Can the important deficits in our NHS be adequately remedied by more money and staff? If not, why not? David Zigmond suggests that a brief survey of the past 100 years may clarify
It is hardly disputable now that our NHS has “poor performance” compared to other high income countries in important areas, so the election debate shifted to a kind of contest as to who will make a better bid for the banking, training, and recruitment of our service. Now that the Conservative party have won the UK election, even if they can address these problems of funding and resources clearly and positively, will there still remain outstanding problems? What about the kinds of deficit and damage that we have recently incurred, yet now cannot simply “fix” with more money, staff, and equipment?
The blight of morale in many sectors of our NHS is one such complex problem. Many will say, correctly, that this serious malaise is aggravated, and substantially fuelled, by financial austerity: there is little doubt about this now. And it is easy for most of us to understand the stress of being expected to do too much with too little. It is all too easy, therefore, to conclude that the simple and clear remedy is to increase investment.
Yet while such an explanation and prescription is clearly necessary, it is in many ways not sufficient. For most experienced NHS practitioners—together with other veterans across other welfare services—know that there have been greater yet subtle losses to their service, but of a human rather than material kind. These losses do not receive the focused attention that disputes about money generate. They are of professional and personal ethos, trust, fraternalism, creativity, identification . . . and thus any deeper work satisfaction and élan vitale.
The loss of these very human vagaries has effects far more serious than mere malcontent: the unhappiness is deep and complex, and leads ineluctably to a malfunctioning and impoverished workforce. So our staff increasingly break down, get ill, seek chemical comforts, give up, or—shockingly—take their lives. The many tales of all these are legion.
These qualitative human losses have paralleled and accumulated with our serial NHS reforms, now for 30 years. We need to understand the nature and history of these processes if we are to have any success in repairing the damage, and then securing those repairs. More money and more practitioners alone will again drain away with a kind of tragic inevitability.
So what has happened, and why? Here a long view is worth taking.
1) Pre-1948: Individual capitalism and charity. Each man for himself
Before the NHS in 1948 most doctors worked among wealthier populations where they could be paid. The poorer and much larger majority of people therefore had very little access to medical help. There were many singular exceptions provided by charities, religious organisations, and remarkable proto-socialist doctors, but the overall trend was unmistakable: most doctors worked either for themselves or for small, profitable groups, operating like small independent shopkeepers.
This guild or small shopkeeper culture may have incorporated some vocational spirit toward individual patients but remained, mostly, protectionist at a social level. That is why most doctors (or at least their representative BMA) fought so hard against the founding of the NHS. At the time it seemed unlikely that doctors would mostly settle with, and for, this revolutionary reconfiguration of their work: many experts then were pessimistic about the viability of this new NHS.
2) 1948-c1990: Social and vocational medicine. We’re all in this together
Yet the sceptics so obstructive to the launching of the NHS were emphatically proved wrong. In hindsight we can now see how remarkable was this unprecedented and rapid reform. There were individual failures, of course, but most practitioners and institutions were guided and motivated by an often unspoken sense of social vocation. There was little reference to contracts and no inspections, commercialised competition or commissioning, or metricised appraisals.
This 40 year period may, from today’s perspective, seem remarkably lax, unincentivised, and unmanaged. In a way this is true. It is also true that demands and expectations were then lower. Even so, most veteran practitioners would say that this pre-1990 period was one of greater work efficiency due to its better personal relationships, trust, and morale. And then the more seamless and synergistic relationships that could flourish between its operational groups. We all had a clearer sense of belonging with and belonging for. So what happened?
3) 1990-present: corporate capitalism and micromanaged medicine. The system will decide
In short, this last and current period can also be denoted by healthcare via the rising culture of neoliberalism and systems of cybernetics. Or, in more ordinary language: markets will propel and decide, and computerised systems will micromanage.
Here was a new concoction—a potent mixture of culture, ideology, and new technologies that, in effect, said: “Welfare services cannot possibly provide their best by relying mostly on the personal motivations, skills, relationships, and judgments of those who work in them. That is far too capricious and unreliable. We must, rather, incentivise by introducing competitive pseudomarkets. We can further ratchet up quality and value for money by computerised micromanagement. This will instruct and monitor all employees, and then, where necessary, sanction or eliminate.”
These reforms were first unleashed in the heyday of the Thatcher government, a regime with a quasi-religious belief in the liberation of markets, yet the astringent external governance of welfare. Despite the increasingly evident destructive effects over these 30 years, each successive government has colluded with, elaborated, or amplified these Thatcher-era initiatives.
So what has been the result? It is mixed, but mostly not good. Most investigations conclude that the marketisation has brought inefficient bureaucracy, perverse incentives, and mistrustful fragmentation of services. There is little evidence of greater healthcare efficiencies or better motivation.
There has been similar research indictment of the policed regulation and inspection aspects of micromanagement. While it may identify the few egregious individuals who need calling out, we create a far greater problem among the rest by generating a mistrustful—often hostile—environment with an enormous burden and distraction of compliance tasks and bureaucracy. Most healthcarers find this not only unintelligently unhelpful but divisive, dispiriting, and exhausting of their limited energies. The net effect, again, has been negative.
Such negative effects can be illustrated by a metaphor: our earlier NHS (era 2: social and vocational medicine) was handled more like a living tissue—with understanding, care, nurturance, and protection it would mostly grow to produce a natural synergy and balance between its parts. In contrast, our current NHS (era 3: corporate capitalism and micromanaged medicine) is approached, rather, as an inanimate mechanical object—a motor engine, say—that must be designed, engineered, and manipulated to surrender the performance we choose and command.
What has this led to, in human terms? Well, it has yielded us the rootless, lonely, fractious “no one knows anyone but do as you’re told” culture. Here, now, data and metrics displace personal understanding; corporation eclipses vocation; nuanced judgment, initiative, and collegial trust are all needlessly pushed aside by the blunt rigidity of (often commercialised) corporate contracts.
The personal warmth, spirit, and reciprocal nourishment—the essentials to sustain our difficult work over long periods—is starved and dies. We have removed the metaphorical human heart of human warmth and inclusion, then replaced it with a mechanical heart that can only pump to order.
That is why we now have such serious problems with NHS practitioner morale and then staffing. Money may easily purchase short term staff, but it will rarely secure us veteran vocational doctors.
David Zigmond is a GP in London.
Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.