JUST COUNT THE SUITS
Theodore Dalrymple gives a doctor's jaundiced
view of the exponential growth in health service bureaucracy
THERE IS nothing people in positions of Power (except for us doctors, of course) dislike so much as the truth, so it is no wonder that the Health Secretary, Mrs Virginia Bottomley, was cross with her Cabinet colleague, Mr Redwood, when he virtually admitted in public that the princi- pal function of the Health Service is to reduce white-collar unemployment. As Bernard Shaw makes a schoolgirl say of Shakespeare in one of his early and egre- gious novels, 'Silly old fool expects credit for saying things everyone knows!'
The most casual observer would be able to tell that bureaucracy has increased exponentially in our hospitals just by counting the number of bad double-breast- ed suits to be seen walking down the corri- dors nowadays. For some reason bureaucrats love these suits, which look all right in the shop, no doubt, but have a crumpled, slept-in appearance the moment they are actually worn.
Of course, like most profound but unde- sirable social trends, this one has been gathering pace for many years. My boss at the outset of my glorious medical career, nearly 20 years ago, used to take me to meetings with the management because he said it was good for my general education to plumb the depths of human folly. Little did he suspect the folly to come, whose depths, like those of the Almighty's love, there is no plumbing!
1 first realised that Management was an autonomous activity, completely unrelated to any other human purpose, when our wards went short of bedclothes. This was in part because £30,000 worth of new bed- clothes had recently been stolen by the Staff (but the Union, then in the heyday of its power, threatened action, or rather inaction, if the police were brought in to investigate), and partly because the laun- dry had just been reorganised along mod- ern Management principles, complete with People called Line Managers, so that what had previously taken a day to do now took two weeks, or wasn't done at all. It was winter, and our elderly patients on the wards were dying like flies, mainly of cold and exposure, wrapped as they were in flimsy gowns — of which there was a sud- den, unexplained excess — and paper tow- els which, faute de mieux, took the place of sheets and blankets.
Meanwhile, down in the overheated cor- ridors of power, where one had to remove one's jacket if one did not wish to contract heatstroke, the chief administrator was busy choosing new satin curtains for his office, and contracting also to buy some very expensive office gadgetry of dubious benefit to the health and welfare of the nation. Naive as I was in those days, I asked why the money for the curtains and office equipment couldn't be used instead for bedclothes for the freezing patients. It was as if 1 had suggested opening a Disney park in Mecca to a devout Muslim.
The expenditure for his office, I was told sternly, came under a different 'head'. What was earmarked for one purpose (`ring-fenced', in the new NHS jargon) could not be used for another, even in the event of a new Black Death. I realised then that when flexibility and self-interest did not coincide, it was the latter which would always win.
I must emphasise that all this took place in the good old days, several reforms of the Health Service ago, when junior doc- tors were still looked after by kindly wid- ows who cooked nourishing meals for them and made them cups of tea after a night on call. By now it is perfectly clear that ' any attempt to introduce efficiency into the service must increase inefficiency, and any attempt to reduce bureaucracy within it must increase it. Quite where this leaves policy makers, I am not sure.
Inefficiency can be quite easily mea- sured mathematically, however, and I have developed a few standard measures: for example, the weight of circulars sent by hospital administrators to consultants per week (in pounds avoirdupois), divided by the average number of patients per clinic who fail to keep their appointments and do not telephone to cancel them. Alterna- tively, one can multiply the number of hours a doctor spends on administration per week by the minutes he spends on the telephone trying to get hold of a social worker, divided by the number of sand- wiches provided per participant at lunchtime meetings (a constantly declining figure, in an attempt to control costs).
Last week, the General Manager called us all to a meeting to explain that our hospital had a very bad local reputation. This, he hastened to add, was no reflection on us: we were, individually and collectively, fine men and women, highly competent, moti- vated, caring etc. Nevertheless, our hospital was known everywhere as an antechamber to the cemetery. This was bad for business.
For business? What did he mean? At that very moment there were a hundred people in the casualty department and all the beds in the hospital were full. I have never seen so many patients, so either there had been an outbreak of the death wish in our area, or the hospital didn't have the reputation imputed to it.
The General Manager went on to clarify what he meant. He wasn't endorsing the local opinion of our hospital, and he didn't believe it was true; it was, he said, 'a per- ception', not what he called 'a reality'. What we needed to do, collectively speak- ing, was to sell ourselves.
Well, you didn't have to be Nostradamus to see what was coming next. Yes, what we needed was better public relations. But of course, being only doctors, we didn't really know how to go about improving them; therefore, what we needed was a public relations officer. He had in mind just the man we needed to project our image into what he called, in an ill-chosen word con- sidering the mayhem outside the hospital gates, the 'community'.
What would his salary be? asked one sus- picious colleague. Well, he had kindly con- sented to join the hospital staff when a glittering career was opening up to him elsewhere, so we couldn't have expected him to come cheaply. At a rough estimate, I would put his salary at upwards of 890,000 lunchtime sandwich units.
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