  
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
