The unspeakable treatment of the elderly documented last week by the NHS ombudsman Ann Abraham – worthy of a prison camp rather than a hospital – makes the blood run cold and then boil with rage. It was complemented by a deeply unflattering account in the Financial Times by writer Eva Figes of her stay in a ward for the elderly and bracketed a few days later by a report implicating an ‘overstretched and understaffed’ midwifery service in the preventable deaths of 34 babies in the West Midlands in 2008-2009. How did one of the richest, supposedly advanced economies get to the stage where its health service can only deal humanely with citizens in the prime of life, not at the beginning and end when they need it most?
The horrifying thing is that these weren’t pardonable cases of medical error. Clinically they were banal: having babies and getting old are hardly new or unexpected conditions. The failings are management ones, and they throw in sharp relief a stark truth. We know much more about the human body than human management.
These aren't random accidents. They occurred because we devised systems that brought them about and were powerless to stop them. Economist John Kay once remarked that in terms of scientific knowledge, management is about where medicine was in the mid-19th century. The history of the NHS is a graphic demonstration. As medical science steadily advances, management marks time: in important ways, as the ghastly events above (and many others in both public and private sector: at random: BP, Lehman and the whole financial crisis) demonstrate, it is marching backwards.
In a prescient 2002 pamphlet (1), Duncan Smith coins a telling image. In the absence of an internal thermometer to provide feedback, the NHS has never been allowed to become a self-regulating (learning) organism. Instead, ‘it became an anatomy on which outsiders [politicians and management consultants] were allowed to operate with very little opportunity for the patient to express its opinion’ – not to mention zero qualifications. It has been a costly experiment. The patient has been bled, purged, starved, fattened, cut up, reassembled and given so many potions that it now resembles a shambling Frankenstein, which Andrew Lansley’s expensive and pointless reform will make even more grotesque.
In the rogue’s gallery of fake healings that have been administered over the years, two faulty prescriptions stand out. Both of them are traceable back to the neo-liberal economics that has held sway since the 1980s. The first is the driving out of social norms by market norms. Recent work by behavioural economists suggests that we simultaneously inhabit two worlds: the social world and the market. We know perfectly well how each works – we don’t expect altruism from the butcher or baker, nor do we expect our partner to charge for supper – and have no difficulty switching from one to the other in our everyday lives.
The trouble comes when one infects the other. For many decades nursing and medicine generally were governed by strong social norms. Medicine was a vocation, so motivation was intrinsic (the job) rather than extrinsic (money) and the public-service ethos was strong. As with many other profession with similar norms, ‘efficiency’ was a secondary consideration.
From the 1980s, impatient governments started importing market notions to challenge the public-service ethos (ie ‘inefficiency’) of the NHS. Taking a leaf from the private sector, they subordinated medical professionalism to an increasingly stark performance-management regime of targets backed up by fierce incentives and sanctions (‘deliverology’ was the unlovely name coined for it by Michael Barber at Tony Blair’s Delivery Unit; in the NHS, it became known as ‘targets and terror’, a much better handle for a management method that comes straight out of the Soviet central planning handbook).
Targets ‘work’, in the sense that if enough resource is devoted to a priority it will be met. But there is always a cost elsewhere in the system, as people stop paying attention to often essential aspects of the job for which they don’t get brownie points.
For the caring professions, the combination of market norms and targets, particularly when linked to pay, has been catastrophic. As Figes’ account graphically exposes, instead of centring on patient needs, whatever they are, today’s nurses and doctors have learned to do only what they are paid for and the targets tell them. Nurses wash their hands (target), but not elderly patients (no target). Thus do we arrive at the heart of darkness, the oxymoron of a health service which does compassion only if there’s a target for it.
This tendency is made infinitely worse by the second prescription of the management flat-earthers, economies of scale. True to form, this is a century-old concoction that comes to us in direct descent from the mass-production car manufacturers of the early 20th century. In the belief that is that is cheaper to do things in bulk, products, whether cars or patients, are batched and processed in turn, before moving on to the next process. Work is specialised and repetitive, and each worker takes responsibility only for his/her part of the process. Workers have no line of sight to the whole.
Even in manufacturing, these arguments have been rendered obsolete by Toyota, which by concentrating on economies of flow – shortening end-to-end times to build a car – rather than scale, despite recent problems has become by far the most effective volume car maker on earth. In services, literally applied economies of scale lead to travesties of efficiency like the grim sweatshop call centres of HM Revenue and Customs, the Department of Work and Pensions and many mobile phone companies, full of bullied, target-driven workers whose only concern is to get people off the phone, whether by passing the buck to someone else or requiring them to phone back. This is the high road that in the NHS leads to fragmented care and health services where everyone is ticking boxes and protecting their backs, while the patient becomes a condition to be treated and expedited to the next station. The result: a Stalinist (I use the word unapolagetically top-down, arse-about-face system that is built to achieve abstract meta-targets (no longer than four-hour wait for emergency treatment, a 50 per cent reduction in MRSA infection) but not individual patient care.
The desperate irony is that starting from the other end – the individual patient – and employing economies of flow delivers results that are not only incomparably better but far cheaper. For every condition, demand into hospitals and doctors’ surgeries is amazingly stable and predictable. Wouldn’t it be more sensible to design an organisation to meet this demand, and nothing else, rather than unleash another whirling dervish of change with the fruitless aim of making central planning work better? As befits a junior, less mature profession that wields far more power than it knows how to handle, before launching yet another reform management should take its cue from medicine and vow 'Primum non nocere' – first do no harm.
(1) Physician, Heal Thyself: The NHS needs a voice of its own, Duncan Smith, Socialist Renewal, series 3 no 2, May 2002