HEALTH CARE ANALYSIS VOL. 2:227-232 (1994)

Critique The Management of Illness The Need for Health and Social Philosophy

Michael Loughlin

In .the last issue of Health Care Analysis, Critique 1 examined Future Health Care Options (FHCO), 2 the most recent report to be produced by the Policy Unit of the Institute of Health Services Manage- ment (IHSM). The stated aims of Future Health Care Options are to 'restate the values on which health services are delivered' (FHCO p.5), to 'open up' a comprehensive debate about the future of the British National Health Service (NHS), giving particular attention to questions about rationing and funding, and to discuss the purpose of the health service and the role of managers within it--more precisely, to impress upon people the importance of what it calls the 'distinctively managerial perspective' which, the authors of the report believe, 'is critical in its capacity to bring objectivity and is too often neglected' (FHCO p. 6). The report is worthy of attention not so much for the clarity of its reason- ing or the depth of its insight, but rather for the political importance of the institution behind it: the government tends to take the statements of the IHSM very seriously indeed. 3

The authors of the report were seen to claim a special status for managers who, as 'non-partisan guardians' of the decision-making process (FHCO, p. 32) speak with 'particular authority' on the question of 'whether the health service is achieving its purpose' (FHCO p.8, repeated p. 31). 'All other groups' working in and using the service are said in the report to be 'partisan' (FHCO p.32). This has an implication which might have been embarrassing to more modest authors, and which would appear to undermine the democratic rhetoric which characterises parts of the report. Since the report speaks for the IHSM (sentences frequently begin 'It is the view of the

IHSM that ... ') and the authors state that the IHSM 'has a unique authority speak (sic) for management as a whole', it follows that the authors of Future Health Care Options speak defini- tively on the purpose of the health service, such that no-one else is qualified to challenge them on this issue. Either the authors failed to notice this implication (although the tributes they pay to their own work, particularly in the foreword, sug- gest otherwise) or else they fail to see anything perverse in calling for a 'debate' on an issue, only (effectively) to declare themselves the only people qualified to contribute to it.

"The authors fail to see anything perverse in calling for open debate about an issue on which only they have "authority" to

speak"

These claims were shown to be indefensible, and the special objectivity claimed for management was seen to be spurious. Managers are no better qualified than anyone else to state the purpose of the health service? In what follows I examine the proposals put forward in Future Health Care Options about rationing, funding and the appro- priate scope of health service activity and con- cern. These proposals are presented as being grounded in the document's claims about values and the purpose of the service. Stripped of the defence that they are backed by the 'unique auth- ority' of a perspective which possesses special objectivity, the Institute's views on such funda- mental questions must stand up for themselves: they require the support of arguments intelligible even to those of us who are 'not trained managers'

CCC 1065-3058/94/030227-06 © 1994 by John Wiley & Sons, Ltd.

228 CRITIQUE

if we are able to have any good reason to take them seriously.

The report states that the funding of the NHS should be 'reviewed" since 'the limitations of gen- eral taxation are increasingly evident' (FHCO p. 39). It discusses other forms of funding includ- ing private insurance, "top up payments' and local taxation, arguing that:

'It is possible that other funding options would facilitate the creation of a more effective market' (FHCO p. 42).

The advantages of such alternative methods of funding include making the process of the distri- bution, and hence (given scarcity) the rationing of health services resources 'more transparent' (FHCO p.41). The report treats rationing as a necessary feature of the health service, whatever forms health care delivery may take in future (FHCO p. 11). Thus it is important to make ration- ing as 'fair' as possible (FHCO p. 11) (however one decides what counts as 'fair'). It states:

'It is the view of the IHSM that much of the perceived dissatisfaction which the general public has with the NHS reflects the unsatis- factory nature of the rationing process' (FHCO p. 8, repeated p. 37).

"The report gives no clear account of what it means by equity, efficiency and

effectiveness"

As well as being 'as transparent as possible' the rationing process should be 'based on the values of the NHS such as equity, efficiency and effec- tiveness' (FHCO p. 37). This, presumably, would make the process more 'satisfactory'. Unfortu- nately, the report gives no clear and consistent account of what it means by these terms, nor does it explain how exactly a rationing process can be "based on" them. While advocating 'transpar- ency', its own account of the 'values' it wants to see clearly 'demonstrated' is hopelessly opaque. It at one point seems to suggest that 'equity' means 'equal care for equal need' (FHCO p. 14) although it does not explain how needs are identi- fied and measured, and it is unclear as to how we are to know when needs are 'equal'. Without such knowledge it is obviously not possible for any

rationing process to be both 'transparent' and 'based on' this conception of "equity'. Nor do the authors seem entirely sure that the service should be 'based on' such a 'value' since they go on to admit that there may be 'some scepticism about the legitimacy of these values' and to express the worry that this definition of equity:

'violates the principle of equality because some individuals derive greater benefits from the system while paying less for it' (FHCO p. 14).

Unlike socialist conceptions of 'equality', this 'principle of equality' appears to be concerned with people getting no more and no less than they pay for. The authors do not say what weight, if any, they give to the 'principle of equality', having mentioned it, nor do they explain why anyone should take it seriously as a moral prin-

"Without any account of what the standards are, and how they are set, the

report's statements are vacuous"

ciple. They do not say anything to combat the 'scepticism', either, but it nonetheless vanishes almost as soon as it has been stated, so it does not prevent the authors from confidently asserting the fundamental nature of these and several other 'underlying values' throughout the rest of the report, and claiming that in doing so they have 'brought clarity to bear' on the values and pur- pose of the NHS (FHCO p. 14).

In addition to 'efficiency and effectiveness' (perhaps in explanation of one or both of them) the report also states that health services 'should be delivered at the highest possible level of qual- ity' which means 'keeping to certain standards' and 'also means that the needs of the patient determine the system and not the other way around' (FHCO p. 38). Without any account either of what the standards are or how one rationally sets them, and without any coherent account of 'needs', these statements are vacuous. Equally vacuous is the claim that:

'It is axiomatic that this society should provide comprehensive health care to the level it is will- ing to afford' (FHCO p. 39).

It is hard enough to determine what a society can afford, let alone what it 'is willing to' afford. Out-

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side the linguistic laboratory of management literature, where the abuse of language is commonplace and where new, meaningless (and frequently horrifying) hybrid expressions are constantly being created, one would speak only of someone's being 'willing to' afford something ironically. In response to my claim that I cannot afford something you may suggest I am not will- ing to afford it to imply that it is not really a matter of what I can afford: rather I am simply unwilling to pay for something and pretending that I am unable to pay for it. So this 'axiom' states that society should pay for as much health care as it is willing to pay for. It does not, of course, state

"There is little point in having an axiom from which nothing can be deduced"

how much health care society should be willing to pay for, so the 'axiom' states nothing: certainly nothing follows from so empty a claim. Since there is little point in having an 'axiom' from which nothing can be deduced, we can only assume that the use of such a word is part of the attempt to convey a bogus 'scientific' feeling to the proceedings, as if the authors were engaged in an enterprise comparable to Euclid's work in geometry. It is hard to find any meaning for the word 'comprehensive' in this context when the authors go to such lengths to stress that rationing is inevitable and that many services which people might desire simply cannot be provided. Despite this, 'comprehensiveness' is stated as another of the 'values' on which the service should be 'based' (FHCO p. 14).

Since Future Health Care Options cites as its main influence on questions of value the briefing paper Values and the NHS 4 by Andrew Wall, such con- fusions are not surprising. 5 The report inherits the obscurities of Wall's paper and adds some of its own. Future Health Care Options has much to say on the nature of value, but sadly very little of this is helpful and much of it is incoherent. According to the IHSM, values are things that:

a 'operate at a number of levels within the de- cision-making process' and can 'cover the total provision of health care'

b 'embrace concepts' such as 'distributive jus-

rice, utility, rights, altruism and economic rationality'

c 'provide the theoretical framework for social organisations'

d may 'take on the mantle of moral imperatives' but 'in practice ... change over time and are relative'

e must be 'agreed' or else 'every decision made would be essentially an arbitrary one'

f can 'underpin' institutions like the health ser- vice, but which

g are themselves 'based on' institutions like 'the welfare state'.

All of these claims about values are taken from the same page of Future Health Care Options (FHCO p. 14), but the same or similar claims are repeated with great frequency throughout the document. At several points 'values' are equated with 'prin- ciples' (e.g. 'The values that underpin the NHS are its founding principles') (FHCO p.7) while at other points the word 'values' is used inter- changeably with the word 'criteria' (such as in the discussion of 'basic organisational criteria') (FHCO pp. 23-25). We are told that values must be 'shared' if 'effectiveness' (itself stated as a 'value') is to be possible for an organisation (FHCO p. 25). (So it seems that 'effectiveness' is both that which is facilitated by the 'basic values" and is one of these values itself.) Values are at some points apparently equated with 'interests' which may conflict with one another (e.g. FHCO p. 17) while at other points it is the existence of 'organisational values' ('efficiency', 'effective- ness' etc) which are 'broadly understood and shared by all the participants' (FHCO p. 21) that is claimed to be essential for resolving conflicts be- tween competing interests.

'It is not explained how "'values" can be at once "competing interests" and "shared"

by "'competing interest groups"'

It is of course not explained how values can both be (competing) interests and at the same time be 'shared' by competing interest groups and used to arbitrate between competing interests. Nor does the report explain how values can be the same things as both 'principles' and 'criteria'. We are not told what it means to speak of a value oper-

230 CRITIQUE

ating at a number of levels in a decision-making process or embracing a concept (one imagines some sort of reunion in the jungle, with Efficiency saying, 'Ah, Economic Rationality, I presume') and we of course are given no analysis whatsoever of the various 'concepts' which the values 'embrace'.

How do values 'provide' theoretical frame- works? How do they manage (in the same page) both to be the basis for, and be based on, insti- tutions? How is it possible for the IHSM to ad- vocate certain values as the correct ones, on which the delivery of health care 'should' be based and to which we all (whatever our 'perspective') must 'agree', while at the same time declaring (without, of course, any argument) that all values are 'relative'?

'The authors proceed as if the word "values" can mean whatever they want it

l

to mean . . .

The report does not tell us, but it does say values 'must be defined as realistically as poss- ible' and that ' the application of realism to values' means that 'greater specificity implies greater commitment ' (FHCO p. 16). In short, the authors of the report proceed as if the word 'values' can mean whatever they want it to mean, which was effectively the conclusion of Values and the NHS. 5 Had the authors bothered to consult the vast array of philosophical literature on the nature of value, they might have avoided some of their more absurd statements, and some of the ludicrous misuses of philosophical terms such as 'utilitarianism' and 'rights'. This, however, might have involved them in making some refutable claims, and they might even have been forced to admit that their proposals for reform are not grounded in any coherent view about values and the NHS. Much safer, instead, to assert objectives in so vague a manner that one can decide at one's own convenience (using one's 'special authority') when and to what extent they have been achieved, taking refuge in frequent use of the words 'clarity' and 'specificity' while failing to clearly specify what one means at any point. The report comes closest to having a clear position in its views on purpose, although even here it

does not avoid self-contradiction completely. The report says:

'It is not clear if the improvement of health is, or should be, the primary goal of the health ser- vice' (FHCO p. 7).

On the face of it their claim seems rather perverse. (In fact I will argue it is more disturbing than that.) It certainly conflicts with:

'the purpose of the NHS is to improve the physical and mental health of the population and to prevent, diagnose and treat illness' (FHCO p. 24).

What the writers are getting at in the first of these two statements becomes apparent a little further on in the report:

'The purpose (of the NHS) is to redress differ- ences in health status between individuals by addressing the effects or inequalities (in terms of levels of illness and rates of chronic disease) rather than their causes (such as unemploy- ment or poor housing)' (FHCO p. 14, authors' emphasis).

'According to the report it is not the business of the N H S to try to eliminate the

social causes of ill health"

The IHSM us using a statement about the 'pur- pose' of the NHS to limit ...e scope of health service activity and concern. According to the report, it is simply not the business of the health service to eliminate the social causes of ill health; rather it must 'address' their effects. The medical profession was criticised for a long time for ignor- ing the social causes of ill health to concentrate too exclusively on physiological causes. It seems ironic that representatives of the professional group purporting to replace doctors as the 'lead- ers' of the NHS apparently want to do the same thing. However, the IHSM is not denying the exist- ence of social causes of ill health, nor is it denying that an organisation concerned with improving health would be concerned with tackling the social causes of illness. It is simply denying that this is the business of the National Health Service.

While this position is consistent, it is not grounded in any coherent analysis of the concept

CRITIQUE 231

of 'health' which might explain what is and is not the proper concern of a health service in a more systematic way. It is certainly not obvious that such a service should not be concerned with all the factors which influence health, or that it should limit its interests by dividing health problems into 'causes' and 'effects', and looking only at effects. Traditional medical science does not claim to be interested only in effects and not in causes, and it is not clear how one can properly 'address' the effects of something without want-

"If what I need in order to be healthy is a decent house then the health service cannot

"meet my needs" if it has no interest in such matters'

ing to address its causes. If inequalities in 'health status' are determined by social inequalities then how can one sensibly 'address' the former with- out addressing the latter? If what I need in order to be healthy is decent housing then the health service cannot 'meet my needs' ('meeting patient needs' being another slogan repeated at regular intervals throughout Future Health Care Options) if it has no interest in such matters. The IHSM's view also seems to conflict with other statements in the report, such as the claim that 'consideration should be given to merging health and social service functions' (FHCO p. 8) and its view that health promotion is a legitimate part of health service activity (FHCO p. 12). The first of these two statements can be made consistent with

'Health promotion seeks to eliminate causes of illness--how does this fit?"

the view that the service treats effects and ignores causes given that 'social service functions' and other features of the welfare state are also viewed as being concerned only with 'addressing the effects' of social inequalities. The health service, on this view, is like the dole in that it is there simply to prevent the victims of poverty from dying, not to change the circumstances which threaten their lives. It is harder to make the views about health pro- motion fit in, since if health promotion is to be a

meaningful enterprise it surely must be con- cerned with eliminating causes of illness and pro- moting good health, not merely treating effects. The relevant difference here appears to be that the IHSM envisages health promotion campaigns as being aimed at individuals and their lifestyles rather than at government policies and social in- stitutions. The vital distinction for the IHSM does not, in fact, seem to be between causes and effects but between what would and what would not involve challenging the economic status quo. (It is interesting that the causes of 'inequalities' are specifically mentioned as things in which the health service has no legitimate interest.) It could not plausibly claim that its concern is not to be 'political' when it has been so closely associated with politically charged reforms and it is propos- ing radical changes in the funding of the NHS--- changes which represent a move away from gen- eral taxation. What all of its 'radical' proposals have in common is that they are entirely consis- tent with the free market economy, and indeed involve bringing ever more of the ethos of the market into the delivery of health care.

"Apparently the health service cannot question the economic system'

Its views about funding and rationing are related to its central conviction that the one thing the health service cannot do is question the economic system. The claim that rationing will 'always' be necessary in any health care system is taken to follow directly from the fact that resources are finite (FHCO p. 11): in line with Adam Smith it is assumed that demand for finite resources will always outstrip supply. But when the resources are treatments for illnesses caused by social con- ditions, they are only in demand for so long as society continues to make people sick. It is be- cause it is tacitly assumed that there will always be inequality that the Institute can confidently assert that there will always be far too many sick people for the health service to treat, with the result that there will always be a need for ration- ing, and that current methods of funding will eventually become inadequate to meet demand.

This is why I find the most coherent part of the report to be also the most disturbing. As

232 CRITIQUE

managers its authors are dedicated to the market economy: their whole 'mind-set ' is determined by free-market assumptions. The IHSM's position is reactiona~ in the fullest sense of the word. It views the role of the health service as 'reacting not understanding' : treating problems that are there but refusing to consider how one might eliminate them whenever doing so would involve raising serious questions about the structure of western society. The position is like that of a battlefield doctor who continues to patch up the bodies

"Instead of asking why it is that the richest countries in the world habitually make their people sick, the political system is

taken as a "given""

brought in, but who never questions why the war is going on or whether it should be being fought at all, because that's not his job: such questions are the concern of the generals. (The IHSM's rote would then be that of the doctor 's 'supervisor ' , who spends his time devising systems for deter- mining who should get the last dose of the remaining anaesthetic.) Instead of asking why it is that the richest countries in the world habitually make their people sick--so sick and in such numbers that they cannot find the resources to treat them all, even when their illnesses are terminal - - the nature of the political system is to be taken as a 'given' in the debate about the future

of health care that the IHSM claims it wants to see. The discussion is to concern the management of illness, and of course managers then have a key role in telling us how to do this as 'efficiently' as possible.

It should be noted that the alternative to the IHSM's view is a radical one. Pursuing this alternative would involve having a different debate, one in which social and political philoso- phy became an essential aspect of any discussion about health and the future of the health service. 6 Either one takes the nature of the political system as given, and starts discussing rationing and al- ternative methods of funding, or one does not. The debate we need to have has not really started yet.

References

1. Loughlin, M. (1994) Critique: the poverty of management. Health Care Analysis 2(2), 135-139.

2. Institute of Health Services Management. (1993) Future Health Care Options. Final Report, Institute of Health Services Management, London.

3. It was as a result of a previous IHSM report Alterna- tive Delivery and Funding (1988) that the pur- chaser/provider split was introduced into the organisation of the NHS.

4. Wall, A. (1993) Values and the NHS, Institute of Health Services Management, London.

5. For a full analysis and criticism of this briefing paper, see Loughlin, M. (1994). Critique: behind the wall paper, Health Care Analysis, 2(1), 47-53.

6. Seedhouse, D. (1994) Fortress NHS: A Philosophical Review of the NHS, John Wiley and Sons, Chichester.