The National Health Service was established on 5 July, 1948. It formed the cornerstone of the welfare provisions devised and enacted by the UKâs post-war Labour government under Prime Minister Clement Attlee and was conceived following the experiences of the First and Second World Wars and their aftermath. The welfare state represented a radical attempt at changing the social, economic and class structures of Britain. It was a technocratic, state-led solution to the challenges of providing education and reducing poverty, unemployment, homelessness and ill health; a programme not uncommon in other post-war countries (McCann, 2014). One of the motivating principles was the fact that government ownership, administration, rationing and investment had worked successfully in wartime, which supported the belief that the same could be achieved in peacetime. Aneurin Bevan, Minister for Health at the time and often referred to as the architect of the NHS, founded the service on the collective principle that âno society can legitimately call itself civilized if a person is denied medical aid because of lack of meansâ (1952: 100). As a result, the nationalized health service was built on the principle of care to be given free of charge at the point of need. The NHS has been the most popular and enduring element of Britainâs post-war settlement (Pierson, 1994: 132; Taylor, 2013).
State welfare provision has never received universal support and the nationalization of healthcare was not without its critics. Most notable perhaps was the initial resistance from the British Medical Association and Bevanâs frustrated observation that he had pacified doctors by âstuffing their mouths with goldâ as he was forced to accept continued private practice of NHS consultants. Since then, clinicians of all kinds have typically given strong support to the NHSâs single payer (tax-funded) principles, which (usually) allowed clinical professionals to focus all their attention on clinical needs without being distracted or constrained by considerations of financial cost (Harrison, 1999). As a result of the improvements in the health of the UK population, the NHS has been described by a former British Medical Association council chairman as âone of the greatest achievements in historyâ. 1
This book was intended to follow on from our Managing in the Modern Corporation (Hassard et al, 2009) in its in-depth coverage of the intensification of managerial work following organizational downsizing. That study featured themes of stress, exhaustion, demoralization and resentment about top management strategy. Certainly, all of these themes remain very much present in this current text. However, in researching NHS organizations, it was impossible to avoid a much bigger and more clearly political and moral story; that of the disturbing tension between business imperatives and ethics of care and, in many cases, a rapid sense of loss of control among many working for the NHS â hence Deconstructing ⌠. This made everyday working life in the NHS effectively a political space into which employees, including junior and middle managers, projected their moral and political values about the meaning and importance of their work. Yet, despite the efforts of governments and consultants to encourage the NHS to be more businesslike (Davies and Gubb, 2009), it remains a public service, not a profit-driven enterprise. Patient care remains the number one priority for NHS trusts, both in official pronouncements and in a great deal of practice.
Deconstructing the Welfare State therefore offers a critical examination of working life in a changing NHS as seen through the eyes of junior and middle managers. As this book demonstrates, those working for the NHS are beset on all sides by pressures for marketization, policy reforms and system-wide restructuring, resource shortages, and increasing demand for services. This chapter describes the broader sociopolitical environment in which our managers found themselves, and as such, it serves as an introduction to the various themes of the book. It opens by sketching out the background to the NHS in order to demonstrate that organizational and policy change in this field is highly politicized and deeply infused with ideological and moral rhetoric. The chapter then moves on to describe the current condition of the NHS, drawing attention to the profound challenges it is facing in terms of growing patient demand, shrinking resources, and the rise of external competition. These challenges are then explained in more detail with reference to a resurgent neo-liberal attack on the idea of free public healthcare and the autonomy of clinical professions. This has a dual form, as manifested in: i) policy drives to open up public services to free market competition; and ii) an intensification of attempts to control public servants and attenuate professional discretion, often using various forms of performance indicators. Broadly speaking, these trends are labelled as New Public Management (Hood, 1991), a pervasive and powerful form of managerialism (Klikauer, 2013). The chapter concludes with an explanation of why we have chosen to draw a distinction between management and managerialism. We do this not least because, as seen in Chapter 2, the deconstruction of the NHS is played out through middle managers in particular as an imposed form of managerialism; yet many managers believe strongly in the foundational ethos of the NHS as a public service for patient care rather than as a business or commercial enterprise. Chapter 2, in keeping with our interest in middle managers, details how the deconstruction of the NHS has been achieved incrementally over recent decades. It examines how these policy changes were effected through and by NHS managers.
Throughout our study, we drew together macro, meso and micro levels of analysis (Mills, 1959). Chapter 3 details the distinctive Critical-Action perspective we used to examine how organizational structures and processes were influenced by overt and covert ideological factors and forces. In Chapters 4 to 7, we see how these interactions played out in the lives and work of junior and middle NHS managers in four types of NHS organization: an acute trust (Chapter 4), an ambulance trust (Chapter 5), a mental health trust (Chapter 6) and a primary care trust (Chapter 7). Each of these empirical chapters portrays the significant effects of this changing environment on a distinct type of NHS organization. The final section (Chapter 8) draws the conclusion from our findings that something more than a simple NHS reorganization is underway. There is a new ideology to consider â of care provision linked to business income rather than patient need. We see how this thinking pervades the mindset of politicians, senior managers and business consultants. We argue that this deconstruction of public welfare ought to be subjected to critical scrutiny if we are to genuinely consider what marketization does to care. The reforms are all the more insidious for being largely conducted through stealth, without proper oversight, and without adequate public accountability, approval, or even debate (Leys and Player, 2011; Tallis, 2013). This is what we mean by Deconstructing the Welfare State â the NHS is our subject of enquiry amid much larger social, political, economic and organizational debates about the shrinkage of public service provision and the effacement of democracy by a neo-liberal âstealth revolutionâ (Brown, 2015).
The NHS: politically untouchable?
It is widely argued that changes to public welfare provision are difficult for governments to enact because they potentially create constituencies who lose out through cutbacks and reform (Pierson, 1994). This is nowhere more apparent than with the NHS. In 2014, a US think tank rated the NHS overall as the best value health system in the world (Campbell and Watt, 2014). In 2000, the World Health Organization ranked the UK in eighteenth place (out of 184 national systems) for âoverall health system performanceâ, with France coming first and the US, thirty-seventh (World Health Organization, 2000). The NHS is currently Europeâs largest employer (with around 1.38 million staff in 2014) and is one of the worldâs largest and most famous public service institutions, designed to provide universal healthcare on the basis of patient need, not on their ability to pay. Over and above its national importance as an employer, it is also popular with patients. Recent reported levels of patient satisfaction with the NHS are high. British Social Attitudes surveys from 1983 to 2000 show a trend line of between 40 per cent and 50 per cent of patients self-reportedly either âvery satisfiedâ or âsatisfiedâ, but this has been climbing rapidly since the 2000s to a high point of 70 per cent in 2010. 2 A Care Quality Commission survey of NHS patient care in England reports in 2014 that 84 per cent of around 56,300 respondents rated their treatment at between seven and ten out of ten (NHS Confederation, 2015). It has proved to be a mostly effective and very popular institution â one whose existence is widely supported by the British public, by patients and by clinical professionals.
Its much-loved status is quasi-mystical, and it is often described as being politically untouchable; so much so that small-state Conservative politicians are often forced to promise that it will be âsafe in their handsâ (Pierson, 1994: 133). The late Tony Benn, once a symbol of the Old Left in British politics, when interviewed by the US left-wing documentary film-maker Michael Moore for Sicko â a film about the failings of the largely private American healthcare system â described the existence of the NHS as follows:
BENN: [I]tâs as non-controversial as votes for women; nobody could come along and say âwhy should women have the vote?â now because people wouldnât have it; and they wouldnât have in Britain â they wouldnât accept the deterioration or destruction of the National Health Service.
MOORE: If Tony Blair would have said âIâm going to dismantle the national healthcareâ âŚ
BENN [interrupting] Thereâd have been a revolution. 3
Perhaps Benn was right. If a government had announced such plans then widespread opposition would indeed be likely. Itâs perhaps best, therefore, not to announce them. Despite discouraging polling data on the British publicâs opinion of how well the Conservative Party would handle the NHS, the Conservatives won an overall majority in the UK general election of 2015. In the first Prime Ministerâs Questions session of the new Parliament, in June 2015, David Cameron again committed to a publicly funded NHS, claiming his government would raise an extra ÂŁ8 billion in funding that it had not committed to prior to the election. Once more we see public claims about a much-loved NHS that is safe in Conservative hands. But, as we see in more detail below, there is every reason to be sceptical about these claims.
Recent years have seen a radical reshaping of the NHS in ways not always open to public scrutiny. This is why we adopt the phrase âstealth revolutionâ (Brown, 2015) to describe the changes to the NHS. Political rhetoric continues to uphold the sanctity of the NHS while legislation quietly opens the doors wide to âany qualifiedâ provider. We see in Chapter 2 how public and professional criticism of reforms only seems to have emboldened neo-liberal policymakers.
Taking a pulse: assessing the current health of the NHS
The NHS in England treats about one million patients every 36 hours, almost all free of charge (NHS Choices, n.d.), and it is facing continued increased demand for services at a time of severe financial pressure. Austerity measures designed to tackle government budget deficits in the wake of the financial crises of 2007â8 have placed practically all organizations and staff in the NHS under added pressure. The NHS as a whole was ordered to achieve ÂŁ20 billion in cost savings out of a total budget of ÂŁ100 billion by 2015 (Taylor, 2013: 82). This is alongside the growth of anticipated funding shortfalls estimated at between ÂŁ20 billion and ÂŁ40 billion due to a growing and ageing population (Appleby et al., 2009: 2). Budget cutbacks are combined with pressures related to performance improvement and accountability to taxpayers and patients. With standards of NHS care officially under intense scrutiny (if not always in practice), the NHS is assailed by challenges and criticisms from_ government that wishes to reform the NHS in the direction of greater marketization and better value for money for taxpayers; from patient support groups such as Cure the NHS who regard the everyday working culture of the NHS as callous and uncaring; and from corporate interests that believe they can offer high-quality healthcare services at lower cost than traditional public providers such as NHS hospitals, mental health trusts, community services and ambulance services. Many trusts are in chronic financial distress (amounting to nearly a billion pounds in deficit in financial year 2014â15: Walshe and Smith, 2015). As the Chartered Institute of Public Finance and Accountancy (CIPFA) projected a ÂŁ2.1 billion deficit for 2015â16 â two and a half times the previous yearâs record â many previously financially sound foundation trusts have been brought into difficulty (CIPFA, 2015) and the financial position of the NHS âis indeed direâ (Walshe and Smith, 2015).
Many parts of the NHS are at the cutting edge of patient care and medical research. But other areas are woefully underfunded and un...
