On this blog we have discussed the power of the college and university administrators and the corresponding loss of power of the academics and university workers. In healthcare there has been a similar revolution, introduced under the guise of unquestioned ‘best practice’. It is seldom discussed or debated.
The advent of neoliberalism (or Thatcherism) in the 1980s, a reaction against Keynesian economic policy and the welfare state, led to the importation of management practices – managerialism – from the private to the public sectors, together with radical neo-liberal cost cutting and privatisation of social services.
Managerialism is defined by two basic tenets: (i) that all social organisations must conform to a single structure; and (ii) that the sole regulatory principle is the market, the dominant criterion for decision making. Other humane criteria, such as loyalty, trust and care have been devalued and viewed as anachronisms. Instead there are formal procedures or standards, performance indicators, budget end points, efficiency markers and externally imposed targets.
With these managerialist principles and practices have come standardisation, market-style incentives, devolved budgets and outsourcing, replacement of centralised budgeting with departmentalised “user-pays” systems, casualisation of labour, and an increasingly hierarchical approach to every aspect of institutional and social organisation. Professional managers can be overtly hostile to the values of health care professionals and the missions of health care organizations. Bullying has become more widespread, and individuals are given no discretion or autonomy. Loyal long-term staff are dismissed and often humiliated, and rigorous monitoring of the performance of the remaining employees focuses on narrowly defined criteria relating to attainment of financial targets, efficiency and effectiveness.
The result of all this is that humanity has been excised from a humane profession.The result has been a shift in power from clinicians to managers and a change in emphasis from a commitment to patient care to a concern with budgetary efficiency. Increasingly, the priority is the reduction in bed stays and other formal criteria, and everything is about time and money. Older and chronically ill people become seen not as subjects of compassion, care and respect but as potential financial burdens. The system is still staffed by skilled clinicians committed to caring for the sick and needy, but it has become increasingly hard for these professionals to do their jobs as they would like.
Meanwhile, health care managers have become increasingly richly rewarded, apparently despite, or perhaps because of the degradation of the health care mission over which they have presided. The system threatens primary care, where doctors are allowed a small, fixed time in which to deal with the human beings in front of them. This interferes with doctor-patient relationships, reduces the training and education of (mostly foreign immigrant) nurses and seriously affects morale. Vulnerable patients become more vulnerable, staff turnover mounts, whistle-blowers are penalised and capital equipment, such as MRIs are overused unnecessarily to enhance income.
In short American healthcare governance lacks accountability, transparency, honesty, and ethics. In some cases the leadership is ill-informed, ignorant or even hostile to the health care mission and professional values. It is incompetent, self-interested, conflicted, sometimes even corrupt. If you change the nationality from American to Brotish, much the same observations can be made. We are being dehumanised, desensitized and treated like numbers. (adapted from a longer article by Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University).
We are being dehumanised, desensitized and treated like machines or objects. People worry about the mechanization of the world and the growing use of artificial intelligence and robots, but, properly programmed, these “creatures” might well prove better, more thoughtful, kinder and more thorough caregivers and administrators than the present lot of bloodless number- crunchers.
Is all this exaggerated? Do you recognise it?
The classic defence of neoliberalism is the alleged benefits of competition. In this case, healthcare providers will try to provide the best service for the lowest price. If people don’t like their existing healthcare provider, they can go elsewhere. Companies have a right to make a profit, even if it comes at the expense of more humane benefits such as loyalty or treating employees well.
But sometimes the market isn’t competitive. If you have been hit by a car, and are bleeding out on the street, the ambulance has no choice but to take you to the nearest hospital; the hospital in question can charge the insurer as much as it likes for emergency care, knowing it must get reimbursed. That’s not to say there are no benefits of competition. Its simply to point out that the government has a duty to intervene when the benefits of market competition cannot be realised.
Nor is managerialism a natural result of the economy of our time. As you quite rightly point out, this is a recent phenomenon. There is evidence to suggest the era of tight cost-cutting and ruthless hire and fire policies is coming to an end. Across the developed world, the welfare state is diminishing in breadth and scope due to the rising cost of pensions, which has made politicians inclined to cut elsewhere. This has meant that when people search for a job, they don’t just look at the salary as they did in the past. They look at the company’s reputation for being an pleasant employer to work for. Being an equal opportunities employer is particularly important. As the state is rolled back, employers have realised that it is their responsibility to look after their employees.
So in short, you are right. There has been a rise of neoliberalism in corporate management. The relatively neoliberal approach to healthcare policy in America is highly flawed. But I would be optimistic for the future. If nothing else, the rise of social media has made it easier for mistreated employees to communicate and share their stories with the wider public. The public will always demand support for them in their working years, and if the state won’t or can’t do it, the employers will have to.