Feature

It’s behind you

Foundation hospitals are being presented as a return to Labour’s mutual and co-operative roots. But this is just a political pantomime, says Rosamund Stock

We took the Guides to the pantomime after Christmas and I had the pleasure of watching a bunch of oh-so-cool 13 and 14 year olds screaming ‘It’s behind you’ at the comic duo with just as much enthusiasm as any six-year-old Brownie.

I have much the same impulse, although without the pleasure, faced with the people driving the foundation hospitals debate. ‘You are not even looking in the right direction,’ I want to yell.

To my co-operative colleagues who believe the extension of mutuality, with its emphasis on relationships and involvement, will improve health outcomes and strengthen communities, I would say unequivocally: you are being used.

The politicians, on the other hand, suffer from what Dominic Harrison in the last issue of healthmatters called ‘system agnosia’. They are simply incapable of recognising or comprehending systems and how they work.

Foundation hospitals must be seen in their political context: they are not about mutualising the health service, they are about ‘marketising’ it. Foundation hospitals are the Trojan horse, and a splendid wheeze they are too. It is difficult to object to them in principle: they clearly offer possibilities for greater local accountability, for involving people in their own health care and for becoming part of strong, integrated communities.

But that is not why the government is in favour of them. They represent a move to a plurality of providers. Health secretary Alan Milburn has promised that by 2005 all patients will be able to choose to be treated at a private hospital if they wish.

A plurality of providers has three useful functions. First, if your health service is open to a number of different providers then under the terms of the General Agreement on Trade in Services (GATS) you must open it providers from other countries on the same terms. You will not be permitted to favour home-grown local community trusts over large multinational health providers.

Second, it is one of the main planks in turning the health service into some kind of market system; the other primary elements are patient choice and the ‘money follows the patient’ principle.

There is a row going on, as I write, between chancellor Gordon Brown who thinks markets are a good idea but that there is not enough ‘consumer sovereignty’ in health care, and education secretary Charles Clarke and Mr Milburn who think the public should offered as much choice as possible.

But both still work within a basic market paradigm, they too are not looking in the right direction. For what both politicians and proponents of mutuality are missing is the way that the health service functions as a system.

Understanding the system

They assume that systems are basically self-righting – there are anomalies and specific problems but these are deviations from the norm of a stable, self-equilibrating system.

But even former health secretary Frank Dobson has realised foundation hospitals could lead to unequal outcomes because there are knock-on effects within a system.

The problem is that human behaviour is non-linear and dominated by positive feedback; the rest is mathematics. While it is traditional to measure attitudes, and even intentions, on graded, linear scales, behaviour is fundamentally non-linear. I either do or do not use my local hospital; I do not decide halfway there to choose a different hospital. And, more importantly, once I have used a particular hospital, I am considerably more likely to use it again.

I would like to support my local, and somewhat beleaguered hospital but there is a huge pile of notes at the other hospital involving several different departments. When something else goes wrong with me it makes a great deal of sense to go back to the same hospital, not least because as a patient I know my way round it, can find the cash machine and know what you have to do to get a porter when you need one.

Most human social behaviour is dominated by positive feedback: if you have done something once, you tend to do it again. Many basic social and interpersonal processes are also dominated by positive feedback: we give preferential treatment to those who are attractive and popular, to people we believe to be important and we infer that people are important from the way that others treat them.

These processes are the bread and butter of social psychology, they are often operating at a non-conscious level and they operate in dozens of tiny decisions and judgements as we go about our daily business. They are built into our social fabric. They are also the building blocks of discrimination and unequal treatment. We have seen what has happened with schools: a school that gets a bad reputation all too easily goes into a spiral of decline and can result in closure.

What happens, for example, if your local hospital finds its chest clinic is less than viable for reasons of local demography, the existence of a nearby specialist centre and, say, a bad financial year. Once people go to another hospital for one thing, however, they will prefer to go there for something else. And people who have no experience of the system may infer from the fact that most people go to hospital B that it is better than hospital A.

If you take a system that has a lot of positive feedback and give it a starting point of small random fluctuations, you can end up with a pattern of wildly diverging outcomes for different parts of the system. These reflect not the characteristics of the participants, not their deservingness, hard work, talent or achievements, but the process characteristics of the system. If you then make the system non-linear, you also have a problem with unpredictable and unstable systems.

This comes to the final characteristic sitting behind the politicians and the mutualisers: overall outcomes matter. And again agnosia strikes hard: in the influential Mutuo pamphlet setting out the case for mutuality in the NHS, health minister Hazel Blears writes: ‘It will be vital for all parts of the system to share the same values and to be interconnected and interdependent.’ Fine, but she has left out the important bit – what is the structure of that system?

For as long as resource allocation is a zero sum game, and for as long as there is resource scarcity or a finite number of patients, the components of the system will be competing. Put people into competitive situations and, unsurprisingly, they compete.

More than that, the reward structure – the distribution of resources and distributions – is, by definition, a system property, which has a profound effect upon a whole set of attitudes. Inequality leads to competitive or individualistic relations, divisive attitudes, less trust, less inclination to co-operate – differences become salient. Talk to people in voluntary organisations trapped in the competitive bidding culture. They also come to see inequality as fair and just. Equality, or greater equality, on the other hand, is associated with co-operation, seeing those around you as similar and a host of other more pro-social attitudes.

Work on the psychology of distributive justice suggests a two-way relationship between resource allocation and social relationships, and it appears to be a profound effect that can occur even in the teeth of people’s stated convictions. In other words, you can be as co-operatively inclined as you like, but if you are put into competition with other hospitals for patients, because with patients comes money, you will compete.

Intellectual dishonesty

The mutualisers argue that the present configuration of the NHS belongs to a former age and lacks relevance as well as leading to poor performance. Perhaps, but any discussion of the state of today’s NHS that fails to address the effect on a complex human organisation of 20 years of underfunding is basically dishonest.

Proponents of mutualisation also point out that 50 years of equal provision has resulted in greater health inequalities. To discuss health inequalities without mentioning income inequality is just as dishonest.

There is a staggering lack of comprehension of the system level effects of inequality. It is not being at the bottom of the heap alone that does the damage, it is being in an unequal heap in the first place. As I said, it’s behind you!