Image: "Taylorism", Flickr/Lars Plougmann
We need to “do more for less”, is the new ministerial mantra. Jeremy Hunt presents it as a solution to the impending doom of having to treat the old fatties.
Re-engineering the health system has become a hobby of thinktankers, in the best spirit of the blind watchmaker. But policy wonks are still unable to escape from the fact that the NHS is not a widget factory. The management school of Frederick Taylor is unfit for purpose in considering outcomes rather than outputs. It can only really focus on costs - with horror reserved for unpredictable costs, like those ‘unplanned admissions’.
Is the tide turning on all that? National policy conferences discuss wellbeing, particularly in long term conditions like dementia which require both health and what has been defined as 'social care'. “What is a good outcome for a person with dementia?” we ask. “How can we empower people with dementia to lead fulfilling lives?” “How can we care for the whole person, merging their health and social care in an integrated way?”
But much is left unsaid at such conferences - which are priced out of the reach of ordinary people.
Everyone knows the social care system only survives through the large army of unpaid family caregivers.
Glossed over, too, is the fact that much social care is provided by large companies returning massive shareholder value by focusing relentlessly on costs, paying their staff a pittance on zero-hours contracts and claiming this makes the companies ‘efficient’ and ‘productive’.
Don Berwick, before he became patient safety Tsar, challenged a 2005 report from the Office of National Statistics that NHS productivity had declined by 3-8% (depending on the method of calculation) between 1995 and 2003. Berwick commented, ““Production of what?” is the key question here. If we ask the wrong question the answer may lead us to the wrong policy conclusion.” The calculation of productivity was fundamentally flawed, he argued:
“it does not assess improvement in the mix of these so called outputs, such as when innovations in care allow patients to be treated successfully in outpatient settings rather than in the hospital. To its credit, the ONS notes carefully that “the output estimates do not capture quality change.” Its interpreters need to show equal caution.”
“The people of the UK should be not asking, “How many events for the pound?” but rather, “How much health for the pound?” At least, that is what they should ask if they desire an NHS that can keep them healthy and safe at an affordable price for as long as is feasible.”
But Berwick’s call to focus on health and quality productivity was not heeded.
Five years on, the Kings Fund were still focusing equating productivity with so-called ‘efficiency’ of the kind Frederick Taylor would recognise, in other words, cost reduction, in their report ‘NHS productivity: More with the same not more of the same’.
“As the evidence brought together here shows, there is huge scope for using existing expenditure more efficiently, in relation to both support and back-office costs, and particularly variations in clinical practice and redesigning care pathways. It should be noted that the actual sums identified as potential savings may have already been partly achieved by the programmes listed, and so the figures should be interpreted as an indication of the scale of potential savings rather than an absolute figure.”
And of course ‘efficiency’ has become a euphemism for cuts, whilst the NHS lives with denial that its budget is being squeezed by a £20bn between what it needs and what it’s getting, the ‘Nicholson cuts’ that have resulted its services for patients systematically reduced and its staff shed.
For dementia, and other conditions that require both health and social care services, there is widespread enthusiasm for ‘integrated’ care, bringing the two together. This will treat the ‘whole person’ and save money, we are told.
The poster child is Torbay. The area has established five integrated health and social care teams for older people, organised in localities aligned with general practices. Health and social care co-ordinators liaise with users and families and with other members of the team in arranging the care and support that is needed. Budgets are pooled and can be used by team members to commission whatever care is needed. Hospital admission has gone down - though not dramatically, and over a considerable time period.
But with unified integrated budgets, or 'whole person care', it becomes difficult to identify where the cutbacks are occurring.
Against this background both ‘care planning’ and ‘self-care’ – helping patients to better manage their own condition – has been promoted as being effective in reducing emergency admissions. But at worst, 'self-care' is a figment of the Big Society - a turkey which never flew. A slimmed state, with many services annihilated?
The think tankers are keener to talk about ‘improving staff productivity’.
If productivity in the NHS is extremely difficult to quantify, what about the general economy? Are we managing to do ‘more with less’?
According to NEF, productivity per hour worked fell by 0.3% over the middle part of 2013. This means whatever economic growth occurred over the last year was not the result of people working better, or more efficiently. It was the result of an increase in the total number of hours worked. Productivity, over the whole year, barely improved, and has been stagnant since the start of the recession. Roll over Taylor.
In a paper published by the Institute for Fiscal Studies, researchers concluded that the key contributing factors to stagnant productivity are likely to be low real wages, low business investment and a misallocation of capital. Meanwhile “flexible” labour markets have been proved to be very effective in delivering part-time and temporary work, at low cost to employers. This is where market forces can lead to exploitation. To lower costs, but less effective care.
A “zero-hour contract” creates an ‘on call’ arrangement between employer and employee. It does not oblige the employer to provide work for the employee. The employee agrees to be available for work as and when required, so that no particular number of hours or times of work are specified. The employee has no guaranteed income but receives compensation only for hours worked. And they are popular - one survey suggests that up to 5.5m people are now working on a zero hours basis. Meanwhile, underemployment – those who would like to work more hours, but cannot – is at record levels. When faced with collapsing markets in the recession, employers – rather than reducing the number of people in work – effectively cut wages and hours of those working.
Doesn’t this sound perfect for addressing the NHS funding gap in dementia?
Reviewed by Roger Kline, several reports have made clear that recent changes in employment practices are undermining safe and effective care outside hospitals. In particular, according to Skills for Care, 307,000 social care workers are now employed on zero-hours contracts. This accounts for one in five of all professionals in this sector and the numbers are growing rapidly.
And personal budgets means a growing section of the homecare workforce is directly employed by isolated individuals - often on quasi self-employed terms - meaning virtually no employment rights at all, and serious questions about support, quality, training and supervision.
All the main political parties have been keen to pursue personal health budgets. They all agree on the need for 'efficiency savings'. They are largely singing from the same hymn sheet.
The think tanks dishing out the hymn sheets seem to have airbrushed out low paid workers and unpaid carers without whom the system would collapse.
In paper after paper on ‘integrated care’ - “Making best use of the Better Care Fund” from the King’s Fund or “Whole person care” from the Fabian Society - there is unease about talking about these groups.
Converging evidence from the macroscopic picture of our economy, in the form of the ‘productivity puzzle’, and the landscape of social care for dementia paints a grim picture of legitimising a solution to 'the funding gap'.
The solutions put forward are as important for what they don’t say, as what they do. They offer no real answers for the low-paid carers on zero-hours contracts, along with the army of unpaid family caregivers in conditions like dementia.
This isn’t about “doing more with less”. It’s been “doing a lot with virtually nothing”. And whatever your precise definition of ‘productivity’ for these workers, it is clear that many are at breaking point under consider psychological and financial pressures themselves. But few want to discuss this with the general public.
Exploitation of carers should not be the solution for solving “the funding gap”.