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