalist project of
proletarian revolution. The usual form, if this were the case, would be to
start winding up now with rhetorical salutes to the indominable spirit of
rebellion, etc., which will surely break the wily tricks of the managerial
class. The trouble with these projects is that they either solve all problems
by an eschatological leap into an era peopled by different beings from what
exists now, or contrive to bring into being a system so thoroughly
politicised, so totally committed to its goals as to render the manipulations
and seductions described above the epitome of free practise.
Unsupported by any such faith, my objections to the infiltration of
managerialism begin and end with what they do to the idea of a self-governing
humanity and the capacity of human society to remain substantially democratic
as opposed to merely procedurally so.
Perhaps after ecology, no other subject is more vulnerable to political
exploitation in the late twentieth century than health. If you wish to change
behaviour you are guaranteed more success if you associate a particular
practice with ill-health than if you declared that God didn't like it. The
proclaimed attachment of the advent of the new managerialism in the NHS with
improved health services (as an LGI Management Briefing brashly puts it "High
quality management leads to high quality care") makes any full-frontal
opposition particularly difficult. Coupled to that the years when management
was only a place you kicked incompetent staff upstairs to, the vigorous,
"hands-on", New Age types who are taking over look like an improvement. But
their techniques seem to demand premature participation, are constitutionally
opposed to conflict, and seek to run the organisationas if it were a body, a
self-contained organism with "feedback loops" and "equilibrium" (always good)
with no contradictions or dilemmas. The result could be a kind of paralysis,
an organisation so hyped-up on its own "positivism", so ready to channel
dissent up its own pre-patterned lines of communication, that it will
progressively dampen down critical thought and reduce negativity to a
non-rational underworld.
Opportunities
If managerialism requires oblique and perhaps "homeopathic" critique (see
"Found on St.James Noticeboard" in H&N no.10) it doesn't mean that no
opportunities for self-organisation are emerging from the results of the
reforms. The release of management from national wages and conditions
bargaining has led to a corresponding release for the workers themselves. It
opens a possibility for the existence of trade unions with an active
membership based around the reality of local negotiations. This is a somewhat
fragile possibility given the reluctance of national union negotiators to
give up their power and status, and the equal reluctance of local managements
to create the conditions for mass meetings and genuinely accountable union
negotiators. Such a response could also upset the pseudo-democracy of diffuse
managerialism. Unfortunately some unions seem to be taking a very narrow line
about the potential of local negotiations. For example the London Region of
COHSE seems to be arguing for a strictly "industrial" involvement on union
activity: i.e. leave the managers to manage and the union goes hell for
leather to improve wages and conditions regardless of cost of consequences
for the health service.
It remains to be seen whether these changes will breathe new life into union
structures shrivelled by the corporatist yearly round of Whitley Council
negotiations in London. Or perhaps such decentralisation will turn out to be
phoney, as cartels are created amoung hospitals and regional negotiations
based on the state of the regional labour market (backed by a regional
database on employee availability, as envisaged by LGI management) render
bargaining a technical exercise based on the scientific assessment of the
price of labour in the area.
In Place of a Conclusion
It's instructive to speculate about how these reforms will affect the nature
of health care. A Marxism Today article saw it as a chance for health
promotion to take over from cure as a priority. The argument went that a
purchasing authority could decide to "invest" in health education programmes
as opposed to expensive cardio-thoracic operations. Such long-term thinking,
the article suggests, will in the end reduce the need for expensive
high-tech, acute procedures.
The trouble with this argument (leaving aside its misplaced optimism on the
power of education to solve such problems) is that it takes a few more steps
along the road of blaming the victim for their disease. With alternative
medicine already attempting to resurrect the 19th century view of the sick
personality (from the idea of the tubercular character to trendy notions of
cancer being the body's response to psychic discomfort) the idea that some
illnesses are less "innocent" than others already has a toe-hold in the
medical establishment.
Backed up by the kind of market disincentives mentioned above, a coronary
patient who smoked despite his exposure to a health education programme might
find if very hard to get life-saving surgery. The power that such a
development could give the health promotion lobby to change "lifestyles"
should give cause for concern. In theory it amounts to treating all people
who are well as if they were ill. Dependency, once confined to the period of
illness, could be extended indefinitely.
Left outside the scope of the reforms but lurking unseen in the background is
the question of the appropriateness of medical intervention. Surgical
cripples, stroke patients condemned to spend their last years bedbound on a
general medical ward, life prolonged past the point of dignity, haunts the
subjects of an age committed to the benificence of medicine.
Already it is those least qualified to judge, the health economists, who are
"facing up" to the problem. With the formula of Quality Adjusted Life Years
(a measurement based on surveys of healthy individuals' opinions about the
acceptability of one post-operative prognosis compared with another) the
vision of a computer democracy, complete with value formation and
legitimation, shifts into focus.
Here, finally, could responsibility for the nature of health care be shifted
from the shoulders of government to the abstract community, a representation
of personal preferences carrying the weight of objective necessity.
Steve Bushell
From Here & Now 11 1991 - No copyright