Sunday, October 6, 2013
Thoughts of Maurice Brinton on the NHS, 1978
Originally published in Solidarity: for Social Revolution (London, UK) No. 2 April 1978, under the title “YOUR STATE OF HEALTH AND THE HEALTH OF THE STATE”.
The NHS is the biggest, sickest employer in the country today, an employer dealing with over a million people.
Every week the media carry reports of hospital closures, difficulties in maintaining standards, long waiting lists, ill-treatment of the mentally ill, of scandals due to inadequate staffing and of rampant dissatisfaction (both among those working for the NHS and among those for whom it was designed). Have you ever tried to ‘get through’ to your GP in the course of a 5-minute surgery consultation? Have you ever tried to get minor surgery carried out on a child, in a hospital, on a Sunday afternoon? If you have, you will know exactly what I am talking about.
The NHS crisis is developing against a background where – despite substantial improvements in health standards since 1948 – there are still gross inequalities. These involve both the social distribution of disease (1) and the distribution of facilities for coping with it. A general practitioner has even written of an Inverse Care Law (2) whereby the availability of good medical care tends to vary inversely with the need for it. The cut-backs in the NHS are widely – and rightly – perceived as an attack on the social wage.
Confronted with these truths, the average radical talks about ‘the crisis of capitalism’ and ‘the onslaught on the working class’. He bemoans the small proportion (only some 8%) of the Gross National Product devoted to health care, and the wrong priorities of governments – both Conservative and Labor.
I don’t propose to deal here with this wider perspective – not because it is irrelevant but because I want to focus on another aspect of the crisis: the bureaucratisation of the NHS. This is part of a trend which started long before the last five years. Inflation and recession have certainly accelerated the trend. But ‘administrative’ reflexes and attitudes, widespread on the left, have also reinforced it, thereby creating further problems.
Growth of the Bureaucracy
If we think of a bureaucracy as a group of people primarily concerned with ‘the direction and management of the work of others’ (and with the perpetuation, while at it, of their own privileges), then the NHS has witnessed an undoubted growth of bureaucracy over the last couple of decades. Anyone working in a British hospital – through the 1960s and 1970s – will have seen the remorseless forward creep of areas allocated to administration. Areas devoted to patient care have meanwhile grown little or not at all; sometimes they have actually shrunk.
New blocks go up, noisily and dustily, near the seriously ill. New Committee rooms are built, where planners plan and administrators administrate. New furniture is ordered and delivered. Men carrying carpets or delivering filing cabinets suddenly appear in cluttered hospital corridors, among the trolleys carrying patients. The alienation due to the growth of specialisation (where doctors in one specialty can hardly understand what those in another are talking about) is now compounded by another alienation, where no one understands what the administrators are talking about. New memos, new regulations, new rules, a new vocabulary. The phones can hardly cope with [the] surging tide of administrative yap. Patients cannot get through to doctors. Doctors can’t get through to the lab, or to other hospitals. Both swear at the telephonists, who return it… with interest.
In 1964 there were 52,085 doctors and dentists in the NHS. A decade later there were 63,110 (an increase of about 20%). Over the same decade the number of administrators and clerical staff had increased from 48,016 to 79,114 (i.e. by nearly 65%). (Written reply, House of Commons, Oct. 29, 1975). By 1975 the administrative staff had swollen to 86,707.
The cost of this vast bureaucratic superstructure (and its relation to expenditure on medical care) can be seen in the following figures:
Hospital expenditure (UK) 1974-75: (Source: Written answer, House of Commons, February 10, 1976)
Administration £107,930,991 Medical Care £167,118,313
In other words, the administration of the NHS consumes nearly 2/3 [two thirds] as much as the provision of medical care.
The basic facts can be put in a different way. A decade ago there was an administrator for every 9.5 hospital beds. Today the figure is one to every 4.8 hospital beds. (Evening Standard, Jan. 24, 1977). This is undoubtedly a change in the organic composition of the Health Service. ‘Dead labour’ in the offices is clearly dominating ‘living labour’ on the wards.
Unfortunately few on the ‘official’ left are prepared to campaign on such issues. Their cult of a certain (bourgeois) type of efficiency and their endorsement of hierarchy in so many aspects of their lives – not least in their own organisations – renders them rather impervious to facts of this kind. It was left to rank and file workers at the Westminster Hospital to point out that ‘senior management… are provided with flats and offices furnished with expensive and unnecessary desks and equipment, while the cleaning budgets have been cut, allowing mice and cockroaches into wards and kitchens.’ (Evening Standard, Jan. 24, 1977).
The Question of Priorities
This is not the place to discuss the growth of social services or of the ideology of ‘welfare’ in the 20th century. They were the result of a developing awareness among those who ruled society: those who made it function had to be kept in a reasonable state of health.
When Aneurin Bevan spoke of the NHS as inaugurating an era when ‘poverty would not be a disability, and wealth not an advantage’, he was speaking through his hat. He had himself described politics as ‘the language of priorities’. Those of a social structure that had only been tampered with were soon to assert themselves.
That NHS priorities over the last 10 years have been ‘wrong’ is certain. But the ‘errors’ were no accident. They were an essential feature of how bureaucratic societies function. They show the sort of issues such societies can sweep under the carpet, the sort of pressures they respond to, even the nature of their responses. People like health. They get angry when health facilities are cut back. The bureaucrat reasons that people won’t miss what they haven’t had. The lower limits of expenditure on health are therefore always determined by fears of political backlashes (i.e. lost votes).
Between 1953 and 1973 the annual expenditure on the NHS has only increased, in real terms, by 141%. During this 20 year period government spending on education increased by 274%, and on personal social services by 506% (World Medicine, Nov. 17, 1976). The NHS bureaucracy realised, at an early date, that the best way of ensuring that potentially expensive ‘demand’ did not arise was to ensure that the resources to meet it were never available. ‘A hospital that has not been built, a bed that has not been put in place, a specialist who has not been trained, a complex piece of equipment that has not been bought, all of these cannot be used. The secret of saving in the Health Service was quickly understood to be the non-provision of resources. Here was the origin of the waiting lists that are so characteristic of the Health Service today’. (ibid.) From the government’s point of view there was and is no cost attached to the wretchedness and misery of a patient who must wait a month, a year, or several years, to get his ‘elective’ (i.e. non-urgent) problem handled; the patient’s pain, discomfort and mental turmoil do not have to be entered in the books.
Organising… for Chaos
In 1968 the Labour Government published a Green Paper on the Reorganisation of the NHS. McKinsey & Co., an American-based firm of management consultant[s], had offered expensive advice, much of which was accepted. In 1972, after further talks with the select few, the DHSS [Dept. of Health and Social Services] (now under a Tory administration) published its famous Grey Book (Management Arrangements for the Reorganised Health Service). The pregnancy had been long and difficult: no fewer than 6 members of the Steering Committee producing the document had resigned between Sept. 1971 and June 1972. The opening words were prophetic: ‘The way in which the National Health Service is organised, and the processes used in directing resources, can help or hinder the people who play the primary part’. The hindrance really got going.
It is said that a camel is a mammal designed by a committee. The main principles of the new Act could only have been conceived by a Committee of bureaucrats, sitting in an office. There would be ‘three levels of statutory authority: Area Health Authorities (AHAs) accountable to Regional Health Authorities (RHAs) accountable to the Secretary of State. Authority would flow downwards, accountability upwards. This was stated in so many words. To make things nice and tidy the AHAs were to be co-terminous geographically with new Local Authorities (Counties and Metropolitan Districts) and with the present London Boroughs or combinations of boroughs.
It was conceded that the odd problem might arise. ‘For example, although Henley-on-Thames will be in the Oxfordshire Area over 90% of Henley residents requiring in-patient treatment will receive it in Reading, which is in the Berkshire area’. The ‘overlap’ problem would, it was admitted, ‘arise in many places’. But who cared? A whole new group of office staff would be devoted to ‘defining District boundaries’. The basic operational unit of the new Scheme had to be the ‘District’– defined as a population (usually about 200,000 to 300,000 people) supported by the specialist services of a District General Hospital. And that was that!
The Scheme sought to ensure the participation of those concerned ‘as a systematic part of the service’. The participation (its limits clearly defined) was imposed from above. There was precious little discussion among working nurses, doctors, physiotherapists, radiographers, laboratory technicians and all the others involved in the functioning of a modern hospital.
Great emphasis was placed on ‘integration (with other social services) at District level’. This was to be carried out by District Management Teams (DMTs) [… ]
[… Quite lengthy description of the DMTs in the new organisation, as summarised in charts:]
The whole structure is firmly in the hands of a permanent bureaucracy. The elected representatives are just the gilt. The DMT, it is stipulated, need meet ‘no more frequently than once a week’. Some only meet once a month. Under these circumstances the role of the full-time administrator becomes paramount [… ] These full-time officials know who pays the piper. They know which side their bread is buttered. They know they are there to implement government decisions, not to challenge them. They ensure that economies never start with the administration itself. In the upper echelons of the hierarchy they are past masters at ‘losing’ a request or a decision. Meanwhile, at DMT level – and even more in hospital wards and corridors – the issues have become stale, or have suppurated. Those concerned may have left in disgust.
The thinking behind the ‘reorganisation’ is bureaucratic through and through. According to the Grey Book the non-medical members of the DMTs ‘can suitably be organised in managerial hierarchies and the effective provision of health care will thus depend to a considerable extent on the effectiveness of many thousands of managers’. Incidentally the minutes of DMT meetings are secret. There can be few other instances where an overwhelmingly non-elected body has such power and need give so little account of how it uses it.
The provisions of the Act have now been in operation for nearly 4 years. They seek to define not only the functions of the DMTs but also, in ridiculous detail, those of the RHAs and AHAs. Every conceivable relationship between these bodies, and between these bodies and the outside world, is envisaged, discussed, blue-printed – in the abstract. So abstract are some of the discussions that ridiculous and often mutually incompatible recommendations are made: for instance to ‘increase throughput’ in the wards while cutting down on the number of radiologists or laboratory technicians necessary to ensure any ‘throughput’ at all! No one really understands how it works. No one really knows how or where decisions are made, sometimes not even the Administration itself. Recruiting a new typist becomes a major procedure.
Everybody’s work is scrutinised from above, below and sideways: from ambulance drivers to laundry workers, from medical records officers to catering staff. Space prevents me from going deeper into all this here. Suffice it to say that dissatisfaction is widespread. Not only with salary structures, but with the strains and frustrations caused by the incredible inefficiencies of the system. Seeking to organise everything and everybody from the outside, the system generates a colossal ‘couldn’t care less’ attitude. People withdraw. And the chaos deepens.
This is the bedlam that is now the NHS. The structures and mechanisms have been endorsed by the politicians of both parties. No wonder that the firm of McKinsey & Co. now describe the 1974 ‘reorganisation’ as ‘bureaucratic, overelaborate and cumbersome’. They should know, They played the key role in setting it up!
[Slightly edited for typography and as indicated by square brackets]
An Interview with Maurice Brinton has been posted on-line at libcom.org, along with some more of his Solidarity articles.