Soon after the last government’s reforms of the National Health Service, hospital administrators and other staff held meetings to decide a vitally important question: that of the mission statement that should appear at the bottom of the new, improved hospital stationery. How else than through a brief slogan (something of the order of “Working Together for a Healthy East Teesside”) were surgeons, neurologists, venereologists, haematologists and so forth to know what they were supposed to do? Indeed, how had they worked all these years without the guidance of such a slogan? It must have been pure anarchy.
Since then, we’ve moved on from mission statements: for what is scientific management except permanent bureaucratic revolution? Now we are into visions – though it must be admitted that, thanks to Alan Milburn, they are now rather more honest than of yore. The new Health Secretary has acknowledged that the government must shift its focus from cutting hospital waiting lists – one of the five “key pledges” at the last election – to tackling cancer and heart disease.
Yet if this government has somewhat scaled down its vision for the health service, a foul miasma of euphemism, impenetrable jargon, moral corruption and dishonesty, as well as inefficiency and incompetence dressed up as accountability, still shrouds this country’s public services. On the pretext of trying to obtain value for money, and to increase efficiency, the last government destroyed the independence of all the professions, and the present government is no different: for there is nothing a politician of any stripe hates so much as a body of people that escapes his control. It is a red rag to a bull; it is a heretic to a Savonarola.
The means by which control over the professions has come to be exerted is by the gathering of statistical information and the setting of arbitrary targets, decided by governmental fiat; the whole process supervised by a new echelon of bureaucrats. The setting of targets is supposed to introduce the kind of discipline that the need to make a profit exercises in commercial enterprises: but in the market place of the new public services, there is no carrot, only stick. Fear of losing one’s job is the only motive and turns everyone into a compliant zombie who follows directives no matter how absurd or even unethical. “I am only obeying orders” is the universal cry of every British public servant.
I am not a Luddite anti-statistician; but in order for statistics to mean anything, judgement has to be exercised. It is surprisingly difficult to compare like with like, and crude league tables of death rates between hospitals, for example, are harmful because they give the illusion of knowledge without its substance. Policy based on illusory knowledge is likely to be far worse than policy that acknowledges the extent of our ignorance.
But the purpose of information-gathering and target-setting is neither knowledge nor improvement in services: it is control, just as in Ceausescu’s Romania the tapping of every telephone was not to gather intelligence (for such quantities could not possibly be analysed) but to instil fear. That the vast majority of information gathered is never used for any purpose whatsoever is a conclusive demonstration of this. As an experiment, I have several times filled in forms supposedly aimed at informing management of my activities with answers that could not possibly be true: but never once have I been asked to explain it. Many of my colleagues have had a similar experience: so the purpose of the forms is to inform us that Big Brother is Watching Us.
The vast majority of human activity is not susceptible to worthwhile statistical analysis – and in any case the gathering of information is not itself without cost. I have several times had occasion to point out to authorities that I can either do my work or fill in the proposed forms relating to my work, but not both. Since I am not in the least afraid of losing my job, they have given way; but I know that their ideal is administration without anything external to it to administer, and that one day they will return to the fray.
But the large-scale gathering of pseudo-information that undoubtedly takes place is not without its effects, all of them undesirable. For example, it is a truth universally acknowledged by police on the beat that all chief constables are sub-contractors to the great spin-doctoring machine of government. They are vastly more concerned with the public representation of the situation than with the situation itself, and what appears in the press is infinitely more important to them than what actually happens. They do not care if an entire area is overwhelmed by rapine, robbery and murder, so long as a favourable light can be thrown on their leadership and the wool pulled over the all-too willing eyes of their political masters.
The ordinary police officer, who knows better, becomes bitter and disillusioned; and it is one of the reasons why our are now fundamentally nothing but minor clerks for insurance companies, whizzing through the streets in silly cars distributing crime numbers so that people can make fraudulent claims against the insurance companies. The rot is deep and spreading.
Every demand calls forth its supply, and if the government demands statistics, it will get them. But they will be statistics of what Trotsky (himself no great lover of truth) called the Stalinist School of Falsification. While everything gets worse, or at least no better, the statistics will demonstrate that we are well on our way to Utopia. But an old lady waiting eight hours in casualty for a bed will still be an old lady waiting eight hours in casualty for a bed. The difference is that her expectations will have been changed by the public lies, and so she will be even more miserable than she would otherwise have been.
I do not suggest that at any time in the recent past the public services of this country were beyond reproach. I yield to no one in my contempt for our school system, for example. A quarter of British children leave school after 11 years unable to read fluently or to spell, virtually as innumerate as the day they were born and without any fund of knowledge whatever. (In the past nine years, I have met only two people between the ages of 15 and 20, out of hundreds, who knew when the second world war was.) Our schools are the scandal of all scandals, the absolute guarantor of our future misery.
But the answer to this catastrophic situation is not to badger teachers with endless bureaucratic procedures that have little or no connection to the problem at hand and that can in any case easily be subverted. I was taught more than adequately (I only wish on reflection that I had done my teachers the honour they deserved instead of playing them up whenever possible), but they filled in no forms, or at least very few by comparison with today’s teachers. To improve the school system would take vastly more political courage than any politician possesses: it is easier to bomb Serbia and devise yet another form to fill in.
Our universities have been turned into beehives of bureaucratic activity, which is to scholarship what colonic irrigation is to gastroenterology. Targets are set and the easiest way to meet them is to reduce standards. A horrible pall of mediocrity has settled over higher education in this country, in which productivity is measured by the number of pages published and the number of people with useless degrees churned out. Distinguished scholars are harried by inquiries, forms, inspections and so forth as if they were criminals.
Universities did, in the past, harbour some slackers and other parasites. But it was simply not true that the average university teacher was such a slacker, and therefore there was no need to change him into a time-serving clerk, who could be proved to be working hard, but alas at nothing useful.
Strong management in the public service inevitably worships false gods. For example, the only justification for the existence of a broadcasting corporation subsidised by public funds is that it should produce high-quality programmes that commercial companies would not produce. It is inherently an elitist conception, and none the worse for that. But what do we find? In the hands of managers, there is a straining in the BBC after large audiences, which naturally enough results in the publicly subsidised production of ever cheaper trash.
Where a service is publicly funded, the government has the opportunity and the locus standi to poke its nose in. The nationalisation of the British medical profession in 1948, for example, always carried the implicit threat that doctors might become minor functionaries of the state. But for a large number of years the profession was left as an independent corporation that regulated itself. Like all human institutions, it was imperfect; among the scores of thousands of doctors there were rogues, fraudsters and villains who got away with murder (no doubt sometimes literally).
But there is no way of eliminating human frailty and no evidence to suggest that government regulation will improve matters (not that improvement is the object of government regulation). Doctors are intelligent people, who have generally worked hard to enter the profession; the vast majority are reasonably public-spirited.
Increasingly, however, they are being treated as if they were criminally inclined and stupid into the bargain, in need of the superior wisdom of the government to keep them in order. Their freedom is increasingly circumscribed and the result is only natural: half of all doctors now wish they’d never entered the medical profession and three-quarters of hospital consultants want to retire as soon as possible. Demoralisation, if not complete, is substantial.
The government wishes to turn the professions into a civil service, the better to control them. But there is no reason to suppose that centralised control of decision-making down to the smallest detail will improve performance, and much to suggest the opposite. The more central control there is, the greater will corruption – moral, intellectual and financial – become.
A symptom of this corruption is the language that management uses, which has little or no contact with reality. The once-popular management term “brainstorming” has been banned because it is disrespectful or objectionable to epileptics: we must now thought-shower. Meanwhile, epileptics are routinely refused work in any capacity whatever because of their condition.
The writer is an inner-city GP
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