[… comment removed… ]
Is business really the best way to manage government, also health care?
Government certainly needs to be managed, but management also needs to be governed. It cannot just be let loose on public services, especially in the form of the “New Public Management” that imitates fashionable practices in business. Governments no more need to be run like businesses than businesses need to be run like governments.
The New Public Management, a label for old corporate practices, seeks to (a) isolate public services so that (b) each can be run by an individual manager (preferably called a CEO), who is (c) held accountable for quantitate measures of performance, while (d) treating the recipient of these services as “customers.” Let’s take a look at all this.
Am I a customer of my government? I am a citizen, thank you, not a mere customer of my government, who buy services at arm’s length in the marketplace of caveat emptor (“let the buyer beware”). Do I really need to be called a “customer” to be treated decently? Are soldiers drafted in wartime customers of the government they are expected to serve? And criminals: are they customers of the justice system? I may be a customer of the state lottery, but frankly, does government have any business encouraging me to gamble.
Can government services be isolated from each other, as well as from political influences, so they can be managed by their managers? Sure sometimes—back to that state lottery. But how about diplomacy? Can a government really have one brand manager for waging a war and another for diplomatic negotiations to end it?
What’s the bottom line in government? Governments don’t have a bottom line; they has all kinds of them—[diplomacy, protection of the citizens, education of children, and so on]—many of which are can be vague and conflicting.
Is just government bureaucratic? Ask people who work in big business about that. (Better still, read Dilbert.) it is no coincidence that two of the most popular best ways in the history of management—time and motion studies to control employees hands and strategic planning systems to control their brains—have been embraced most enthusiastically by communist governments and Weston corporations.
As a consequence of all this, much of public service now ambles about like an amnesiac, pretending to be business.
And so does much of health care.
I am not my doctors’ customer, thank you. These people are professionals with whom I trust my health. I don’t give some hospital my business because I am a buyer who wishes to beware; I must give it my trust because I have no easy way to judge its competence. Nor do I “consume” health care services, because they might consume me. I hope that my physicians and nurses are not human resources who need to be “empowered” as workers, but human beings who are engaged in their calling. To any manager in a hospital who needs a mission statement, I say: find a job somewhere else.
When administrators try to manage a hospital like a factory, they hit what can be called the great divide of health care, when their technocratic fixes coming down the hierarchy meet the protocols of the professional services. The two mix like oil and water. [REF Myths book and BMJ article]
Do most physicians, nurses, and other health care professionals work as conscientiously as they do, in the face of so much pressure, and frustration, in order to maximize “value “on some bottom line? No. As Abe Fuks put it, they have “a latent drive…to do the right thing.”