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!
M.B.
[Slightly edited for typography and as indicated by
square brackets]
