Notes from the Health Factory

Part 1.

Steve Bushell reports on the latest re-structuring in the supply of health.

'Working For Patients' (the 1989 White paper on which the  NHS reforms
were based) sought to enhance local management's control over the
'delivery of health care'. What has been called marketisation might be
better described as the decentralisation and franchising of a large
national firm, the better to respond more ruthlessly to the variations
of demand and supply. This empowerment of management has occurred in
order to reduce the cost of labour, to remove obstacles to profit in
the medical industry, and to ensure a more effective servicing of the
'human resources' of the country, This last point has come about as a
reaction to political criticism, but more importantly as an attempt to
defuse the critiques of medicine, by ensuring more 'sensitive' medical
policing, including the institution of the paraphernalia of
'customer-care'. Naturally enough the first target of the new
management has been the medical profession, whose guild power this
century has attempted to secure sole rights over the designation and
cure of disease. Such an ambition had led to proliferating costs as
well as popular disaffection with the service. The new managers have
employed rudimentary cost-benefit analysis onto doctors. This
undermines 'clinical automy' and ensures that the rationing of the
scarce resource known as 'health' is overseen by managers more tuned
in to the needs of the State and Economy than doctors who might be
moved by common humanity or overweening professional ambition. The
response of doctors to this assault has largely been confined to
publicity campaigns, although Junior Doctors (paradoxically the most
'skilled' and exploited of the NHS workforce) have threatened
industrial action if their hours are not cut to 72 a week. This itself
would require them to challenge their own guild tradition by taking on
their master consultants. 

The Industrialisation of Nursing.

Nurses make up the largest section of the NHS workforce. The effect of
the new managers has been, at first glance, contradictory. The assault
on the medical profession is applauded by those nurses who see the
critique of medicine as an opportunity to advance their own claims to
professional status. Hence the production of 'holism' as a (spurious)
opposition to the 'medical' model in the treatment of sickness.
'Holism' has become the ideology of all the proliferating
para-professionalisms who are displacing the medical profession's
monopoly as purveyors of health. As a result, some aspirant
'professional' nurses have allied themselves with the new managers.
However, nurses themselves are responsible for a large wage bill and
use up a lot of the resources involved in treatment of the sick. This
puts them in line for strict managerial control. Before the developing
crackdown in the 70's & 80's nurses and doctors used resources by and
large as it suited them. Budgets were based on last year's costs plus
a bit for inflation. This relaxed attitude is a distant memory in the
current tight world of self-administered budgets, with sisters and
charge nurses given responsibility for devolved accounting on the
wards. This is represented as a conferring of autonomy (which panders
to aspirant ' professionalism') but in reality means that more and
more of the nursing craft becomes tied to the needs of money, and the
money-managers. As management, budgeting and cost control become part
of the job of nursing the possibility of using 'professional
knowledge' against the diktats of finance recede because increasingly
the definition of a 'professional nurse' is one who takes on such
financial responsibilities. The much-prized 'status' which the new
managers claim to grant is little more than the acceptance by some
nurses of the role of surrogate accountant. At the same time new work
study systems have been implemented which, far from pandering to the
illusions of those seeking professionalism's mitre, point to a
thorough-going Taylorisation of nursing. I will describe two systems
currently operating at the Leeds General Infirmary and at the
Huddersfield Royal Infirmary. 

G.R.A.S.P.   "Time is money". Benjamin Franklin.
This is a system developed in the U.S. It stands for Grace (name of US
hospital), Reynolds (source of cash for the study), Application and
Study of PETO (Poland, English, Thornton and Owens - the name of the
researchers who organised a work study of nurses in the American
paediatric ward). The PETO study was done by timing (without the
nurses knowledge) various nursing actions in order to arrive at a
'time' for these actions. These times  were then used as an indicator
of the intensity of work on the ward and therefore used to affect the
admissions policy. (In the past admissions were based on bed
availability, now work intensity was to play a role). From this
original study developed the idea that all nursing actions could be
timed and that each patient on a ward could be assessed to give a
figure for Patient Care Hours (the amount of nursing hours a patient
requires). In the US this measure was seen as an exercise in costing
patient care by introducing a specific nursing labour component into
it. (At the moment in the LGI there are no plans, as far as I know, to
use the study for this purpose, but it can't be ruled out for the
future). 

In the LGI GRASP is used as a method of assessing the amount of nursing
labour required on each ward. The original studies however, are not
performed by work engineers but by the senior nurses on the ward
themselves. On the basis of their knowledge and experience they give a
time (in decimal hours) to common activities on the ward. For example,
oro-pharyngeal aspiration is given a value of 8 - this means that over a
24 hour period any patient requiring such treatment will take up to
8/10ths of an hour of a nurses' time. Time values are given for
practically any task you could imagine on a hospital ward - and it is
the nurses themselves who disclose the activities. The result is a
chart (see diagram) which outlines all the possible time-values on
that ward for each patient. The time-value for the activity is fixed
by the senior nurses - the job of the nurse actually doing the work is
to indicate which activities are necessary for the particular patient.
The time-values of these activities are added up by the nurse in
charge of the tream thereby arriving at a number of Patient Care Hours
(PCHs) for each patient. This is compared with the actual number of
Nursing Care Hours available each shift. In common with factory work
study methods fatigue allowances are given, but rather than the
detailed assessments of the industrial schemes 13% is given across the
board because the hospital is old. There is even a time-value given
for filling out the GRASP form - a possible future contradiction as
the time and effort of keeping accounts eats into the time and effort
necessary to attend to what they purport to be an 'account' of.
Regardless of management's explanation for the introduction of GRASP
(that it is intended to improve staffing levels), in effect GRASP is
about putting a price on each nursing activity (a 'unit cost' worked
out on the basis of the grade of the nurse and the time taken). This
allows them not only greater control over the nurses' working day, but
enables them to start the process of increasing the nurse's effort for
the same wage by exerting downward pressure on the GRASP times (which
although nominal have a vague relation to the actual work done). So
far this system is still at the data-collection stage. Every week
management receive raw figures on the time values of each patient on
the ward. As well as team leaders filling out PCH forms, they are
expected to fill in a questionnaire on the adequacy (or not) of the
care delivered. This is then used by management to check that if there
is a significant disproportion between PCHs and NCHs that the
inadequacy of care is noted by the team- leader. Along with 
spot-checks by the GRASP committee this is simply another way of
making sure the system is 'properly' enforced, by making it very
difficult to use the figures to justify, for example, more staff on
the basis that one is already working too hard. 

Nursing Information for Change Mangement. (NISCM)
This system seems to have been developed by a firm of management
consultants in the UK, and applied by the Huddersfield Royal Infirmary
who now have taken a patent/copyright on their application (CPRS -
Care Planning and Recording System) The HRI is important because it
was one of the hospitals used by the government as a guinea pig for
its Resource Management Initiative - a measure involving radical
devolution of budget holding controlled by networking information
technology. The NISCM provides a way for computerised wards to get an
immediate picture of staffing requirements (and its costs) in order to
ensure maximum staff 'flexibility'. Unlike GRASP it is not a system I
have worked under so I can only describe it from the documentation
which has fallen into my hands. The system describes itself as giving
the 'nursing profession' the ability to 'express their work and its
varying demands in simple statistical terms'. It involves setting up a
patient classification system not unlike GRASP but ranking patients
into 'Demand Groups'. These Demand Groups are based not so much on the
severity of the patient's illness as the amount of nursing time they
require. The model suggests that there can be 5 batches of demand
groups per ward, although in the name of flexibility the system will
admit more. The definition of each group is undertaken at the ward
level. At the end of each bed is a chart upon which the nurse records
the time spent with the patient, by ticking off the activities
performed. (each activity has a computer code). An average time spent
for each patient is then established. Re-calculation of these averages
is to take place 4 or 5 times a day, so staff and management can work
out how much labour is required, and of what kind  each shift.
Workload calculation is obtained by multiplying the number of patients
in each 'demand group' by the average time for that group. The use of
computers enables activities per patient to be recorded and stored.
'Activity analysis' of staff is conducted by each member of staff
carrying 'Activity Diaries' in which they record the number and nature
of the activities they perform. This is only done when 'Activity
Sampling' is being performed in order to check up that the skill mix
etc. is 'appropriate'. The literature reveals 5 purposes for such an
analysis : 
        "To establish the proportion of time spent on direct care.
        To establish the proportion of non-professional duties.
        To establish the extent of the "mis-use" of staff's time.
        To establish the current work pattern for Skill Mix re-profiling.
        To establish a comparison of duties between staff grades".
When fully computerised the system will provide management with a
permanent 'window' on ward activities without being physically
present. They will be able to re-deploy staff according to the
'busy-ness' of the ward revealed to them by the auto-surveillance of
the nurses themselves. Duties will be 're-aligned' (including nursing
staff taking over junior doctors' duties in the event of an hours
reduction), and non-qualified staff (nursing Auxiliaries and Health
Care Assistants) could be employed working on what was once qualified
nurses' territory. Much tighter job descriptions will be attached to
nursing grades in an attempt to avoid the sort of problems which
generated the 4 year Clinical Gradings dispute (1). In the light of
debates on modern Taylorism (see Here & Now No. 12) it is instructive
to note that one of the selling points used by the management
consultancy firm is that the work study is performed by themselves,
thereby removing the cost of employing time study engineers. 


Responses.
Both systems intend to "rationalise" nursing work on the wards.
("Rationalise" means, here, both to drive down the costs of nursing
labour and to simplify, by fragmentation, the nursing craft in order
to render managerial control over the nurse/patient relationship more
comprehensive). Even 'indirect', 'psychological' and 'emotional'
support are given time values (see diag.). The opportunity for
'resting' is diminished because management can re-deploy staff to
busier areas of the hospital. Labour discipline is tightened up simply
with the knowledge of the scheme's existence. It's well-known that
management intend to use the scheme to justify a reduction in
qualified staff and their replacement with unqualified (and cheaper)
Health Care Assistants, justifying such cutbacks on the ground that at
least some proportion of a trained nurses' time is spent doing
'unqualified' tasks and new schemes will 'scientifically' prove this.
The intensification of 'costing' - and by giving everything that can
be measured a 'time-value' and filling up the accumulated time-value
with NCHs means that which cannot be measured has no place or time on
the ward or shift. In other words the more managerial/technical
control, the less convivial, sociable relations between staff and
patients. Managed hearts doling out 'emotional support' according to
an internal stop-watch are more likely to dispense such support as a
rationed task, unless the actual purpose of these schemes to create a
climate of measurement on the wards can be deflected. Such deflection
is patchy, confused and contradictory but likely to grow rather than
diminish. (Here I can only talk about GRASP).  Because the scheme is
still at the data-collection stage no dramatic effects have occurred
either in terms of 'improving staffing levels' (management's
justification of the scheme to staff) or re-composing 'skill-mix'
(management's justification of the scheme to themselves). There is
widespread awareness amongst nurses that GRASP will be used to
split-off 'non-qualified' jobs from qualified staff in order to reduce
trained nurse numbers and increase Health Care Assistants. There is
some resentment about the reduction of the nursing craft to measurable
time-values, both by those hankering for a 'professional' ideal, and
those who just don't trust management. Active resistance in the form
of refusal to fill out forms, or rendering them useless by always
giving maximum times, exists, but is dispersed, and very vulnerable to
being identified and neutralised by senior nurses or the GRASP
committee. Passive resistance is much more engrained with nurses
treating the scheme as just another managerial ploy, and not letting
it have any effect on what they do on the ward. When the system
actually starts to operate, and nurse numbers are reduced, conflict
between the desire of nurses to have a 'happy' ward, and that of
managers to have a 'tight' one can only intensify. However further
reduction in staffing will be the one weapon management can use to
force compliance with the GRASP criteria. A side-effect of reducing
trained staff is that the replacement staff of HCAs are likely to be
more militant as their numbers and responsibilities increase, and
their qualified overseers more disgruntled by their loss of autonomy 
in doing the job and their managerialisation. (The bait of 'primary
nursing' - where each patient is designated a specific qualified nurse
is an attempt to hang onto a more humane system, and is given support
in John Major"s Patient"s Charter, but it simply does not work under
current conditions of over-work and speed-up of patient through-put.
Officially it has been in existence on my ward for 1-2 years, but in
practice it is put aside when things get busy). Trades union attempts to
confront it been at the level of wanting to be 'involved' in the timing
etc. Sindone by nurses who are their members, they have been
outflanked any boycotts, even if they wanted to. 

Further Recompositions.
The overall tendency of the reforms has been to accelerate the
process of hospital specialisation (centralising specific kinds of
health care within a particular hospital- 'niche- marketing' in
ad-man's terms). This has led to an alteration of the composition of
patients treated by 'general' hospitals, an alteration which exposes
deep changes in the social role of such institutions. What has
happened (and what continues to happen) is that sectors of chronic and
long-stay patients have been sub-contracted to the private sector for
'care'. Many of the elderly and very dependent patients have been
transferred to private nursing homes, although the cost continues to
be carried by the State (although this is means-tested). Part of the
reason for this is the hospital's shedding of the role of 'moral
universe' established by the necessities of the C19th capitalism. The
hospital is no longer either the officially-sanctioned repository of
'charity' (2) nor part of the State's armoury of social regulation
through 'care' - that role has been dispersed into the 'community'
(3). The modern hospital is less and less a site of 'care' in that
non-specific sense of a place people go to when they are sick, and
more and more a purveyor of customised health supplies. Emphasis on
'Value-for-money, medical audit and work study systems betray this
development from general 'care' provider (with an often haphazard
understanding of the results of 'care') to a specialist health factory
applying cost- benefit analysis to all its operations. 'Health' from
being something prescribed by the monopoly of the medical profession
now has a superfluity of suppliers, from wholefood restauraunts,
fitness centres, alternative medicines to health visitors, social
workers and health educators. The contemporary hospital recognises its
niche in the market, that of, high- tec intervention, and consequently
has begun to shed the responsibility of antiquity. At the same time
indicators are being established which, for the first time, will
provide costings for this scarce 'resource' thereby furthering the
process which locks being alive within the conditions of scarcity. 

Notes.
1) After sporadic strikes and actions throughout the NHS in 1988 the
NHS management determined a new set of grades for nurses, which
connected rates of pay to responsibility. This led to thousands of
appeals which clogged up the NHS Grievance Procedure. 4 years later
not all appeals have been heard. 
2)  The origin of Leeds Infirmary (like other infirmaries in the U.K.)
emerged as an attempt to promote sensible charity and overcome the
divisions in the upper middle classes which could trace their source
from the dissolution of the monasteries;
  "It is a recommendation of this scheme, that the benefits of it are
not confined to any particular sect or party in religion;  but that it
is equally open to all who may stand in need of it."

Joseph Priestley. 'A Sermon on Behalf of the Leeds Infirmary.....' 1768
The infirmaries also marked the beginning of calculated charity which
betrayed a poorly concealed social engineering purpose. In the same
sermon Priestley appealed to the enlightened self-interest of his
audience. Give thoughtlessly, he warned, and: 
  "with the best intention in the world, you may be doing nothing
better then encouraging idleness, profligacy and imposture; but in the
cases for which this infirmary is provided, there can be no
imposition, and avarice has none of its usual paltry excuses to avail
itself of." 'A Sermon...' 
3) The regulation of lifestyle, which was always a part of the purpose
of 'caring' institutions has become far more diffuse and subtle than the
use of the fear of incarceration.  Health education, public health
programmes, and medical screening have become more effective means of
penetration into social life. This is not for the archaic purpose of
moral regulation on the basis of certain Christian or national mores,
but as the inevitable result of the need to reduce the costs of
supplying the health commodity.  However, such 'community health', far
from increasing automy, only further exacerbates dependencies upon
professionals and experts, confirming the idea that 'health' is
something these people sell (albeit through state insurance). It asserts
an identification of being alive with the ministrations of the
para-medical complex, leading to a view of the body as a system needing
to be 'worked-on' and perpetually up-graded like any other piece of
industrial technology. The ideology of 'human resources' is only the
frank recognition that a person has now become a resource which has to
be managed. 'Holism' in this context, simply acknowledges the need for
management to encapsulate the whole of human experience, the better to
avoid unmanaged protests. The success or failure of such ambitions
rests, not only on active resistance, of which there is plenty, but
also on the creation and sustenance of convivial and unofficial ways
of living (however partial to the whole of a person's life). In the
U.K. these still remain confined to  the byways, the sidings, the
back-waters and the diminishing commons of the country. 

This is Part 1 of a revised version of an article originally published
in Reader III of the (German) Wildcat papers of 'Militant Research'.
Part 2 will discuss some of the fragmented struggles in the NHS,
including the emergence of 'whistleblower'.

From Here & Now 13, Glasgow, Autumn 1992
