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This page created April 2000 by Michael Wynne
Efficiency in the corporate marketplace is
used to rationalise and justify substandard care. The human costs of
efficiency imposed by management using a broad brush are contrasted
with the opportunities presented for efficiencies and humane care by
understandings developed in the context of individual situations. The
latter approach is advocated.
No one contests the desirability of being efficient in what we do. This is not the issue. The issue in the market is the delivery of substandard care and the neglect of individuals in the name of efficiency. The difficulties in preventing this are well shown in the USA.
There are two sets of rhetoric used by for
profit groups. One loudly proclaims a commitment to, and the
provision of "quality care". The words are mistaken for reality and
many believe them. The other is a commitment to cost cutting,
efficiency and profit. This is the mode in which the health care
corporations operate. Too often the way in which the two commitments
confront one another are simply ignored. One commitment becomes
public vapourware, the other the justification for screwing the
system for profit. This is well illustrated in aged care.
By measuring what is actually done physically by nursing staff - time and motion studies by businessmen - staff levels required to go through the motions for caring for the physical needs of a nominal easily moved nursing patient can be calculated. This sort of board room analysis reveals gross overstaffing - fat in the system which should be trimmed to improve efficiency. Some market enthusiasts in the USA seriously claimed that standards of care and efficiency are improved by cutting staff. This could only occurs in a bloated system. Only the most extravagant of private clinics would have this.
Hidden videos taken in US corporate nursing homes where staff had been cut "to improve efficiency" reveal the impossibility of any humane and caring interaction with patients when this approach is adopted. Pressure on time cause patients to be treated like so many cattle which is what the videos show.
The public face of efficiency must be set against what actually happens in the name of efficiency in the health care marketplace, and the way those who challenge and expose what happens are victimised.
Nurses in the USA have been crying out about
the lack of care for years. Those who spoke out lost their jobs. The
efforts of the nursing unions to warn the public were met with
threats, accusations of self interest and defamation actions. A nurse
recently described on television exactly the same situation in the
new aged care marketplace in Australia.
Corporate efficiency bases its approach on broad measurable dimensions and an outside view. The relaxed time stopping to listen to someone in a nursing home who is dysarthric or deaf and chatting to them about their family is very difficult to equate with efficiency. Yet it is just these essential unmeasurable small inefficient and time consuming activities which make nursing home and hospital life tolerable and give life meaning - both for the patients and those providing care.
Cox and Cox see life as the " small narrative based on lived lives, the diverse, the complex and the unique - an approach which acknowledges individuality, complexity and the subjectivity of personal experience"1. The very essence of living and of caring lies in individual experience and action in unique and sometimes complex situations.
The anguish revealed by exploring the individual and unique stories of those experiencing the modern health care system on the www is revealing of the way the imposition of efficiency from outside has decimated the individuality of care.
(1. see Cox & Cox MJA 2000 Vol.172
p332 and their quotation of Lyotard)
Clearly wastefulness should be avoided and there are areas, particularly in hospitals where efficiency can very considerably improve both care and cost. Many of us have over the years agitated for more efficiency in our public hospitals. Because situations like that described in the preceding paragraphs are the norm decisions about efficiency can only be made by staff on the spot.
The consequences of making decisions about efficiency in the care of patients in board rooms without reference to those actually providing care is apparent from the aged care debacle in the USA and Australia.
The problem in government run public
hospitals has been that efficiency at a grass roots level has not
been supported by a cumbersome bureaucracy. While it is the cheapest
and the most equitable system it is not necessarily the best system.
Within the sort of community based service that I am thinking about the community (past and future patients) and the staff, both involved in the day to day operation of the facilities would decide on what they value highly, what efficiencies can be introduced and what should be funded. They would have access to all of the broad overview information available and can assess its relevance to their individual situations.
What we cannot have is vulnerable people exploited for the profit of others in the name of efficiency. In a market system the risks of this happening are high.
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