David Zigmond argues that it is not just economics that is at the heart of the problems in the NHS - more than this is the lack of attention to the issues of the heart.
Author: David Zigmond
A recent article by Timmins, "Back in the Emergency Room", conveys clearly the twenty-five years of economic waste and organisational inefficiency brought by the serial reforms to our NHS. The author, though, does not address the human damage and cost. Here is a corrective.
Bad administration, to be sure, can destroy good policy, but good administration can never save bad policy.
Adlai Stevenson, speech, Los Angeles
September 11 1952
Nicholas Timmins, writing recently of the woeful predicament of our NHS (‘Back in the emergency room’, Prospect, April 2017), offers a knowledgeable and narratived analysis through a political-economic lens. His notions and questions are clear and now mostly familiar: our lives lengthen, our burgeoning technological progress multiplies both our possibilities and our expenses. We cannot stop expectation and demand, so who is going to pay? And how? And who will decide?
Timmins’ crisp and engaging survey finishes with:
‘That’s the heart of the problem … “It’s the economy, stupid”.’
Let us linger where Timmins leaves us. Yes, we cannot easily ignore economic realities if we want better influence and understanding, but the ‘heart of the problem’ must also include the ‘heart’ of our healthcare. What is that? And what is its relationship to the economy?
Most of us, I believe, think of healthcare’s heart as its humanity: a seminal principle motivating resonant personal connections, contacts and relationships, even if very brief. So it is synonymous with healing, palliation, fraternalism, empathic imagination and – that word now so prey to slick packaging – compassion. It is the art rather than the science of our work; the spirit rather than the machinery. And here is a conundrum, for these things are difficult to measure or evidence directly, yet we are, mostly, very sensitive to their presence or absence. So though such humanity is often crucial, it mostly eludes procedure. How, then, do we plan or manage?
Such heart in healthcare cannot be purchased by any economy, just as money cannot buy us love (though imitations are easily purchased). This is because healthcare’s heart is an organic phenomenon; it must grow indirectly from personal interactions, so it cannot be directly manufactured by institutional plan.
Yet there is certainly a strong relationship between healthcare’s economy and its heart. Clearly unwise financial threats, pressures and incentives can and do cause damage, failure and even arrest of our communal heart. Our heedlessness of this has caused profound disruption in our health service far beneath the surface of our troubled system’s economics – the realm so well captured by Timmins’ analysis and history. His frame and language do not extend to this: our healthcare’s human heart-failure.
Paradoxically, it is much easier to collect data about unhappy and failing relationships than good ones. We now have many quantifiable indices to show us how much the NHS professional staff are sickening under the stresses of ‘improvement plans’ that relentlessly ratchet performance management and remote control: dramatic rises in staff sickness, early drop-out and career abandonment, premature or earliest retirement, drug abuse and alcoholism, new psychiatric illness, marital breakdown, intra-organisational litigation… and suicide – all these have come with the reforms that are designed to provide better efficiency, value and safety for the public.
Such widespread human disconnection is increasingly expensive, too, and so becomes less and less sustainable.
On this last point Timmins points out how fragmenting, disruptive – and thus inefficient, expensive and wasteful – have been our incentivising initiatives since 1991. He examples, particularly, the purchaser/provider split, autarkic Trusts, private finance initiatives and the entire complex of marketisation. He could fit far more into this net: the wider and parallel processes of attempted industrialisation, together with attempts to universalise micromanagement of procedure and performance – all these have incrementally stupefied, stultified, demoralised and depressed many health workers who were previously good-enough, or considerably better.
So Timmins’ portrayal is of a quarter of a century of politically vaunted economy and efficiency reforms becoming a catalogue of misfiring missions. But the damage is even wider and deeper – more paradoxical and perverse – than he describes. For, in attempting to ‘drive’ industrial type output and efficiencies from healthcarers, successive governments and their guiding gurus have lost us far more than we have gained in this quest: we have lost sight of what best motivates and sustains such workers. We end up driving out vocation: our incentives demoralise. Goals and targets may be met, but professional integrity and judgement flags and then dies. First galvanised by confused fear, our healthcarers will later withdraw their spirit or their labour.
Such is both the pathos and bathos that follow the last two decades of commercial or industrial-type managerialism that does not understand deeper motivations of healthcare or the social psychology of human networks.
Some examples of how we have done this? The pre-eminence given to economies of scale leading to ever larger and depersonalised hospitals, medical schools, and GP surgeries. Abolishing personal lists with GPs, so replacing a person by a place. The dispersal of Nursing Schools to Universities, destroying a culture of apprenticed loyalty and familiar identification. The similar effects from replacing the personal stability and continuity of consultant-led ‘firms’ and wards by a remotely controlled system of teams and rotas. The anti-fraternalism and contra-colleagueiality that must follow a competitively marketised system... there are many more.
Such are the losses to our human sense and relatedness deemed ‘necessary’ for us to gain in efficiency. Like over-strict and over-controlling parents who ‘only want the best’ for their family, we may assure early compliance, but later evolution will depart far from our plans. We usually end up with far less.
It may be possible to manufacture good cars without much need for motivational, social or depth psychology but this neglect cannot succeed in providing good personal healthcare.
Timmins’ analysis of our problems – so erudite about the politics and economics, yet absent of such psychologies – instructively reflects the nature of our broader predicament.
Live together like brothers, but do business like strangers.
Many articles exploring similar themes are available via David Zigmond’s blog here. David would be pleased to receive your feedback.
The publisher is the Centre for Welfare Reform.
A Healthy Heart for the NHS © David Zigmond 2017.
All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.