Who Was Accountable for the Shambles?

A novel about an historical event reminds us of the health redisorganisation of the 1990s, raising issues remaining relevant to today. 

I puzzle at how politicians and advisers can make giant mistakes but are never held accountable. The notion of accountability became fashionable in the neoliberal changes of the 1980s and many people further down in the system now work under tighter surveillance than they did then. But others, especially those higher up in the hierarchy, completely avoided accountability despite having been deeply engaged in, and supportive of, policies which proved disastrous.

I was once more faced with the puzzle when reading Ian Cowan’s novel, Not Our Problem, based on the health redisorganisation of the early 1990s. Cowan is a consultant radiologist working at the Canterbury District Health Board. However the novel’s hero, Stephen Cassidy, is a talented surgical trainee. He suffers burnout and takes a year off, joining the managers trying to implement the redisorganisation in Paxton hospital, a thinly disguised Christchurch one.

Note I increasingly avoid the word ‘reform’ with its overtones of ‘improvements’. Too often, despite the hype of the advocates, their changes do not improve the situation much – often making things worse. Such it was with the health redisorganisation, a neoliberal attempt to impose commercial practices without any understanding the reasons why the public sector organisations existed; their purpose cannot be summarised in a single output variable such as profit.

By joining those involved in the implementation, with responsibilities for staff liaison, Stephen is nicely – for the novel – placed as the ham in the sandwich between the two sides of the controversy which is at the centre of the novel and which occurred at the time. The confrontation is reported in one form or another in page after page. It is nicely captured in this passage (Claudia represents the funding agency, a Regional Health Authority (RHA), one of the institutions deeply involved in the implementation.)

            ‘And you think I’ll tell somebody with a new cancer that we can’t treat him because of an externality do you?’ Cassidy laughed. ‘I don’t think so. No Paxton doctor would do that’.

            ‘Why not.’

           ‘Because it would be immoral. And unethical. And unfair ... don’t you agree?’

            She chewed for a moment . ‘I don’t have an opinion on it.’

            “What? How can you not have an opinion on something as important as that?’

            My job is to make sure the RHA is protected from risk,’ said Claudia, ‘and that’s what I do. If they had employed me to debate ethics I would, but they didn’t so I don’t.’

The clash here is between two different approaches to one’s job. Stephen is a professional steeped in an ethic which places responsibility at the centre of an individual’s performance; Claudia is a manager who is accountable for what she is contracted to do.

Actually Claudia is a ‘generic’ manager. That is, she knows nothing (or very little) about what she is managing and so is unable to take into consideration the particularities involved. She, like most of the other managers in the novel (and, in my experience, in practice), constantly stumbles against the realities of what they are managing. An example, not used in the novel, is that managers insisted that bed usage in wards be increased, without understanding that the more intensively they are used the more likely there will be cross-infection. Doctors tell me that people died as a result. I’ll leave you to read the novel for many other examples.

Yes, people died as a result of redisorganisation, many more experienced greater discomfort, and – as the novel details – resources were wasted. Managers rarely take into consideration the resources they are using in order to save resources. I think Cowan is broadly correct in that the additional resources used by the managers to govern the professionals roughly outweighed the ‘gains’ in efficiency the managers made, while quality deteriorated.

The novel’s portrayal of the medical profession is much as I recall them at the time. Totally committed to their profession and hence to their patients but baffled by what was going on; Stephen, though, is well informed – the book is backed by numerous references. The portrayal of the generic managers is of people who are arrogant and obsessed by a theory which proved wrong while ignoring contradicting evidence; occasionally their humanity breaks though. My memory suggests the picture is a bit harsh, although that is certainly the way that most came across in public.

The novel chronicles the collapse of the redisorganisation (it actually took longer than the story’s span), as time and again reality stopped the plans of the managers. In summary, no gain; plenty of pain. But the reality was supplemented by stout resistance from professions in the health sector  – who the managers describe as ‘vested interests’ – and the public.

This happened two decades ago but the novel, as well as being a contribution to the historical record, remains pertinent today. The clash between professionals and managers occurred not only in the health service, but also in the universities, in science and in many other parts of the public sector. The point is that a properly regulated private sector business can contribute to our welfare, but many activities cannot be so regulated and it is better to make use of professional responsibility. As we undermine professionalism, we get an inferior job done.

The central problem is captured in the novel’s title. The managers thought the delivery of health care was not their problem while the health professionals tended to ignore the resource restraints which the managers faced. When, before the redisorganisation, I used to teach health economics sixth-year medical students I would write on the board in large letter ‘either doctors take responsibility for the resources they use or accountants will make medical decisions’. The message glared, making some of the students profoundly uncomfortable, for they saw their job was to save lives – not to worry how much it cost.

Cowan nicely captures the shambles of the redisorganisation. Despite its almost total failure, the novel describes managers totally captured by the neoliberal ideology and totally confident they could deliver although a few are doubters by the novel ends (including Claudia).

It is unlikely one of the committed managers will write a novel defending what they did; I guess they would say in the dock, as they do in the novel, they were only doing what they were contracted to do. (As the trial of Adolf Eichmann, an SS officer and organiser of the Holocaust, reminds us, following orders is not a defence.) I suspect few recall their contribution with pride, if they remember at all. Stephen Cassidy will; thankyou Ian Cowan for reminding us.