Targets, markets and a vision of health

Savi Hensman
By Savi Hensman
12 Apr 2007

The condition of public services profoundly affects not only individuals and families but also communities. State measures to improve such services raise important issues about values and priorities. In health, for instance, what is ‘good’ care for patients, how does this fit in with the public good and how can it be achieved?

The National Health Service has undergone major reforms over the past decade-and-a-half or so. Those who work in or for the NHS now have numerous targets by which their performance is measured. Markets, or market-type systems, have been extended, even for patients not on private healthcare schemes. In the government’s view this is the way forward if efficiency and excellence are to be achieved. But others have questioned these claims.

It would be unhelpful to condemn all the changes which have taken place. For instance, it is merciful and sensible that junior doctors should no longer have to undergo an endurance test based on their capacity to work extremely long hours, and try to act safely while struggling with fatigue.

Likewise it now seems unsatisfactory that injured patients should often have had to wait ten or twelve hours in an accident and emergency department, or staff not even know how infection rates at their hospital compared with others. The pay of GPs having their own practices is now excessive, but some increase was needed to attract more doctors into primary care, where many were on the verge of retirement.

And it would be difficult in today’s world to persuade most people that old-fashioned paternalism by health professionals towards patients, and blatant hierarchy in which white male senior doctors dominate, should not be questioned.

Yet it would also be unhelpful to welcome all aspects of modernisation uncritically. To some extent, the effects have been reduced because professionals and managers have often found ingenious ways (for patients’ benefit or self-interest) of appearing to meet targets while staying within budget and carrying out urgent treatment. In the NHS, things are not always what they seem.

But the changes have had an impact – and it is clear that some of the gains which were supposed to result have not taken place. For instance in some places staff morale is low, there are deliberate delays in treating patients to avoid being punished for ‘overperforming’ and many older and disabled people fail to get the most basic care; and overall more women using maternity services are dying. Nor is this a problem only in England or indeed the UK: throughout the world, apparently scientific ways of organising public services are not living up to expectations. How can this be?

Some NHS reforms are based on questionable beliefs about how humans behave and what they are worth.

The emphasis on controlling work by breaking it down to a set of separate tasks with strict guidelines on how they should be done not only makes privatisation easier, since tender specifications can be drawn up on this basis, but also involves choices on where time and effort should be directed. For instance today, in ‘efficient’ wards, nursing staff often do not have time to make sure that older patients’ basic physical needs are met, such as help with eating if needed, let alone to spend enough time talking and listening to them to find out if they are confused, frightened or need pain relief.

This is inhumane and may not even be economical in the longer term, since lack of care may result in unnecessary health problems and staff may quit or be affected by stress because they feel they have not been allowed to do their jobs properly.

Senior policy-makers are probably influenced by notions of human usefulness and worth based on making money, or helping others to do so, as investors, employees or paying customers. Many older people make great efforts to get by without asking for too much help from public services. Nevertheless they tend to use up a considerable proportion of NHS resources, since obviously they are more likely to get ill and take a long time to heal than younger people.

Language used by some of those who help to shape the NHS, such as ‘bed-blockers’ and ‘frequent fliers’, suggests a certain resentment. Sometimes this is based on lack of imagination and empathy. But attitudes may be affected (sometimes unconsciously) by an assumption that retired people are no longer useful, especially if in their working lives they were low-paid or unpaid and so have few savings.

But to Christians (and many of other faiths as well as most humanists), everyone is of value: human worth is not dependent on owning, buying or selling, employing or being employed. And a good life does not necessarily involve accumulating wealth or enabling others to do so – in fact excessive riches can be harmful to oneself as well as others.

Unpaid caring for grandchildren, other relatives, friends and neighbours, volunteering, appreciating beauty, reflecting on the meaning of life, loving and being loved are important. Many faith traditions positively encourage people to spend time doing what might seem useless, even wasteful, from an economic standpoint. Life is more than food and clothing (Matthew 6.25-33).

The notion that the best way to encourage energetic and skilful work is by setting strict specifications of what is to be done, and rewarding or punishing people on this basis, is also questionable. Admittedly, some believe that this is what religion is about – a God (real or imagined) who is a hard taskmaster, setting numerous and sometimes unreasonable targets, reprimanding those who do not achieve the goals and priorities handed down from above, and casting into the outer darkness those who do not turn themselves around after being warned by his representatives on earth!

A more mainstream Christian view, however, is that people tend to strive for excellence and grow through relationships with the divine and other humans, especially those in need, and indeed with other living things. If doctors are too clubby and wrapped up in ‘old boy networks’, the answer is maybe not to try to impose on them the kind of discipline against which factory workers have rebelled, trying to turn them into robotic beings who do not interact or think for themselves, but rather to encourage them to relate more widely to patients, carers and other professionals.

Nor do they need to become better at ruthlessly competing to cut costs and become profitable, if necessary at the expense of patients, exchanging their passionate interest in health for narrow business-mindedness. Compassion for those who suffer, camaraderie among those who care for them and the encouragement of mentors skilled in doing good can be powerful incentives.

Learning and sharing can be extended beyond a small group without becoming wholly impersonal, and initiative need not turn into chaos if individuals act in the context of community. And compassion can be combined with prudence in using resources. Some of the NHS reforms did in fact take the tack of focusing on relationships with peers and colleagues, service users and the wider public, but these have largely been swept away by a more mechanical, top-down approach.

There are no easy answers to the challenges facing health services today, including getting the right balance between emphasising prevention and treating the sick and injured. Scapegoating should be avoided. What is positive needs to be celebrated, including the commitment of so many people to care and healing rather than death-dealing and destruction, even if there are disagreements on how this can be best achieved. The specialist knowledge and experience of those overseeing and managing the NHS, and the difficulty of their task, should be recognised.

However public debate on public services is important. Christians and people from other faith traditions can play an important part in encouraging deeper reflection on often unspoken (and sometimes unconscious) values and assumptions about excellence in public services, and careful consideration of the views and concerns of those whose lives are most deeply affected but who often go unheard.

Savi Hensman is an NHS user and carer and works in the voluntary sector, largely on health and social care. She is an Ekklesia associate.

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