(Chapter 7 of Sick and Sicker: Essays on Class, Health and Health Care.)
As capitalism expands, it causes more damage to human health and increases the need for medical services. Escalating medical costs are compounded in nations with for-profit medical systems.
Capitalists need a reasonably fit work force. However, they cannot reduce the damage they do without cutting into profits, and they don’t want to pay more than necessary for medical care. Their solution is to cut costs in the medical system using the same methods they use in industry.
Before we examine how factory methods are being imposed on the medical system, let’s briefly review how these methods developed.
The Degradation of Work
For several hundred-thousand years, human beings worked and developed the skills necessary for survival. They taught these skills to their children who developed them further and then taught them to the next generation, and so on. This is how science, technology and society evolved.
Within the past two hundred years, most workers have been reduced to cogs in the machine, prevented from using their creativity and their judgment. What happened?
In Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century, Harry Braverman explains that for capitalists to gain control over production, workers had to lose control over the labor process.
During the early years of capitalism, peasant farmers were denied access to common lands and resources. Unable to make a living, the rural population was forced into the cities and into the factories.
Initially, capitalists needed skilled workers to manufacture saleable goods. Because capitalism is based on competition, every capitalist sought to beat his competitors by increasing productivity (raising more capital). Skilled workers presented a problem – they would work only so hard for so long. In the late 19th century, Frederick Winslow Taylor solved this problem by developing a method to transfer control of the labor process to the capitalist class.
Taylor’s first principle is to de-skill the labor process. Managers gather all the traditional knowledge possessed by the workers and reduce it to simple rules and formulas. Time-and-motion studies are one way to do this. Management can then re-design the work for maximum productivity.
Taylor’s second principle is to separate thought from action. All possible brain work is removed from the shop floor to the planning department. Those who make all the decisions do none of the actual work. Those who do all of the work make none of the decisions; they are reduced to “hands.”
Taylor’s third principle is for management to control every step of the labor process. Each worker is given detailed instructions describing the tasks to be accomplished, the method to be used and the time allotted. The worker is reduced to an animated tool of management, a general purpose machine, adaptable to a large range of simple tasks.
Observing Taylorism in practice, the 19th century writer John Ruskin observed,
“It is not, truly speaking the labor that is divided; but the men: divided into mere segments of men — broken into small fragments and crumbs of life; so that all the little piece of intelligence that is left in a man is not enough to make a pin, or a nail, but exhausts itself in making the point of a pin or the head of a nail.”1
Workers fought against a fully-managed process that stripped them of skills and subordinated them to machines. However, small workshops cannot compete with factories that produce large quantities of cheap goods. Most artisans were forced into these factories, leaving only a few to provide custom work for the upper and middle classes.
Because they proved so effective for cutting costs and subordinating the work force, Taylor’s methods spread to other sectors of the economy, including food service. Over the past 60 years, mom-and-pop eateries have been transformed into international chains of fast-food, assembly-line outlets. The same transformation is currently taking place in education and in the medical system.
Social Service Factories
“The latest attack on public education has come in forms that are familiar to many workers: de-skilling, speed-up, top-down mandates, and intense control by superiors over most aspects of working conditions.”2
Schools have adopted standardized testing, and classroom courses
“are scripting everything that happens in the classroom, right down to instructions on the appropriate hand gestures to make while teaching.”
As one principal instructed his teachers:
“When I stand in the hallway, I should be able to hear all fourth grade teachers saying the same thing. Do not deviate from the scripted program and do not fall behind in the pacing plan.” 3
Medicine has suffered a similar transformation.
Hospitals function like factories, where different departments attend to different parts of the body in assembly-line fashion, moving patients through the system within predetermined time limits.
In some places, medical care is rationalized across regions, so that a hospital in one city will specialize in pediatrics, a hospital in a different city will specialize in neurology, and so on. This process is described as “local health integration,”4 when it is actually a disintegration of services. Because local hospitals no longer offer full-service care, patients must travel much farther to access care, when they can afford to travel at all.
In 1985, a multi-disciplinary team of statisticians, physicians, economists and measurement specialists at Harvard University began to develop the Resources-Based Relative Value Schedule (RBRVS), which applies industrial time-and-motion studies to the practice of medicine.
The RBRVS ranks and rates physician services according to the time, mental effort, physical effort and stress required to perform those services. By 1992, the US government had switched Medicare to an RBRVS payment system.
The RBRVS has become the primary method for determining physician payments. However, it can be used for much more than that. Dissecting medical work into its component parts and pricing those parts makes it possible to apply the same de-skilling, dehumanizing methods that are so profitable in industry.
Under “managed care,” physicians who were trained to use skill and judgement to diagnose and treat patients are provided with detailed manuals listing the services to provide for each condition they encounter.
Management can also hire cheaper workers to perform the less-skilled portions of medical tasks. Wherever possible, physicians are being replaced with nurse practitioners; registered nurses with practical nurses; practical nurses with orderlies; orderlies with clerks, and so on.
The Impact on Health Workers
Today’s medical institutions are dominated by managers obsessed with budgets, “cost-efficiency” and “cost containment.” In contrast, the priority for health workers is providing patient care. The result is class conflict, as workers battle managers bent on making them do more for less at the expense of their health and the health of their patients. This conflict is global. In the following comments, nurses in the United States, Canada and Northern Ireland describe their experiences.
Eileen Prendiville works as a registered nurse in a San Francisco hospital:
With managed care, registered nurses were laid off by the thousands and replaced by unlicensed personnel and licensed practical nurses with less training. The registered nurses who remained were overworked and overstressed, and they left the profession in droves, creating an industry-wide shortage of RNs.
The California Nurses Association fought for passage of the first Nurse-to-Patient-Ratio law in California(5) to prevent more nurses from being laid off and to protect patients. Studies showed that patients in hospitals with more RNs had fewer hospital-acquired infections and better overall outcomes.
Despite legal challenges by the hospital industry to prevent enactment of the law, it passed, and many registered nurses returned to acute care. To keep costs down, hospitals cut ancillary staff such as unit clerks and practical nurses, making RNs do more non-nursing tasks.
As the economic downturn progressed from late 2008 to 2009 and the newly-unemployed lost their health insurance, my hospital froze our wages and imposed a hiring freeze.
Each department was required to cut its budget by at least 10 percent. Our full-time functional attendant who stocked our unit, ordered supplies and kept track of special equipment was laid off. Nurses, unit clerks and central service staff are now expected to pick up her duties. Lactation consultants were let go, and medical translators were laid off but asked to stay on a per-diem basis (without benefits). Vacated nursing positions were left unfilled for months, while the patient load remained high.
There are reports of managers in non-union units refusing to pay for missed meals and missed breaks and illegally altering time-cards to avoid paying overtime. All this to stay within their budgets.
Non-union employees are afraid to speak up for fear of losing their jobs. Unionized nurses who uphold the mandated standard of patient care are constantly harassed and disciplined for ridiculous and petty things.
RNs and other health workers have organized unions and umbrella organizations, like National Nurses United, to step up the fight for patient care. Members of the California Nurses Association have also joined the San Francisco Labor Council to advance our common interests.
Aisha Jahangir works as a registered nurse in an Ontario hospital:
I’ve been nursing for about 12 years now. When I first started, I was given the opportunity to care for the WHOLE patient. Nurse-patient ratios were a lot lower then. Nurses didn’t have as many patients to care for, so the nurse could devote more time and thought to her care. I had time to give my patients a nice back rub and other evening care. How have times changed!
Now, the only reference to evening care is about giving medications. Forget about back rubs. You won’t even find lotions to give one, let alone have the time.
My day is spent delivering meds and making sure patients are discharged before 11am, so housekeeping can turn the rooms around quickly enough to fill them with new admissions.
I am expected to please the manager and save the hospital money more than I am expected to make sure that my patients get quality care. I often stay late to document what I have done, because there is no time allotted in my shift for that. I wish that I could bring back all that we have lost.
When I first started, the maternity ward was divided into labor and delivery, postpartum, and the nursery. On the postpartum unit, you would normally have four sets of moms and babes to care for and a maximum of five or six. This gave nurses time to teach newborn care and provide breast-feeding support. All in all, the nurses felt that the work was manageable, and both patients and nurses were satisfied.
Then the hospital decided to turn the maternity ward into a labour-delivery-recovery-postpartum (LDRP) unit where each laboring nurse would be with one patient from admission to discharge. A lot of money was spent to cross-train the staff to work in all areas of labor and delivery, postpartum and the special-care nursery. It sounded good, but it didn’t work out.
Not enough rooms were built to accommodate all the moms, so we had to move patients through the system more quickly. There was resistance from staff who were expected to be skilled in all three areas, and we were often short on laboring nurses. This meant that once a laboring nurse had delivered her patient, she had to move quickly to the next laboring mom and never saw her patients through the whole process.
Our manager has cut back on supplies to save money, and we no longer provide much to patients.
Patients are instructed to bring a lot of things with them from home (especially pillows) because we often don’t even have one pillow per room. We provide only a few diapers, and it is getting tighter and tighter. Just recently the manager stopped ordering drinking straws.
The manager often stalls on replacing sick nurses, leaving us short. The end result is overworked, stressed-out nurses and patients not getting the care they deserve.
Patricia Campbell works as a registered community psychiatric nurse in Belfast, Northern Ireland:
Our National Health Service has changed significantly since its inception.
Privatisation took hold during the Thatcher years, and Labour continued Thatcher’s policies, dismantling a health service that was once the envy of the world.
While all NHS patients have health care in principle, the waiting lists for essential procedures and life-saving operations are increasing. As a result, many people are forced to go private.
In Northern Ireland, mental health services are grossly underfunded.
Young people requiring specialist treatment for eating disorders and personality disorders must go to England for treatment. They are effectively exiled from their own country, far away from their families and friends. So health care is not really available for all.
As the cuts bite deeper, frontline health workers are expected to do more for less. Well-paid bureaucrats have started at the bottom of the pay-scale, attacking the most vulnerable, lowest-paid workers first.
Administrative staff have already lost their jobs, and nurses and social workers are now expected to record meetings, answer phones, file notes, type, order supplies and deal with enquiries from the public. These duties are added on to our already extremely busy work schedule.
Meanwhile, flash-frozen meals that are prepared offsite (like the meals served on aeroplanes) are replacing freshly-cooked meals that were previously prepared for patients in the kitchens. Not only are patients losing out in terms of nutrition, cook-staff are being downgraded to food servers. Cooking skills are no longer required.
The work force is being reduced, and essential skills that benefit patients are being lost to benefit private companies.
We don’t have a strong union leadership here in Northern Ireland, and this is reflected in the way our health service is being run down. We are building a new union for health workers, because the existing unions are more interested in developing a relationship with management than in protecting the rights of patients and health workers.
Expanding Class Struggle
Hospitals that are run like factories are unsafe for workers and patients. Every year, an estimated 98,000 Americans die from preventable medical errors. And every year, another 99,000 patients die from hospital-acquired infections, most of which are also preventable. In total, the death toll from preventable medical injuries and infections in the US is close to 200,000 people per year, more than motor vehicle accidents, poisoning, firearms and falls combined.6
Ten years ago, a US federal report challenged the medical system to reduce this death toll by 50 percent within five years. None of report’s recommendations were implemented, with the result that another two million Americans died of preventable medical causes.
The key to prevention is high staff-to-patient ratios, so that health workers have enough time to tend to patients, to ensure that everything is done correctly, and to provide sanitary facilities and nutritious food.
Staff-to-patient ratios promote quality care. But capitalism is not about quality care. Its priority is to make profit and control the subsequent damage in the cheapest way possible. The hospital industry opposes staff-to-patient-ratios because they interfere with the ability of managers to cut costs and, in the private sector, to raise profits.
By expanding Taylorism to the service sector, capitalism has expanded the class struggle. Modern class conflict, born in the factories of the industrial revolution, has now spread to every school and every hospital. Opportunities have never been better to build a unified movement of the working-class.
1. Ruskin, J. (1897). The stones of Venice. Boston: Estes and Lauriat, Section II, Chapter VI, p.162.
2. Sides, M. (2005). Mandated programs push classroom de-skilling. Labor Notes, January 1.
3. Sides, M. (2005). Mandated programs push classroom de-skilling. Labor Notes, January 1.
4. Ontario Ministry of Health and Long-Term Care. Local Health Integration Networks.
5. California Department of Public Health. Nurse-to-Patient Staffing Ratio Regulations
6. Crowley, C.F. & Nalder, E. ( 2009). Dead by Mistake: Within health care hides massive, avoidable death toll. Hearst Newspapers, August 10.