Challenging Medicine

David Kelleher, Jonathan Gabe, Gareth Williams

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135195106
• Edition: 2
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This highly topical and controversial book presents a lively re-appraisal of the current changes to the health service and analyzes their effects on the status and practice of health professionals.

Modern medicine is a powerful institution. With the help of highly-developed drugs and surgical techniques, it promises to relieve suffering, improve the quality of life and extend the life-span. Conversely, it is expensive for the governments, insurance companies and individuals who pay for it and sometimes appears to be insensitive to the needs of those for whom it provides. And while recent restructuring of healthcare delivery services has provided medical practitioners with new challenges, there has been very little consideration of the range of pressures that they now face.

Edited and written by experienced medical sociologists, this book draws together analysis of a number of diverse challenges to medicine, and provides original debate on the challenges posed from within medicine from nurses and managers and alternative practitioners, and from outside by self-help groups, the women's movement and the media.

1 From tribalism to corporatism

The continuing managerial challenge to medical dominance

David J. Hunter

In the case of prophesizing, or projecting trends into the future, due caution requires being aware of the danger of mistaking short-term, ephemeral trends for long-term trends and cyclical change for linear, progressive change.

(Freidson 1993)

Introduction

A constant theme running through successive reorganisations of the NHS since the mid-1970s has been the search for improved management. The search has been accompanied by growing centralisation, with occasional lapses into decentralisation and the application of market principles to the delivery of care (Hogget 1991; Hunter 1994). As Hoggett observes more generally in the restructuring of the public sector in Britain, elements of decentralised, hands-off, market-based approaches to delivering public services have been ‘dwarfed by visible elements of centralization … and the extended use of hands-on systems of performance management creating a form of “evaluative state”’ (Hoggett 1996).

Since Labour took office in 1997, these developments have both intensified and been modified. Most recently, attention has focused on combining a strong performance management culture with competitive impulses resulting from the application of market-style practices and the engagement of the private sector in the direct provision of services alongside state-run ones. However, following political devolution to Wales and Scotland (it is presently suspended in Northern Ireland), there is growing divergence in health policy within Britain (Greer 2001). What follows describes developments in England, and although there is some overlap with those occurring in Wales and Scotland the relationship between management and medicine in general terms is less fraught and adversarial in those places.

Thirty years ago, in his classic analysis of the organisation of health care systems, Robert Alford characterised reformers as falling into one of two camps: ‘market reformers’, who hold state involvement in health care and bureaucratic complexity responsible for the ills apparent in health care systems; and ‘bureaucratic reformers’, who claim that the defects are all the fault of those who subscribe to markets and competition which obstruct the orderly planned provision of effective health care and have no place in medicine (Alford 1975). The successive waves of reform that have swept over the National Health Service (NHS) represent varying mixes of these two competing notions. The Conservative government, which held office for some 18 years from 1979 to 1997, introduced the internal market changes which put policy-makers firmly in the camp of Alford’s ‘market reformers’. Towards the end of their term of office, the Conservatives retreated from their market-based ideology and reintroduced a range of more orthodox bureaucratic reforms which tightened the centre’s managerial grip on the NHS. When Labour took over in 1997, its approach to the NHS during the early years could firmly be located in the category of bureaucratic reforms. But by 2001 or so, the government began to move in the direction of devolution and localism accompanied by the introduction (or, to be more precise, re-introduction) of market mechanisms and competition thereby putting it in Alford’s first camp as well.

If there has been a consistent thread running through the numerous changes imposed on the NHS, it has been a never-ending fascination with economic rationalism and a belief that market-style incentives are necessary in some form to temper the excesses and producer-focused nature of public sector practices (Evans 1997). There is little to divide the two main political parties on this point. Nor is the issue confined to the UK. The prevailing wisdom that has taken root in many countries in recent years is that as long as the state controls the funding of health care then it matters rather less who provides it. Indeed, the UK government has pushed such pragmatism further asserting that what matters is what works, not whether it is publicly or privately managed and delivered. The introduction of pluralism and a mixed economy of care are believed to inject healthy competition to drive up standards and make services more responsive to users. Public–private partnerships are in high fashion as exemplars of the end of ideology, demonstrating a pragmatic commitment to efficient and effective delivery of care.

But, as Alford argues, reform strategies based on either market or bureaucratic models are unlikely to succeed because they neglect the way in which groups within health care systems develop vital interests which sustain the present system and vitiate attempts at reform. The two types of reform are not mere ideological constructs. They

are also analyses of the structure of health care which rest upon different empirical assumptions about the nature and power of the health profession, the nature of medical technology, the role of the hospital, and the role of the patient … as passively receiving or actively demanding a greater quality and quantity of health care.

(Alford 1975)

It is a failure on the part of policy-makers to appreciate this feature of both market and bureaucratic reform models that accounts for the disappointment that quickly sets in when reforms do not match expectations.

Alford’s ‘structural interest’ perspective remains useful in understanding the organisational life of health care systems regardless of whether they are predisposed to market or bureaucratic ideal types, or a mix of the two. According to this view, powerful interests benefit from the health care system precisely as it is. This applies regardless of whether it is a US-style market system or a UK national health service. In either model, the ‘dominant’ interests (clinicians – the ‘professional monopolists’) manage to do rather nicely and exercise considerable power to preserve their privileges. For their part, the challenging interests (managers – the ‘corporate rationalisers’) are party to a constant expansion of their functions, powers and resources justified by the need to control the professional monopolists. Meanwhile, the goal of easily accessible, low cost and equitable health care remains elusive and the source of repeated reform efforts on the part of frustrated policy-makers restless for results.

An intrinsic feature of successive reforms has been the role of management and managers as the means by which the changes, whether market-based or of a more bureaucratic type, are implemented in pursuit of the desired goal. A principal feature of the evolution of management in the NHS has been the struggle between doctors and managers for control of the health policy agenda. Each of the major reorganisations that have convulsed the NHS since 1974 has sought to shift the frontier between medicine and management decisively in favour of management. The various reorganisations all have in common the attempt to modify the individualism, and often sectionalist tribalism, which characterises medicine (Freidson 1993), and to subject it to the corporate disciplines of management (Griffiths 1983; Hunter 2002). On one reading, it can be argued that the reforms that have been taking place almost continuously since the early 1990s have virtually completed the bureaucratisation, or proletarianisation, of medicine and its penetration by management (McKinlay 1988). Doctors are being compelled to account for their working practices which have hitherto remained hidden from public scrutiny and to subject themselves to regular assessment and validation to ensure that their skills keep them ‘fit for purpose’ in an age of ever-greater complexity and rapid technological change. At the same time, exercising professional judgement in respect of who should receive clinical treatment is being superseded by a managerial target culture which places a premium on meeting nationally set targets over waiting times and access to care. In practice, except where there is non-compliance or ‘gaming’ to meet targets, these targets take precedence over clinically defined priorities in respect of individual cases.

Many observers believe that such practices, irrespective of their merits and alleged success, are having a corrosive effect on the medical profession, in particular undermining professional values and an ability to act in accordance with these values. For example, Simon Jenkins believes that the Thatcher reforms of the NHS in the early 1990s ‘left an uneasy feeling that a professional relationship of trust between patient and doctor and hospital and community had been broken’ (Jenkins 1995). He contrasts these managerial reforms with Aneurin Bevan’s original model for the NHS: ‘His health service was concerned simply with offering doctors and nurses an administrative apparatus “for them freely to use in accordance with their training for the benefit of the people of the country”’ (Jenkins 1995). But therein lies the rub for recent governments, often goaded by sections of the media and a more critically aware public, who have remained unconvinced that the professional ethos is as altruistic and selfless as it is portrayed to be. For them, it is an appealing, but ultimately flawed, myth. They suspect, not without some justification, that the NHS has been run more for the convenience of those providing services than for those receiving them with the result that restrictive practices abound.

The Kennedy report on the Bristol Royal Infirmary, following the fatalities in the paediatric cardiac surgical service, pointed to the ‘insular “club” culture, in which it was difficult for anyone to … press for change or to raise questions and concerns’ (Bristol Royal Infirmary Inquiry 2001: 302). Furthermore, such a culture was not unique to Bristol but evident across the NHS. Another more recent high-profile inquiry into the deaths of hundreds of patients under the care of general practitioner (GP) Harold Shipman was also extremely critical of the way complaints against doctors were handled and of the weaknesses in rooting out poorly performing doctors (The Shipman Inquiry 2004). The entire system of professional self-regulation has come under the spotlight and pressure brought to bear on the medical establishment to remedy its own practices or risk having its freedom to self-regulate replaced by external scrutiny.

Whether, to use Alford’s terms, the professional monopolists have begun to see their power base significantly curbed in recent years in the face of the challenge from the corporate rationalisers is a matter for empirical inquiry and the subject of some debate among researchers (Hafferty and McKinlay 1993; Harrison and Pollitt 1994; Harrison 1999). The questions being addressed include: How far is medical dominance under serious or lasting threat? Will the changes irreversibly modify the prevailing power structures in health care systems? Or is the relentless managerial onslaught causing doctors to pause and regroup around a set of countervailing practices and tactics which may be aimed at blunting the impact of the new managerialism or, more radically, wresting back control by colonising the management function and becoming the new managers in future?

It is the purpose of this chapter to explore these questions by charting the managerial thrust of the NHS reforms as these have been pursued since the 1980s when the management grip really began to be felt. The analysis draws upon recent studies of managers and management in the NHS and their impact on the medical profession. The chapter is organised into three sections. First, there is a brief review of the progression of NHS reform through the 1980s, 1990s and early years of the twenty-first century with particular emphasis on developments since 1997. Second, the impact of the management revolution on the medical profession is considered. In the final section, an attempt is made to look beyond the immediate preoccupations of doctors and managers and consider a scenario that would enable doctors to reoccupy, albeit in a new guise, territory they increasingly feel is being wrested from them. The central theme of this section is that although management and managers are clearly in the ascendancy, and have been for many years, it remains possible for the overall balance of power still to operate in favour of doctors and the medical paradigm to which they subscribe (Mechanic 1991; Harrison 1999).

The rise of managerialism

Management is a fairly recent phenomenon in health care systems and follows from a perception by policy-makers of all political hues over the years that health services, like other public services, have tended to suffer from being over-administered and under-managed thereby failing to hold professionals to account (Hunter 1980, 1998; Harrison et al. 1992). Excluding the first major NHS reorganisation in 1974 which is not considered here, there have been three significant waves of change that are briefly described below. These have tended to roll into each other with the result that the NHS has been in the grip of a permanent revolution for most of its life.

From consensus to general management, 1982–1988

Bevan’s model of the NHS in 1948 was the profession-dominated one which survived largely intact until the first half of the 1980s, when the model was questioned by a businessman, Roy Griffiths, the then head of the supermarket chain, Sainsbury’s. He was brought in by the government of the day to advise on the future management of the NHS. Griffiths sought to strengthen management and to shift the emphasis, and ostensibly the balance of power, from producers to consumers, in line with commercial practice. He was tapping into a trend that was becoming established globally not only in health care but throughout the public sector. The tenets of what became known as ‘new public management’ (NPM) entered the public sector reform lexicon (Hood 1991; McLaughlin et al. 2002). It was notable for the following distinctive features or doctrines:

• explicit standards and measures of performance

• greater emphasis on outputs and results

• disaggregation of public bureaucracies into agencies operating on a user-pay basis

• greater competition through use of quasi-markets and contracting

• stress on private sector styles of management practice

• stress on performance incentives for managers

• stress on discipline in resource use and cost improvements

• emphasis on the public as customer.

Of particular importance was NPM’s emphasis on standard setting, performance management and target-setting in the sphere of professional influence. But Griffiths went further in his critique of NHS management. He diagnosed the management problem as having four components: (1) management influence was low in relation to clinicians and medicine; (2) the managerial emphasis was on reacting to problems instead of anticipating them; (3) maintaining the status quo was seen as the extent of the management task; and (4) the NHS was producer, rather than consumer, oriented (Harrison et al. 1992).

Unlike previous reorganisations, the Griffiths proposals were more concerned with changing cultures and the prevailing balance of power than with rejigging structures. Intended explicitly to modify the chemistry and balance of power between the key stakeholders in the NHS, the prescription offered by Griffiths, and accepted wholesale...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• Notes on contributors
• Preface
• Understanding medical dominance in the modern world
• 1 From tribalism to corporatism: The continuing managerial challenge to medical dominance
• 2 The challenge of nursing
• 3 Litigation and the threat to medicine
• 4 Television and medicine: Medical dominance or trial by media?
• 5 The alternatives to medicine
• 6 Self-help groups and their relationship to medicine
• 7 Lay knowledge and the privilege of experience
• 8 Sex, gender and medicine: The case of the NHS
• 9 Attacking the foundations of modern medicine? Anti-vivisection protest and medical science
• Index