Mike Levine discusses how we can go beyond the hierarchical form of the National Health Service. The author has spent most of his working life as an NHS researcher.
While the National Health Service is remarkably successful in treating ill people, it is under threat of being opened up to international free markets. Both Labour and Tory/Lib Dem parties seem hell bent on this. The problem with private health providers is that they cannot make a profit out of treating any but the richer part of society unless they are subsidised.
The belief that a health service based upon market systems is more likely than a publicly planned one to lead to a decent healthy life for everyone, is completely unfounded. There is no evidence for it and comparison of the NHS with, say, the USA or European countries shows that Britain spends less in terms of a proportion of GDP for a service which is both good and equally available to everyone.
In recent years there has been a growth in the belief that management is the key. Management is supposed to be a general profession whose members can be inserted at the top of any type of large organisation to create something called ‘efficiency’. The fact is that the operation of a complex technical service like the health service presents difficult problem with its own specific requirements and necessary practices.
Why then, is the public susceptible to the wild claims that are made by the reformers. It is not because they think it is a bad service. People confidently expect the medical services to step in when disaster strikes and they get serious illnesses.
The fact is, that, apart from their local GP (if they are lucky), for most people the NHS is a faceless, rather mysterious and massively powerful institution which they do not understand. Individual stories of inefficiency and waste can always be found and used to damn the whole organisation.
Even the people who work in the NHS are uncertain in their defence of the NHS. For them too the organisation outside their immediate work environment is rather an alien presence. Many decisions that are taken by the managers seem to be counter-productive and wasteful to those who have to carry them out. Working in a private hospital. might not that different to working in the NHS. The conditions, pay and hours might be worse, but the main features of hierarchy and alienation are the same.
The NHS has never been a fully nationalised industry. It was designed as a mixture of private and public enterprise. The GPs have from the start been private contractors to the NHS. The hospitals were originally wholly owned by the NHS which also employed most of the staff but equipment and medical supplies were bought in. Also, building work was undertaken by private contractors.
It is this mixture that has been the subject of the Conservative and Labour reorganisations. Both parties have tried to introduce market mechanisms into the management of the Health Services. The difference between the parties seems to be one of degree. This has resulted in recent years in continuous disruption as policies shift backwards and forwards. In reality, the possibility of a fully nationalised Health Service has never been considered by any post-war British government. The increasing introduction of market forces into the NHS will inevitably degrade the care that NHS patients receive.
If we are to provide medical care equally to the whole population it is necessary that funds are allocated to provide the physical means and quite a large proportion of the population is employed to carry it out. Insurance schemes do not solve the problem unless they are publicly subsidised. So, it is necessary to have a general system paid for out of taxes. Thus there is a question about the relation between the public who finance the system and the people who work in it. Then there is the question about the internal organisation of this large body of workers. Also, it there is the effect of inequality and poverty. One way to reduce ill health in society is to reduce inequality. It has been shown that all types of illness are more prevalent the further down the social scale you go. This is true for all sorts of illness from heart attacks to mental health and even accidents in the home. All doctors recognise this and realise that there is only so much they alone can do. Socialism might be expected to lead to a more equal society in terms of access to resources and also fewer damaging distinctions in status.
What then, could a socialist health-care organisation look like?
In general work can be organised in a wide variety of ways. At one end of the spectrum is the Henry Ford ideal of factory manufacturing, where the whole plant functions as a single machine, following a rigid cycle, with each of the component parts, including the human workers, carrying out its own single repetitive task. The whole operation can, in theory at least, be described down to the last detail as a single predetermined plan. At the other end of the spectrum is the utopian cooperative where each member is equal and where each decision is subject to agreement by the whole collective at every moment.
The health system cannot be organised in either of these ways. It is in its very nature far too complex an operation. A main problem complicating the notion of creating an overall detailed plan, apart from the inherent complexity of each individual patients’ needs, is that the knowledge of disease is constantly changing. Much of this changing knowledge is itself generated within the hospital through continuous re-evaluation of working practices and clinical trials of new treatments, not to speak of fundamental research which is carried out within hospital departments. Clearly, it is absolutely essential that complex technical decisions are left to people with the necessary expertise, which can take many years of study and practical experience to acquire. Much of this knowledge is specialised and therefore there has to be collaboration between specialists. However, this doesn’t only mean doctors. Doctors depend upon large teams of people, many of whom have specialised knowledge and skills not possessed by most doctors and consultants. (pharmacologists, physicists, engineers, biochemists, nurses…..).
Thus, of necessity, hospital organisation has evolved practical strategies based upon a system of committees and case conferences. In this sense the hospital has the aspect of a self-adjusting organism and this might be seen as the seeds of a socialist method of organising.
However, superimposed upon these semi-autonomous structures, is a hierarchy of authority in which each level reports to one above. The commitee will send a report and/or a delegate to a higher committee. The case conference deliberations will be subject to the final decision of a consultant. Key mechanisms for maintaining control in the whole labyrinthine organisation are the ways in which power and very large wage differentials go together. In this respect hospital systems are the same as any other organisation in capitalist societies. People higher up the hierarchy have a stake in maintaining the hierarchy. They covet the positions of the people above them but will defend them against encroachment from below. It is this aspect which needs rethinking if we are to have a more socialist Health Service.
It is particularly this command structure which interacts with the politics of the world outside the hospital. The public need the care and provide the funds. They exert outside control and the care they receive depends upon their political decisions.
There is an alternative. In spite of cuts and the organisational chaos imposed from above, people are motivated generally to make things work.
There is an ethos of service to the community embedded in the NHS which could provide a key motive force for driving structural change. Socialist change could actually come about from the bottom up in an organic way driven by the discontents within the system itself.
Alongside the general cooperative nature of the work, with dedicated people doing more than they are paid to do, sources of conflict abound. Many people in the health system suffer from a sense of alienation in the workplace.
Apart from gross differences in pay and conditions of work there are questions arising from the hierarchical nature of top down organisation. People are often compelled to accept decisions that are seen as arbitrary, unfair or simply mistaken. Everywhere you go you hear stories of inefficiency and waste due to perceived lack of understanding by managers. People who are dedicated to their work are frustrated and complain that they are not listened to.
A major difficulty with planning the health system from the top down is that it is very difficult to quantify everything as you would a supermarket operation. An example is the worsening problem of infection control. The outsourcing of cleaning has led to dirtier hospitals as contractors squeeze the cleaning staff to do more work less well for less pay. What value would you put on the ward cleaner who used to be an integral part of the ward team and who also spent time talking to frail confused old patients.
Another example of the difficulty of quantifying significant aspects of the work people do, is in the maintenance of medical equipment in hospitals. Medical equipment is increasingly sophisticated and needs an efficient organisation within the hospital to ensure it is working properly whenever it is used. The medical equipment workshop carries out regular preventative maintenance and repairs faults when they occur. However, problems occur in the actual application of sophisticated machines in patient care. It is not always easy to know when the readings on monitors are reliable. Errors can be due to improper use or to faulty equipment or both. New models with unfamiliar controls are continually appearing. Close liaison between technical staff and nurses and doctors is essential. On many occasions problems come to light through informal conversations and this involves technicians being familiar with what goes on in the wards. Unfortunately when management try to lower costs by increasing throughput in the workshops they find that technicians are spending time ‘wastefully’ chatting to the nurses and step in to manage more closely. The job of the workshop is redefined as being solely to service the equipment so that it works according to the manufacturers specification. Training programs are instituted but can only be partly effective in avoiding error. An example known to the author was when a technician noticed that a ventilator circuit was connected incorrectly resulting in dry air instead of humidified air being blown into the patients lungs.
It seems that a minimum requirement is a system of works councils .Clearly it is useless to attempt to design an ideal system from scratch. Rather, it has to evolve organically from the ground up so as to be compatible with the complexity of the system and with the perceived needs of the staff and also the legitimate public interest.
This brings us to the problem of the relation between the workers in the health system and the public who benefit from the service and have to pay for it through taxes. This question should be seen in the context of the whole health industry. At present, the NHS purchases services and supplies on the open market.
An example is the drugs which are a mainstay of modern medical advance. A strong case can be made for a socialised drug industry. Drugs are developed through basic research carried out in universities and also in the laboratories of large and small drug companies. The development of drugs in private industry is extremely competitive and involves very large amounts of capital. This competition is often cited as being responsible for the astonishing advances we have seen. However this is not a case that can be cited as an example independent classical free market driven innovation (very few such cases exist in fact).
University research is funded partly by government grants and partly from industrial contracts. However, the universities are not yet predominantly driven by shareholder value! They are in competition inasmuch as they use their research success to attract more funds. The bioscience companies are in competition with each other, but in a peculiar way which is also not akin to a classical free market. The patent laws and the medical profession ensure that. Once a new drug is approved for clinical use there will be generally a consensus medical opinion based upon science about which drug to choose for each kind of application. Thus the market success or failure of each new drug is not decided by individual choices made by millions of atomised customers as in a classical free market.