The National Health Service continues to be the top issue for voters in the build up to the UK general election. With a black hole in its funding to fill, debate over privatisation, centralisation of power, and how it should be run, the NHS is also becoming the key battle ground for politicians hoping to be elected.
In the debate over which party will be responsible for the UK’s public services, and especially the NHS, there seems to be a growing stranglehold of two unhelpful business ideas: “financialisation” and “managerialism”. Both of these approaches dehumanise and objectify staff. It’s a worrying and unhelpful way to talk about the people in the UK’s largest work organisation.
The term “financialisation” was developed recently to describe the increasing dominance of capital-based assessments of what we do and value – at work and outside it. Meanwhile, the religion of “managerialism”, financialisation’s longer-established cousin, points to the main means of making it happen. We occupy a world of detailed performance management systems, hierarchical attempts to control work activity and the measurement of outcomes in terms of cost or cost-based efficiency – all usually resulting in reports and spreadsheets.
Many management textbooks tell historically detailed and colourful stories of how modern managerialism developed – the exotic example of a Pennsylvania steel mill or a French tobacco factory (ignoring its other roots, in the practices of North American slave owners).
The focus on efficiency and performance can be understood as the rational desire of businessmen to make the most of their financial investment and get the most out of the people they employ. Crude managerial actions such as monitoring bathroom breaks and counting key-strokes are widely known and often derided. But less obtrusive and superficially more defensible approaches are more benignly labelled as “talent management” or “career development” and reproduce and strengthen the same logic of efficiency and control.
Increasingly, management research now also acknowledges the effects of taking finance as the main way of assessing an organisation’s performance. When finance is the focus, the concern is not for people, but to satisfy the mythical market that demands more intensive work with reduced resources, for better returns to shareholders or owners.
A spectacular achievement
The NHS is so big that it’s impossible to say exactly how many people work for it on any given day. The best guess for early 2015 is 720,000 doctors, nurses, allied healthcare professions, and managers in England. The proportions are roughly: 21% doctors, 52% qualified nursing staff, 22% qualified scientific, therapeutic or technical staff, and – perhaps surprisingly given the amount of politically motivated abuse they are subject to as useless bureaucrats – only 5% managers. It is, unsurprisingly, unclear how many others work in the NHS emptying bins, cleaning floors, serving meals, and taking phone calls.
The basic achievement in making an organisation like the NHS come into existence every day is impressive. It is often said that only a very small number of other organisations even come close in scale, such as Indian Railways, the Chinese army, the PLA, and WalMart. The complexity is impossible to render through the usual metaphors or diagrams we use to describe or represent organisations.
Nonetheless, in order to make the NHS function everyday, the most important thing that happens is that those hundreds of thousands of people go to work, and do what they are paid to do best they can.
Prizing the most important ‘asset’
When businesses or economies are struggling, employees are often spoken of in comparable fashion to other “assets” like buildings or machines. This practice is a bastard combination of managerialism (reducing people to a means to an end, even while claiming to see them as important) and financialisation (reducing people to a line on an accounting report, either literally or symbolically).
So when we talk about the NHS, as a point of political disagreement or as an organisation that provides services we need to account for in some way, the people at its heart should never be forgotten – as people. There is an increasing number of reports about toxic workplace practices in the NHS, as its people report routinely high levels of stress, burnout, low morale, and high turnover. And this is often driven by impossible financial or performance targets.
The dominance of financialisation and managerialism not only reduces people to objects within organisations, but also encourages this way of thinking for customers, consumers or patients. It is far too easy to forget that every single one of those numbers that make up the staggering total of employees in the NHS is a person, just like us. And just like us, they would like to hear from politicians about the possibility of a good working environment, good jobs that are reasonably paid, freedom from unreasonable political interference, and a degree of trust to manage themselves and their organisation.
The NHS is not ours, or any political party’s – more than anything, it belongs to those who walk through its doors every day of the year to do the work that makes it. If we want to have a better run NHS and protect its future, we should start by listening to them.