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?

Over the last several years, thousands of businesses across the country — from big corporations to storefront shops— have used arbitration to create an alternative system of justice. In arbitration rules tend to favor businesses, and judges and juries have been replaced by arbitrators who commonly consider the companies their clients. The change has been swift and virtually unnoticed, even though it has meant that tens of millions of Americans have lost a fundamental right: their day in court. “This amounts to the whole-scale privatization of the justice system,” said Myriam Gilles, a law professor at the Benjamin N. Cardozo School of Law. “Americans are actively being deprived of their rights.”

In this scenario is there anything to protect the customer or the worker as well as the corporation? Of course not.  For companies, the allure of arbitration grew after a 2011 Supreme Court   ruling cleared the way for them to use the clauses to quash class-action lawsuits. Prevented from joining together as a group in arbitration, most plaintiffs gave up entirely, records show. Still, there are thousands of Americans who — either out of necessity or on principle — want their grievances heard and have taken their chances in arbitration. Little is known about arbitration because the proceedings are confidential and the federal government does not require cases to be reported. The secretive nature of the process makes it difficult to ascertain how fairly the proceedings  are conducted.  This, of course, works out splendidly for the companies involved. For the truly injured parties, not so well.

All it took was to add an arbitration clause, something that most employees and consumers do not even read. . Yet at stake are claims of medical malpractice, sexual harassment, hate crimes, discrimination, theft, fraud, elder abuse and wrongful death, records and interviews show. The family of a 94-year-old woman at a nursing home in Murrysville, Pa., who died from a head wound that had been left to fester, was ordered to go to arbitration. So was a woman in Jefferson, Ala., who sued Honda over injuries she said she sustained when the brakes on her car failed.  Just two of scores of such cases.  Some state judges have called the class-action bans a “get out of jail free” card, because it is nearly impossible for one individual to take on a corporation with vast resources.

The redoubtable Senator Warren talks about tricks and traps in the financial system –  this is what she’s talking about?

How did financial products get so dangerous? Part of the problem is that disclosure has become a way to obfuscate rather than to inform. According to the Wall Street Journal, in the early 1980s, the typical credit card contract was a page long; by the early 2000s, that contract had grown to more than 30 pages of incomprehensible text. The additional terms were not designed to make life easier for the customer. Rather, they were designed in large part to add unexpected–and unreadable–terms that favor the card companies. Mortgage-loan documents, payday-loan papers, car-loan terms, and other lending products are often equally incomprehensible. (have a look at your cellphone terms of business, printed in type size too tiny to read).  And this is not the subjective claim of the consumer advocacy movement. In a recent memo aimed at bank executives, the vice president of the business consulting firm Booz Allen Hamilton observed that most bank products are “too complex for the average consumer to understand. And this is all because, according the the daft Supreme Court (about to get very much worse) the media is owned by corporations and corporations are “people”. Do the justices have any idea what they have done?