Health Care or Health Trade? A historic moment of choice, by J.T. Hart

Julian Tudor Hart

Paper presented at European Network for the Defense of Public Health of the European Social Forum Anti-Summit Conference on Globalisation, Thessaloniki, 18 June 2003.

Since the 1970s, advanced medical care throughout the world has been dragged through a painful but apparently necessary and inevitable metamorphosis. This can be summed up as transformation of medicine to a system of material production, through which an infant culture of trying, based on faith, hope and mutual self-deception, has matured to an adult culture of verified doing, based on evidence, and measured inputs, outputs, and efficiency. Medical care has at last become recognised as a production system, an economy which can be analysed and measured. This could be either a major advance, or a strategic defeat for health care. The answer depends on who will control this new process of production, and whose purposes it will serve.

Britain was the birthplace of the first industrial revolution, which in one craft-based industry after another, successively destroyed the manual skills and supporting customs of individual workers, changing them from intelligent subjects with some control over their work process, into human components of an industrial machine. By the end of the 19th century, virtually no craft skills remained, that were not by orders of magnitude less productive than industrialised production. Productivity was an irresistible force.

Industrialisation of production met huge popular resistance. It violated custom and often broke existing laws, which at least nominally limited the extent to which employers could replace human skills by machines for manufacture. Laws passed by Charles II after England's puritan revolution of 1648 even specified that machine breaking by craftsmen was legal, if employers misused machines to displace skilled manual labour, because the skills of labourers were their property, as much as machines were property of employers. Resistance was therefore able to draw on the huge potential force of popular conservatism, the almost invariable preference of common people for past devils they know to future devils yet to be experienced. Only when the English parliament failed to enforce these protective laws, did popular resistance become machine-smashing, in the Luddite riots in northern English textile counties in 1811-1812. Between 1809 and 1815, all laws regulating employers in textile and other mechanising industries were repealed, machine breaking was made a hanging offence, and many were hung. Though backed by a huge majority of popular opinion, by many landowners and small employers, and by cultural leaders like Byron and Shelley, the machine breakers were themselves broken. They fought to defend ground already won through past struggles, but they had no convincing outline of an alternative future, more productive than the subordination of men, women and children to machines. Their appeal was therefore to sentiment. Though this sentiment was shared by a large majority of people, they could make no claim to higher productive efficiency, and that is the rational test of history.

In the past 30 years or so, health workers and their dominant medical culture have entered the same process of industrialisation that defeated the handloom weavers more than 200 years ago, and in their present state, seem likely to share the same fate. Neither health workers nor patients like what is happening to health services, but they have not yet convinced even themselves, let alone their enemies, that they have any clear picture of an alternative, depending not upon sentiment, but on evidence that it will deliver health and health care more efficiently and with more effective imagination than consumerism in the globalising market.

Medical care is being industrialised because it has at last been recognised as a particular kind of production, with added life as its product. Through medical care, lives can now be made longer and wider. This product is no longer just a hope, resting largely on placebo effects and collusive illusion (as for the most part it was until around 1935) but a reality, growing exponentially as knowledge advances. Today, limits to this reality are set not by the boundaries of knowledge, but by ruling assumptions about the nature of the medical care economy. The minds of politicians with their hands on state power recognise only one possible kind of economy and one possible mode of production, capitalist production for the market, expanding not to meet human needs, but to maximise profit. They believe that if medical care is a production system, then its products must be commodities. Though they pay lip service to the needs of whole populations, in practice they assume these can be met by pursuing only the immediate demands of consumers, giving priority to the most profitable transactions.

For all other commodities, consumer demands are limited only by ability to pay, and the ability of advertisers to make people think that they need something more when they already have everything. When medical science makes added life a probability, or at least a convincing possibility, and when medical care becomes a commodity, two consequences follow. First: in a free public service, consumer demands will be unaffordable by the state. Second: in a free market, corporate providers will find infinite demand for a product of infinite perceived value - the ultimate commodity. We now have free markets for almost everything else, why not for health care? From the point of view of politicians in power, there is no need even to ask this question; they already have the answer.

In September 1996 leaders of US managed health care plans met in Mexico City to discuss opportunities for extending their business internationally. They had rapidly and profitably expanded their business at home to include more than 100 million US citizens, almost all those healthy and rich enough to be profitable customers. As one chief executive of a managed care plan put it, 'We are soon going to run out of people in the United States.'

The managed care discussed at that conference was industrialised care, managing each individual process or episode to minimise costs without obvious loss of quality, perhaps even raising it. Though there is still no solid evidence that managed care has in fact reduced costs or raised quality, its advent did coincide with a plateau in hitherto rapidly rising US health care costs for the first time in two decades. In USA, where most health care was still in the hands of entrepreneurial doctors, managed care was an advance. For the first time, it made US doctors accountable to somebody other than themselves ' but not to the communities they served, but to for-profit corporations now closely linked to the State.

Managed care made health care extremely profitable for its first couple of years, until it collided with the costs of people with chronic problems, and without spare money. Health care for the 'affluent worried well' could provide huge returns for investors, so long as it had no responsibility for very sick, very poor, or very chronic patients. Schemes in which more than 65% of insured people made a significant claim during the year were not profitable. Competitive Health Maintenance Organisations selected and deselected their enrolled patients so as to leave care of these unprofitable people to the State, either to cope with them itself through some lower tier public service, or to purchase care from private agencies at public expense.

This policy, advocated by the World Trade Organisation, the World Bank, and by the EU ministers meeting tomorrow at Chalkidiki, is now generally known as 'reform'. This is now being sent around the world, wherever governments can be persuaded to accept it. The chief outward port for this ideological export programme has been the UK National Health Service, now committed to partnership between for-profit corporations and the State. Step by step since the late 1980s, the ideas of US health economists, notably Alain Enthoven, have been imposed on the NHS, which has then been used for rehearsals of managed care in an inclusive public service the United States was itself unable ever to provide. European policy formers who understand the extravagance and incompleteness of US health care seem easily deceived by promises of large savings in cost and improvements in quality which will surely occur in England, as soon as the latest managed care reforms have had time to work. So far, these improvements have not occurred, and the problems 'reform' was supposed to solve have got worse.

In reformed care systems, managed care will be offered by competing providers in contract with the state. Though direct patient charges will be needed to limit consumer demand, much or even all costs may be met by the state, at least in the first stages while the public still remembers it once had a National Health Service. Unprofitable people, too poor, too sick, too demented or too incontinent of urine or faeces to attract any corporate provider, will continue to be provided for somehow by the State public service. There is no question of total privatisation, in the sense that medical care for the mass of the people will ever be wholly returned to the market. The new global capitalism is a true and devoted partnership between governments and multinational corporations. In the UK in the 1970s, just over 25% of government public spending (other than income transfers such as pensions and allowances) went to private companies. By 1996 this had risen to 60%, and is still rising.

Since 1945, much of the moral authority of postwar European governments has depended on making health care a citizens' right rather than a purchased commodity. The United States is the only industrialised country, other than Turkey and Mexico, without universal health insurance coverage. Though all industrialised states have either signed up to the World Trade Organisation's General Agreement on Trade in Services at Seattle, or hope to do so, even GATS recognises that traditionally free, universal and comprehensive public medical care services can't simply be handed over to for-profit corporations overnight. European governments must proceed cautiously, first laying the foundations for market competition, before retreating step by step from responsibility. In the UK National Health Service these foundations have already been laid, by separating purchasers from providers, and by fragmenting care into marketable units. In principle, the purpose of the NHS as an organisation is no longer to plan and provide care itself, but to commission it from whichever providers offer best value for money.

According to classical economic theory, the way to contain costs is to introduce price competition for purchasers (not patients, but NHS governors and administrators). The way to improve productivity is to ascertain the most efficient way to do each procedure or handle each sickness episode, and then ensure that staff follow these production guidelines. The way to improve quality is to expose competing providers to consumer choice. The consuming public needs league tables that rank doctors and hospitals according to productivity (measured by waiting lists), and quality (measured by operative deaths, delays between admission and finding a bed, or similar indicators). When all this fails either to control costs or to improve quality, Enthoven claims this is because governments have not yet dared to let competition rip through the system, letting failing units go bankrupt.

None of this is what people want, either patients or health professionals. Guidelines for care have been prepared by expert committees, mainly composed of super specialists working in university hospitals, for management of all common specific disorders. Hospital doctors and nurses feel that they now spend more time meeting the requirements of guidelines than on caring imaginatively for their patients. Professional morale is now lower than ever before in my professional lifetime. Real people have more complex problems than can be foreseen by any guidelines. The commonest single clinical problem in European primary care is high blood pressure, but less than 10% of people with high blood pressure have this as a single clinical problem, uncomplicated by other disorders. Even if we exclude complicating social problems like bereavement, bad marriage, or unemployment, complex problems involving several different chronic disorders are not exceptional, but the rule. Solutions to these complex problems require a combination of clinical judgement and attentive listening to evidence brought by patients, their personal stories. If we want substantial health gains at affordable cost, we must accept complex, labour-intensive, continuing solutions, rather than larger, faster, industrialised production of episodic intervention processes.

Through managed care, guidelines are now being applied as frameworks for organising production of health care on standard lines. The quality of doctors' and nurses' work is now measured according to protocols developed from these guidelines, so that much clinical judgement has given way to checklist automatism. There is some evidence of positive effects on the volume, speed, and population coverage of some intervention processes, but huge negative effects on staff morale are obvious. Long before the advent of managed care, there were huge rises in productivity for process: between 1982 and 1991, NHS output per capita rose almost 30%, compared with 16.5% for the economy as a whole. Measured as procedures delivered, not health gain, this was obtained by eliminating long-stay beds, shortening patient stays, closing small hospitals, and intensifying labour throughout the workforce. All these trends were well established before the internal market. There is almost no evidence of positive effects on health gain, other than in a few specialised areas like early diagnosis and accurate treatment of breast cancer, and even these are probably caused mainly by eliminating amateurs at the margins of specialism, rather than managed care itself.

Let me give a typical example of how industrialisation works. A friend of mine is a consultant gastroenterologist, working with three specialist colleagues in a major regional unit in England. To preserve its funding, her hospital must demonstrate its efficiency, so each specialist unit within the hospital has to show high output and acceptable quality for whatever intervention processes are characteristic of each specialty, used as indicators of industrial efficiency. For gastroenterologists this includes endoscopy, searching for disease downwards through the mouth, or upwards through the rectum. Output is measured by number of endoscopies in unit time. Quality is measured by the rate of gut perforations, a potentially lethal accident occurring less than twice per 1000 procedures in units of acceptable standard. Obviously the efficiency indicator encourages work at high speed, less obviously the quality indicator may discourage investigation of old or frail patients at higher risk of perforation. Complex decisions about the balance of risks and benefits for each patient should be considered carefully both by clinicians, and by patients and their relatives, taking into account the resources and experience of the local unit, and the hopes, fears and attitudes of local people, but they should not be influenced by crude administrative targets. My consultant friend was rated worst in her unit for output efficiency, but curiously, unit nursing staff all said they would prefer her if they needed endoscopy themselves. They knew that if patients were in too much pain, discomfort or fear, she stopped, regardless of the effect this would have on measures of efficiency.

Health ministers, economists, administrators and managers are, with few exceptions, deaf and blind to the gross limitations of the industrial model of production and the market model of distribution when applied to medical and nursing care. This is the way most other goods and many services have been produced for the past 200 years, and their salaries and promotion may seem to depend on imagining no other.

The ultimate aim of the global wave of Neo-Liberal 'reforms' is to create profitable new markets for capital investment, and permanently to delete from the world's political agenda public services, pursued not because they are profitable, but because they are needed. As we all know, the sickest people in greatest need are always least profitable, and therefore worst served wherever markets rule. The greatest profits can be most easily gained from the fears and envies of people who already have everything except peace of mind. As a system for distributing health care, marketing of any kind cannot reach the poorest and sickest sections of society, who then threaten the health even of rich people.

What I want you to consider more seriously is the failure of for-profit industrialised care as a production model. A systematic review by researchers at McMaster and University of Buffalo shows that patients in for-profit hospitals in USA are more likely to die than those in not-for-profit hospitals, even after all corrections for case-mix (which mostly favour for-profit hospitals). Over the period 1982-95, including 15 different studies of 26,000 hospitals and 38 million patients, this showed 2% higher risk of death in the growing proportion of US hospitals run for profit, than in the diminishing proportion of US hospitals still run by voluntary or charitable trusts or local government authorities. Another US research study compared the fate of the 67% of US patients with end-stage kidney failure who attend for-profit dialysis centres, with the fate of the other 33% who attend centres run as a non-profit public service. Over three to six years of follow-up, patients attending for-profit centres were 20% more likely to die and 26% less likely to be referred for a kidney transplant, probably because they then ceased to be profitable patients for dialysis. A further study comparing US for-profit Health Maintenance schemes with not-for-profit schemes found worse outcomes in for-profit schemes for all of 14 quality indicators examined. This was the most complete data-set studied so far, but eight other similar comparisons showed similar results, and only two showed no difference. In yet another comparison, for-profit hospitals failed to reduce costs to the State, compared with not-for-profit care. Notoriously, in US for-profit hospitals administration costs were 34% of all costs, compared with 6% in the NHS before the onset of 'reform' in the 1980s, and just under 12% after 'reforms' were in place in 2001.

If pursuit of profit fails in terms of quality and efficiency compared with previous public service, why reorganise care systems on an industrial model originally designed to maximise profit? The only excuse for this seems to be that nobody knows any other model, except the old system of leaving all decisions to doctors, with no accountability to anyone.

If health ministers, economists, administrators and managers can see no alternative, this must be because they are looking the other way. It stares them in the face. Medical care is indeed a productive system. Every encounter between health professionals and patients should have a product - greater mutual understanding of the nature of patients' problems in the context of their personal life stories, on which joint decisions can be taken about clinical interventions. The most important variable in any health care system is less the quality of interventions themselves, than the quality of decisions to initiate them. These in turn depend on evidence brought both by patients and by health professionals, through which rational and appropriate joint decisions can be reached. At every point this evidence and these decisions relate not to engineering certainties, but to social and biological approximations and probabilities. Even the best guidelines for management of common clinical problems provide only a crude and usually obvious outline within which to make these complex judgements. Health care is, and will remain, an extremely labour-intensive industry, and why not? With fewer and fewer people required to make nearly all manufactured commodities, why not invest more people in health care, education, and other use-values which cannot be made into commodities, without fundamentally distorting and damaging their nature?

In terms of health gain, industrialised care will not raise but depress productivity. The industrialised machine we are offered is clinically inefficient and socially destructive, and neither health professionals nor patients want it. Instead, doctors need to develop as socially responsible and accessible human biologists, and patients need to develop as citizen co-producers of health rather than consumers. Neither development can occur within the machinery of industrialised care. Health care and education are the principal growing points for an entirely new and different economy, based not on trade but on gift relationships, aiming not to maximise profit, but to meet human needs.

These gift relationships provide the main hopes we can still retain for a humane global future, resuming history as an ascent toward higher civilisation, rather than a decline to greed and brutality. In our local schools, hospitals and primary health care centres we already have the beginnings of these relationships, supported by local customs with deep roots. These can develop further only through initially local working alliances between patients and professionals, and between students and teachers. Unlike the Luddites, we can develop a clear and convincing vision of a more humane, more efficient, and more sustainable future, where we can use machines to meet human needs. These beginnings are sacred; let nobody sell them, nor take them away.

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