In Jenny Odell’s “Saving Time” she criticises the term “Anthropocene” and writes –
“A history with no actors, only mechanisms”
That phrase stopped me in my tracks. Isn’t this also a perspective we could take on contemporary Health Care – a system “with no actors, only mechanisms.”?
“Agenda for Change”, a management led sweeping reform of job descriptions and contracts was applied to all but medical staff in the Scottish NHS. It involved breaking the daily work of employees (mainly nurses and admin staff) into tasks with the defined knowledge and skills required to carry them out. Once written into the job descriptions and contracts the human beings actually performing the tasks became invisible. Only the knowledge and skills to do the tasks are important. The tasks take first place, who carries them out becomes irrelevant. The process resulted in many staff finding their posts had been downgraded, and, later, that less highly trained, less well paid staff, trained to do specific tasks, were employed to take over much of the work. The concept of the nursing professional, trained and experienced to conduct her or himself with much day to day autonomy in clinical decision making, was eroded. The posts became interchangeable, more minutely monitored, measured and controlled. The “mechanism” became more important than the “actors”.
“Lean Management” techniques, developed in factories and offices, where daily work is broken down into processes and events each of which can be measured and controlled in the interest of “efficiency” were rolled out, with no interest whatsoever in either individual patients or the doctor-patient relationships. It didn’t matter who cared for a particular patient, as long as they carried out the necessary tasks with the prerequisite knowledge and skills. The efficiency of the Service is now measured in terms of numbers – numbers of patients treated each year, numbers of “clinical events” carried out by each member of staff, daily, numbers of various tasks “completed”. In the ward where I worked, where there had never been a case of “hospital acquired infection” or a patient who developed “bed sores”, the nurses had to report the zero number of cases of each of these problems every month to their managers, and to create and display a graph showing the zero number, a straight line, running through a number of months. Concepts like “continuity of care” have been eroded. When my dad was admitted to hospital in the terminal phase of his cancer, I found myself thinking, “Why is it that every single doctor, and every single nurse, I ask about his condition, replies that he is not their patient but they will consult his records and get back to me?” And while visiting another relative in a different hospital I overheard one member of staff ask another if they’d “taken the blood from bed 14, yet?” Good luck getting blood out of a bed, I thought. To be fair, this substitution of patients’ names by their bed numbers was a practice which I’d encountered way back in the 1970s as a medical student where we’d be sent to “listen to the heart murmur” or “feel the enlarged liver” in Ward 3…..”no actors, only mechanisms”.
It’s also a long established fact that a disease centred approach is used both in medical education and in clinical practice. Hospitals and clinics are organised along disease centred lines, with departments of specialisms from Cardiology to Dermatology, Renal Medicine, Endocrinology etc. The disease and the systems of treatment structure the entire institution, irrespective of individuals with multiple comorbidities. As the numbers of people living with three or more chronic diseases rises, more and more people experience their care divided between several different hospital departments, each with their own appointment systems, processes and ever changing staff. General Practice used to be the counter to all this, with both training and practice founded on patient centred, holistic principles, but the same principles applied in hospitals have infiltrated General Practice, with the development of disease-centred clinics within each Practice, and an increasing number of doctors working on limited term salaried contracts, or as locums. None of my relatives can tell me the name of “their GP” any more. Instead, they are encouraged to seek telephone assistance from NHS call centres staffed by people they will never know, and directed to see certain doctors, “specialist nurses” or “assistants” depending on their disease and circumstances. People who they don’t know, and may never encounter every again…..”no actors, only mechanisms”.
An additional systems first approach has become the dominant philosophy in health care – “Evidence Based Medicine” (EBM), based on the statistical analyses of experimental trials. Randomised Control Trials, the “gold standard” of EBM are designed to make the human participants irrelevant. The actual humans involved – the experimental subjects and the prescribers – are “controlled for” – they aren’t named. They don’t exist as anything other than collections of data points. This is the foundation of EBM where treatments “just work or don’t work” irrespective of the nuances and differences between human beings, whether patients or prescribers. It’s a system without actors where individual experiences are disregarded as “anecdotes” of “no scientific value”. Students are taught “patients lie all the time, you can only trust data”, and “if a patient tells you they aren’t any better after taking and evidence based treatment they either haven’t taken it or they are lying” and “if a patient says they are better after taking a medicine which is not evidence based they are either lying or deluded”, or their experience is dismissed as “the placebo effect”. (I’ve heard all these exact statements from young doctors in training). I once heard, on BBC Radio 4, a Public Health doctor dismissing the request for continuing treatment at Royal London Homeopathic Hospital, from a patient with psoriasis who said he’d tried everything dermatologists offered but the only treatment which had really helped his psoriasis was homeopathy. The Public Health doctor said that was impossible because he’d read all the clinical trials and homeopathy did not work. Somehow, his literature review was better able to assess the daily experience of this man’s skin, that the man himself.
Health care with no actors, only mechanisms.
Heroes Not Zombies 