Notes from the Health Factory Part 1. Steve Bushell reports on the latest re-structuring in the supply of health. 'Working For Patients' (the 1989 White paper on which the NHS reforms were based) sought to enhance local management's control over the 'delivery of health care'. What has been called marketisation might be better described as the decentralisation and franchising of a large national firm, the better to respond more ruthlessly to the variations of demand and supply. This empowerment of management has occurred in order to reduce the cost of labour, to remove obstacles to profit in the medical industry, and to ensure a more effective servicing of the 'human resources' of the country, This last point has come about as a reaction to political criticism, but more importantly as an attempt to defuse the critiques of medicine, by ensuring more 'sensitive' medical policing, including the institution of the paraphernalia of 'customer-care'. Naturally enough the first target of the new management has been the medical profession, whose guild power this century has attempted to secure sole rights over the designation and cure of disease. Such an ambition had led to proliferating costs as well as popular disaffection with the service. The new managers have employed rudimentary cost-benefit analysis onto doctors. This undermines 'clinical automy' and ensures that the rationing of the scarce resource known as 'health' is overseen by managers more tuned in to the needs of the State and Economy than doctors who might be moved by common humanity or overweening professional ambition. The response of doctors to this assault has largely been confined to publicity campaigns, although Junior Doctors (paradoxically the most 'skilled' and exploited of the NHS workforce) have threatened industrial action if their hours are not cut to 72 a week. This itself would require them to challenge their own guild tradition by taking on their master consultants. The Industrialisation of Nursing. Nurses make up the largest section of the NHS workforce. The effect of the new managers has been, at first glance, contradictory. The assault on the medical profession is applauded by those nurses who see the critique of medicine as an opportunity to advance their own claims to professional status. Hence the production of 'holism' as a (spurious) opposition to the 'medical' model in the treatment of sickness. 'Holism' has become the ideology of all the proliferating para-professionalisms who are displacing the medical profession's monopoly as purveyors of health. As a result, some aspirant 'professional' nurses have allied themselves with the new managers. However, nurses themselves are responsible for a large wage bill and use up a lot of the resources involved in treatment of the sick. This puts them in line for strict managerial control. Before the developing crackdown in the 70's & 80's nurses and doctors used resources by and large as it suited them. Budgets were based on last year's costs plus a bit for inflation. This relaxed attitude is a distant memory in the current tight world of self-administered budgets, with sisters and charge nurses given responsibility for devolved accounting on the wards. This is represented as a conferring of autonomy (which panders to aspirant ' professionalism') but in reality means that more and more of the nursing craft becomes tied to the needs of money, and the money-managers. As management, budgeting and cost control become part of the job of nursing the possibility of using 'professional knowledge' against the diktats of finance recede because increasingly the definition of a 'professional nurse' is one who takes on such financial responsibilities. The much-prized 'status' which the new managers claim to grant is little more than the acceptance by some nurses of the role of surrogate accountant. At the same time new work study systems have been implemented which, far from pandering to the illusions of those seeking professionalism's mitre, point to a thorough-going Taylorisation of nursing. I will describe two systems currently operating at the Leeds General Infirmary and at the Huddersfield Royal Infirmary. G.R.A.S.P. "Time is money". Benjamin Franklin. This is a system developed in the U.S. It stands for Grace (name of US hospital), Reynolds (source of cash for the study), Application and Study of PETO (Poland, English, Thornton and Owens - the name of the researchers who organised a work study of nurses in the American paediatric ward). The PETO study was done by timing (without the nurses knowledge) various nursing actions in order to arrive at a 'time' for these actions. These times were then used as an indicator of the intensity of work on the ward and therefore used to affect the admissions policy. (In the past admissions were based on bed availability, now work intensity was to play a role). From this original study developed the idea that all nursing actions could be timed and that each patient on a ward could be assessed to give a figure for Patient Care Hours (the amount of nursing hours a patient requires). In the US this measure was seen as an exercise in costing patient care by introducing a specific nursing labour component into it. (At the moment in the LGI there are no plans, as far as I know, to use the study for this purpose, but it can't be ruled out for the future). In the LGI GRASP is used as a method of assessing the amount of nursing labour required on each ward. The original studies however, are not performed by work engineers but by the senior nurses on the ward themselves. On the basis of their knowledge and experience they give a time (in decimal hours) to common activities on the ward. For example, oro-pharyngeal aspiration is given a value of 8 - this means that over a 24 hour period any patient requiring such treatment will take up to 8/10ths of an hour of a nurses' time. Time values are given for practically any task you could imagine on a hospital ward - and it is the nurses themselves who disclose the activities. The result is a chart (see diagram) which outlines all the possible time-values on that ward for each patient. The time-value for the activity is fixed by the senior nurses - the job of the nurse actually doing the work is to indicate which activities are necessary for the particular patient. The time-values of these activities are added up by the nurse in charge of the tream thereby arriving at a number of Patient Care Hours (PCHs) for each patient. This is compared with the actual number of Nursing Care Hours available each shift. In common with factory work study methods fatigue allowances are given, but rather than the detailed assessments of the industrial schemes 13% is given across the board because the hospital is old. There is even a time-value given for filling out the GRASP form - a possible future contradiction as the time and effort of keeping accounts eats into the time and effort necessary to attend to what they purport to be an 'account' of. Regardless of management's explanation for the introduction of GRASP (that it is intended to improve staffing levels), in effect GRASP is about putting a price on each nursing activity (a 'unit cost' worked out on the basis of the grade of the nurse and the time taken). This allows them not only greater control over the nurses' working day, but enables them to start the process of increasing the nurse's effort for the same wage by exerting downward pressure on the GRASP times (which although nominal have a vague relation to the actual work done). So far this system is still at the data-collection stage. Every week management receive raw figures on the time values of each patient on the ward. As well as team leaders filling out PCH forms, they are expected to fill in a questionnaire on the adequacy (or not) of the care delivered. This is then used by management to check that if there is a significant disproportion between PCHs and NCHs that the inadequacy of care is noted by the team- leader. Along with spot-checks by the GRASP committee this is simply another way of making sure the system is 'properly' enforced, by making it very difficult to use the figures to justify, for example, more staff on the basis that one is already working too hard. Nursing Information for Change Mangement. (NISCM) This system seems to have been developed by a firm of management consultants in the UK, and applied by the Huddersfield Royal Infirmary who now have taken a patent/copyright on their application (CPRS - Care Planning and Recording System) The HRI is important because it was one of the hospitals used by the government as a guinea pig for its Resource Management Initiative - a measure involving radical devolution of budget holding controlled by networking information technology. The NISCM provides a way for computerised wards to get an immediate picture of staffing requirements (and its costs) in order to ensure maximum staff 'flexibility'. Unlike GRASP it is not a system I have worked under so I can only describe it from the documentation which has fallen into my hands. The system describes itself as giving the 'nursing profession' the ability to 'express their work and its varying demands in simple statistical terms'. It involves setting up a patient classification system not unlike GRASP but ranking patients into 'Demand Groups'. These Demand Groups are based not so much on the severity of the patient's illness as the amount of nursing time they require. The model suggests that there can be 5 batches of demand groups per ward, although in the name of flexibility the system will admit more. The definition of each group is undertaken at the ward level. At the end of each bed is a chart upon which the nurse records the time spent with the patient, by ticking off the activities performed. (each activity has a computer code). An average time spent for each patient is then established. Re-calculation of these averages is to take place 4 or 5 times a day, so staff and management can work out how much labour is required, and of what kind each shift. Workload calculation is obtained by multiplying the number of patients in each 'demand group' by the average time for that group. The use of computers enables activities per patient to be recorded and stored. 'Activity analysis' of staff is conducted by each member of staff carrying 'Activity Diaries' in which they record the number and nature of the activities they perform. This is only done when 'Activity Sampling' is being performed in order to check up that the skill mix etc. is 'appropriate'. The literature reveals 5 purposes for such an analysis : "To establish the proportion of time spent on direct care. To establish the proportion of non-professional duties. To establish the extent of the "mis-use" of staff's time. To establish the current work pattern for Skill Mix re-profiling. To establish a comparison of duties between staff grades". When fully computerised the system will provide management with a permanent 'window' on ward activities without being physically present. They will be able to re-deploy staff according to the 'busy-ness' of the ward revealed to them by the auto-surveillance of the nurses themselves. Duties will be 're-aligned' (including nursing staff taking over junior doctors' duties in the event of an hours reduction), and non-qualified staff (nursing Auxiliaries and Health Care Assistants) could be employed working on what was once qualified nurses' territory. Much tighter job descriptions will be attached to nursing grades in an attempt to avoid the sort of problems which generated the 4 year Clinical Gradings dispute (1). In the light of debates on modern Taylorism (see Here & Now No. 12) it is instructive to note that one of the selling points used by the management consultancy firm is that the work study is performed by themselves, thereby removing the cost of employing time study engineers. Responses. Both systems intend to "rationalise" nursing work on the wards. ("Rationalise" means, here, both to drive down the costs of nursing labour and to simplify, by fragmentation, the nursing craft in order to render managerial control over the nurse/patient relationship more comprehensive). Even 'indirect', 'psychological' and 'emotional' support are given time values (see diag.). The opportunity for 'resting' is diminished because management can re-deploy staff to busier areas of the hospital. Labour discipline is tightened up simply with the knowledge of the scheme's existence. It's well-known that management intend to use the scheme to justify a reduction in qualified staff and their replacement with unqualified (and cheaper) Health Care Assistants, justifying such cutbacks on the ground that at least some proportion of a trained nurses' time is spent doing 'unqualified' tasks and new schemes will 'scientifically' prove this. The intensification of 'costing' - and by giving everything that can be measured a 'time-value' and filling up the accumulated time-value with NCHs means that which cannot be measured has no place or time on the ward or shift. In other words the more managerial/technical control, the less convivial, sociable relations between staff and patients. Managed hearts doling out 'emotional support' according to an internal stop-watch are more likely to dispense such support as a rationed task, unless the actual purpose of these schemes to create a climate of measurement on the wards can be deflected. Such deflection is patchy, confused and contradictory but likely to grow rather than diminish. (Here I can only talk about GRASP). Because the scheme is still at the data-collection stage no dramatic effects have occurred either in terms of 'improving staffing levels' (management's justification of the scheme to staff) or re-composing 'skill-mix' (management's justification of the scheme to themselves). There is widespread awareness amongst nurses that GRASP will be used to split-off 'non-qualified' jobs from qualified staff in order to reduce trained nurse numbers and increase Health Care Assistants. There is some resentment about the reduction of the nursing craft to measurable time-values, both by those hankering for a 'professional' ideal, and those who just don't trust management. Active resistance in the form of refusal to fill out forms, or rendering them useless by always giving maximum times, exists, but is dispersed, and very vulnerable to being identified and neutralised by senior nurses or the GRASP committee. Passive resistance is much more engrained with nurses treating the scheme as just another managerial ploy, and not letting it have any effect on what they do on the ward. When the system actually starts to operate, and nurse numbers are reduced, conflict between the desire of nurses to have a 'happy' ward, and that of managers to have a 'tight' one can only intensify. However further reduction in staffing will be the one weapon management can use to force compliance with the GRASP criteria. A side-effect of reducing trained staff is that the replacement staff of HCAs are likely to be more militant as their numbers and responsibilities increase, and their qualified overseers more disgruntled by their loss of autonomy in doing the job and their managerialisation. (The bait of 'primary nursing' - where each patient is designated a specific qualified nurse is an attempt to hang onto a more humane system, and is given support in John Major"s Patient"s Charter, but it simply does not work under current conditions of over-work and speed-up of patient through-put. Officially it has been in existence on my ward for 1-2 years, but in practice it is put aside when things get busy). Trades union attempts to confront it been at the level of wanting to be 'involved' in the timing etc. Sindone by nurses who are their members, they have been outflanked any boycotts, even if they wanted to. Further Recompositions. The overall tendency of the reforms has been to accelerate the process of hospital specialisation (centralising specific kinds of health care within a particular hospital- 'niche- marketing' in ad-man's terms). This has led to an alteration of the composition of patients treated by 'general' hospitals, an alteration which exposes deep changes in the social role of such institutions. What has happened (and what continues to happen) is that sectors of chronic and long-stay patients have been sub-contracted to the private sector for 'care'. Many of the elderly and very dependent patients have been transferred to private nursing homes, although the cost continues to be carried by the State (although this is means-tested). Part of the reason for this is the hospital's shedding of the role of 'moral universe' established by the necessities of the C19th capitalism. The hospital is no longer either the officially-sanctioned repository of 'charity' (2) nor part of the State's armoury of social regulation through 'care' - that role has been dispersed into the 'community' (3). The modern hospital is less and less a site of 'care' in that non-specific sense of a place people go to when they are sick, and more and more a purveyor of customised health supplies. Emphasis on 'Value-for-money, medical audit and work study systems betray this development from general 'care' provider (with an often haphazard understanding of the results of 'care') to a specialist health factory applying cost- benefit analysis to all its operations. 'Health' from being something prescribed by the monopoly of the medical profession now has a superfluity of suppliers, from wholefood restauraunts, fitness centres, alternative medicines to health visitors, social workers and health educators. The contemporary hospital recognises its niche in the market, that of, high- tec intervention, and consequently has begun to shed the responsibility of antiquity. At the same time indicators are being established which, for the first time, will provide costings for this scarce 'resource' thereby furthering the process which locks being alive within the conditions of scarcity. Notes. 1) After sporadic strikes and actions throughout the NHS in 1988 the NHS management determined a new set of grades for nurses, which connected rates of pay to responsibility. This led to thousands of appeals which clogged up the NHS Grievance Procedure. 4 years later not all appeals have been heard. 2) The origin of Leeds Infirmary (like other infirmaries in the U.K.) emerged as an attempt to promote sensible charity and overcome the divisions in the upper middle classes which could trace their source from the dissolution of the monasteries; "It is a recommendation of this scheme, that the benefits of it are not confined to any particular sect or party in religion; but that it is equally open to all who may stand in need of it." Joseph Priestley. 'A Sermon on Behalf of the Leeds Infirmary.....' 1768 The infirmaries also marked the beginning of calculated charity which betrayed a poorly concealed social engineering purpose. In the same sermon Priestley appealed to the enlightened self-interest of his audience. Give thoughtlessly, he warned, and: "with the best intention in the world, you may be doing nothing better then encouraging idleness, profligacy and imposture; but in the cases for which this infirmary is provided, there can be no imposition, and avarice has none of its usual paltry excuses to avail itself of." 'A Sermon...' 3) The regulation of lifestyle, which was always a part of the purpose of 'caring' institutions has become far more diffuse and subtle than the use of the fear of incarceration. Health education, public health programmes, and medical screening have become more effective means of penetration into social life. This is not for the archaic purpose of moral regulation on the basis of certain Christian or national mores, but as the inevitable result of the need to reduce the costs of supplying the health commodity. However, such 'community health', far from increasing automy, only further exacerbates dependencies upon professionals and experts, confirming the idea that 'health' is something these people sell (albeit through state insurance). It asserts an identification of being alive with the ministrations of the para-medical complex, leading to a view of the body as a system needing to be 'worked-on' and perpetually up-graded like any other piece of industrial technology. The ideology of 'human resources' is only the frank recognition that a person has now become a resource which has to be managed. 'Holism' in this context, simply acknowledges the need for management to encapsulate the whole of human experience, the better to avoid unmanaged protests. The success or failure of such ambitions rests, not only on active resistance, of which there is plenty, but also on the creation and sustenance of convivial and unofficial ways of living (however partial to the whole of a person's life). In the U.K. these still remain confined to the byways, the sidings, the back-waters and the diminishing commons of the country. This is Part 1 of a revised version of an article originally published in Reader III of the (German) Wildcat papers of 'Militant Research'. Part 2 will discuss some of the fragmented struggles in the NHS, including the emergence of 'whistleblower'. From Here & Now 13, Glasgow, Autumn 1992