Constructing notions of healthcare productivity

17 Pages·2014·0.12 MB·English

Sociology of Health& IllnessVol. 36No.5 2014ISSN0141-9889, pp. 686–702
doi:10.1111/1467-9566.12093
Constructing notions of healthcare productivity: the call
for a new professionalism?
Fiona Moffatt1, Paul Martin2 and Stephen Timmons1
1School of Health Sciences, University of Nottingham
2Department of Sociological Studies, University of Sheffield
Abstract Improving performance is an imperative for most healthcare systems in
industrialised countries. This article considers one such system, the UK’s National
Health Service (NHS). Recent NHS reforms and strategies have advocated
improved healthcare productivity as a fundamental objective of policy and
professional work. This article explores the construction of productivity in
contemporary NHS discourse, analysing it via the Foucauldian concept of
governmentality. In this manner it is possible to investigate claims that the
commodification of health work constitutes a threat to autonomy, and counter that
with an alternative view from a perspective of neoliberal self-governance.
Contemporary policy documents pertaining to NHS productivity were analysed
using discourse analysis to examine the way in which productivity was framed and
how responsibility for inefficient resource use, and possible solutions, were
constructed. Data reveals the notion of productivity as problematic, with
professionals as key protagonists. A common narrative identifies traditional NHS
command/control principles as having failed to engage professionals or having
been actively obstructed by them. In contrast, new productivity narratives are
framed as direct appeals to professionalism. These new narratives do not support
deprofessionalisation, but rather reconstruct responsibilities, what might be called
‘new professionalism’, in which productivity is identified as an individualised
professional duty.
Keywords: productivity, professions, professionalism, health care, governmentality
Introduction
The performance of healthcare systems has come under increasing scrutiny as global trends
mean that both costs and demand escalate. Improving healthcare productivity is deemed a
universal challenge (Numerato et al. 2012). This article examines one such healthcare system,
the UK’s National Health Service (NHS), and questions the implications of improving
healthcare productivity for contemporary professionalism.
In the traditional sociological literature the professions were widely seen as self-governing,
with social control of the professional achieved via ‘the silent pressure of opinion and
tradition… which is around him [sic] throughout his professional career’ (Carr-Saunders and
Wilson 1933: 403). This theorisation of professional characteristics was intended to support a
role viewed as creative and discretionary, rather than one constrained by stifling, conformist
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Constructing notions ofhealthcare productivity 687
norms (Parsons 1951). During the last half century, however, the validity of this conception of
social control became increasingly questioned, with professions often being depicted as
self-serving and injudiciously controlled (Freidson 1984). Sociological interest turned from a
functionalist approach to one characterised by conflict or power theories, where the focus was
on occupational monopoly and the protection of professional jurisdiction (Abbott 1988,
Johnson 1972, Larson 1977). Political and economic transformations during this time initiated
numerous strategies intended to increase state or managerial control over the professions. As a
result, a new sociological perspective emerged, theorising that a change in social control
mechanisms (principally bureaucratisation) was responsible for eroding professional autonomy
(Elston 2004, Ritzer and Walczak 1988).
In the UK NHS the perceived need to extend control over the professions was invariably
predicated on some notion of a ‘crisis’: whether that of rising costs, increased public expecta-
tions and demand, inefficient management or budgetary constraints. Early NHS crises were
mainly issues for government and had few ramifications for NHS staff, but these ramifications
increased over time as more extensive efforts were made to reform the supply side of
healthcare provision. Given the currently widely reported and egregious failings of NHS care
(Francis 2013) and the ongoing economic constraints, the current crisis is one that is also
framed by critiques of practitioners’ professional ethics, their failure in compassionate care,
their inefficient use of resources and their failing productivity.
Anxieties over the management of NHS resources have existed for many years and
concerted government efforts have been made from the early 1980s to create a less paternalis-
tic, more business-like service via the introduction of private sector management practices
(Doolin 2002; Kirkpatrick and Lucio 1995, Lapsley 1997). The alignment of clinicians with
policy has been a key issue because of the considerable clinical autonomy that the health
professions, predominantly medicine, have historically been granted (Ham 2009). Attempts
have nonetheless been made by the state to influence professional behaviour in the use of
health resources. Resource management and productivity initiatives have generally been
circumscribed by managerialism and directed at a cadre of senior clinicians rather than
professionals en masse (Pollitt et al. 1988). It is claimed that there has been a strong sense
among the professions that doctors’ and nurses’ professional responsibilities lay in patient care,
while managers would only be concerned with ‘industrial style management with all associated
ideas of productivity, efficiency and the consequent financial restraints’ (Salvage 1985: 158).
Consequently, professionals have interpreted such managerialism as an intrusion ‘into the
sacrosanct ethical world of professional and caring values’ (Cox 1992: 32).
The devolution of fiscal responsibility to certain professionals has continued, with both doc-
tors and nurses assuming greater responsibility for the utilisation of NHS resources, resulting
in professional restratification (Freidson 1988) and the development of ‘new’ professional roles
for individuals such as clinical directors and nurse managers, a case of poachers turned game-
keepers (Ham 2009) or professional mediators (Spyridonidis and Calnan 2011).
However, this notion of professional responsibility for resource management has continued
to develop and in this article it will be argued that an ethos of a ‘new professionalism’ is now
visible in NHS policy and reports, which is directed not just at the professional elite but at all
clinicians. Consequently, this article aims to explore the emerging notion of a new profession-
alism, specifically via the construction of productivity in contemporary NHS policy discourse.
In particular, the article asks how NHS policy discourse constructs the rights and duties of the
professions in the context of responsible productivity in health care and what consequences
this has for professional autonomy.
The article is structured in six sections. In the first section the nature of the productivity
crisis is presented from a historical context while the second discusses neoliberal reform and
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its influence upon the professions. Sections three and four describe the conceptual framework
and the methodological process. Section five presents and discusses the empirical work, while
the final section offers some conclusions.
The ‘problem’ of productivity
From the inception of the NHS, the state has harboured concerns over the growing costs of
health care and has made repeated attempts to improve health service productivity (Ahmed
and Cadenhead 1998, Lapsley 1997). Since the 1980s these strategies have been defined by
new public management (NPM) with increased emphasis and transparency regarding
performance and output relative to costs (Bezes et al. 2012). With the advent of the ‘New
Labour’ government in 1997 came comprehensive plans to reform a NHS that was perceived
to be underfunded, lacking in national standards and devoid of levers for improving
performance. The White Paper, The New NHS Modern, Dependable (Department of Health
[DH] 1997) and subsequent NHS Plan (DH 2000) constituted a radical modernisation
programme that sought to preserve the founding principles of the NHS but situate them within
the regulatory structure of a managed market.
TheLabourgovernmentwerecommittedtothenotionofamarketthatcould‘jolttheNHSinto
better productivity’ (Toynbee 2007: 1031). An integral part of this plan was a large increase in
NHS funding designed to make healthcare spending comparable with other western European
countries (Klein 2006). In the April 2002 budget an unprecedented rise in NHS funding was
unveiledbutwiththecaveatthattheprofessionsandservicemustbemodernised(NationalAudit
Office [NAO] 2010). The role of accounting became increasingly predominant in policy design
withbudgetsalignedtoclinicalresponsibilitiesandcostsalliedwithefficacyandqualityofcare,
for example, payment by results, and NHS performance frameworks (Ellwood 2009, Lapsley
2008).Inthiswaythetraditionalpublicsectoraccountingfocusincreasinglymovedfromoneof
stewardshiptooneofproductivityandperformance(BroadbentandGuthrie1992).Theinfluence
of scientific-bureaucratic medicine (including evidence-based practice (EBP) and National Insti-
tute for Health and Clinical Excellence [NICE] guidelines) also became increasingly manifest in
NHSpolicyduringthe1990s,advocatingthedeliveryofclinicalservicesthatweredrivenbyevi-
dence of both clinical effectiveness and cost-effectiveness (NHS Executive 1996). However, in
practiceopinionswerepolarisedandmanyhealthcareprofessionalsfearedthattheEBPparadigm
threatenedclinicalautonomyandthe‘art’ofmedicine, andwouldbecommandeered bymanag-
ersasanexerciseinstandardisationthathadthesoleintentionofcurbingexpense(Harrisonand
Checkland 2009, Kuhlmann 2006). Indeed, there is limited evidence that this strategy success-
fullyreducedcosts(Farquharet al.2002).
Despite high levels of growth in funding, a major financial crisis developed in 2005 when it
became apparent that much of the additional monies had been consumed by pay agreements,
capital expenditure, negligence claims, drug costs and meeting NICE recommendations. There
was growing concern that the return on the investment was far from adequate. The effects of
the financial injection produced a number of positive results, such as improvements in waiting
times, quality of care and public satisfaction (Dixon 2012) but there was evidence that hospital
activity had not increased accordingly, and consequently productivity was reported to have
declined (House of Commons Committee of Public Accounts [HoCCPA] 2011). As such, the
nature of the NHS crisis had shifted from being an external crisis of funding to an internal
crisis of productivity. It was also suggested that most clinicians remained disengaged from
reform or actively obstructed it (Dixon 2012). Financial problems escalated further when the
global economy was adversely affected by the collapse of the banking system. Compounding
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factors included mounting public expectations, the development of expensive technologies and
drugs, the changing nature of disease and an aging population (DH 2008). Consequently, in
the NHS Chief Executive’s Report for 2008–2009 it was announced that unprecedented
efficiency savings of up to £20bn would have to be achieved by 2014 (the so-called Nicholson
challenge) and improving healthcare productivity was identified as being critical to this
endeavour (Nicholson 2009).
Contemporary policy documents and reports have reflected the policy imperative to improve
healthcare productivity (Table 1) and this has been specifically addressed in the DH’s
programme: ‘quality, innovation, productivity and prevention’ (QIPP) (DH 2010a). The
publicationofa clinicians’ guide set the agenda as one thatall healthcarestaff hada role in deliv-
ering (Royal Pharmaceutical Society 2012). A complicating factor, however, is that healthcare
productivity remains an elusive metric to capture (Hurst and Williams 2012). While quantitative
measures have been valued in traditional production processes it is recognised that these are not
necessarily applicable to knowledge-intensive organisations (Antikainen and L€onnqvist 2005).
Arguably, the notion of hospital activity may be viewed as a contentious measure of productivity,
particularly given the contemporaneous drive to manage both acute and chronic conditions in the
community setting (Royal College of Physicians 2012). Black et al. (2006) argue that even with
quality-focused approaches productivity remains contentious. Indeed, most recently Black (2012)
suggests that, given improvements in mortality rates, evidence-based practice and patient satisfac-
tion the notion of declining healthcare productivity may be a myth perpetuated for political gain.
Despite the complexity of healthcare productivity and the potential for numerous interpreta-
tions of it, at the time of writing the state remains committed to driving improvements in
healthcare productivity. The potential effects of such an approach on professional groups are
discussed in the following section.
Table 1 Keyproductivity documents
Year of
Document publication Publisher/author
What isProductivity? 2006 NHSConfederation
OurFuture HealthSecured 2007 TheKing’s Fund.
(Wanless et al.2007)
HighQuality Care ForAll. 2008 DH
NHS NextStage Review Final Report
NHS 2010–2015:From Good toGreat. 2009 DH
Preventative, People-Centred, Productive
TheNHS Quality, Innovation,Productivity 2010a DH
andPrevention Challenge:anIntroduction
for Clinicians.
EquityandExcellence: Liberating the NHS 2010b DH
Valuefor Moneyin the NHS 2010 Houseof Commons
HealthCommittee (HoCHC)
Improving NHSProductivity. More With 2010 TheKing’s Fund.
TheSame NotMore Ofthe Same. (Appleby etal.2010)
Management of NHSHospital Productivity 2010 National AuditOffice(NAO)
Management of NHSHospital Productivity 2011 Houseof Commons Committee
(26th Reportof Session2010–11) of Public Accounts(HoCCPA)
CanNHS Hospitals DoMore with Less? 2012 Nuffield Trust.
(Hurst andWilliams 2012)
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Are professionals losing their autonomy?
In any process of healthcare reform a critical concern is the reluctance of health professionals
to adopt managerial values and priorities. This is often played out via the manifestation of a
‘tension between professional values encapsulated within the doctrine of clinical autonomy
and managerial demands for improved efficiency, cost control and accountability’ (Forbes
et al. 2004: 168). Consequently, it could be argued that productivity improvement policies
may be construed by healthcare professionals as an attack on their autonomy or an attempt to
devalue or commodify their unique contribution by diluting professional values and cultural
norms (Sox 2007).
Ackroyd et al. (2007: 10) have previously discussed the intent of NPM to:
Induce a movement from the traditional pattern of administered services (in which profes-
sional ideas about services were dominant) to managed provision and an emphasis on
efficiency (in which professional priorities may be overridden).
In their study the outcomes of reform were shown to be highly variable, with health care in
particular still demonstrating the influence of traditional, entrenched patterns of custodial
administration. The authors attributed this to the ‘professional values and institutions against
which reforms were directed’ (Ackroyd et al. 2007: 10), in particular the ‘public service
ethos’, which may have constituted an uncomfortable bedfellow to strategies related to
management objectives of efficiency control (Ackroyd et al. 2007: 23).
Evetts (2011) considers the links between NPM and the potential emergence of a ‘new pro-
fessionalism’. She argues that while there is clear evidence of change, there are also elements
of continuity. She characterises this changing tide as a drift between two ideal types – organi-
sational and occupational professionalism – where notions of traditional professional values
(occupational professionalism) are ever more influenced by discourses of organisational profes-
sionalism: bureaucratic accountability rather than collegiality; the predominance of organisa-
tional over professional values; financial rationalisation; performance review and targets and
increased state control (Evetts 2006, Pickard 2009). Such a commodification of health care
may therefore be viewed as a threat to professional autonomy, particularly if the impetus
comes from above rather than from within the profession (Evetts 2003, Bezes et al. 2012). For
some, these reforms are conceptualised by the thesis of deprofessionalisation (Elston 2004,
Haug 1988), whereby professions are reconstituted via:
A decline in the possession, or perception that the professions possess, altruism, autonomy,
authority over clients, general systematic knowledge, distinctive occupational culture, and
community and legal recognition. (Ritzer and Walczac, 1988: 6)
It could, however, be argued that the sociological focus of deprofessionalisation is unidirec-
tional and deterministic and may overlook perspectives that other conceptual frameworks offer
(Bezes et al. 2012, Petrakaki et al. 2012). In their review of managerialism on medical profes-
sionalism, Numerato et al. (2012: 637) state that the interplay between professionalism and
management is more nuanced than overt ‘clashes, hegemony and resistance’. Consequently, in
this article a conceptual framework was selected that was deemed to be better able to reflect
this position by considering the potential dynamics between occupational and governmental
logics, sovereignty and autonomy (Rose and Miller 2010).
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Conceptual framework
The aim of this article is to establish how productivity discourse constructs the responsibilities
and duties of the healthcare professions and elucidates the hegemonic processes. As an
alternative to the deprofessionalisation thesis that focuses on the explicit loss of autonomy, this
article uses a perspective arising from the Foucauldian concept of governmentality in order to
address the characteristics of power and knowledge in this context (Foucault 1991).
Governmentality is defined as ‘the dual process of problematizing and acting on individual
behaviours … shap[ing] and manag[ing] “personal” conduct without violating its formally
private status’ (Miller and Rose 2008: 12). Problematisation refers to the process of rendering
something a problem to be addressed. One starting point for this is to question how these
problems are constructed and made visible in multiple domains by multiple agents. At some
point the problems are expressed in terms of formalised knowledge, evaluated relative to
certain norms and associated with diverse socioeconomic concerns (Miller and Rose 1995).
Within this framework it becomes almost inevitable that some aspect of agential conduct will
be held responsible. Two distinct components of the art of governing are described;
rationalities (forms of knowledge that claim the status of truth) and technologies (instruments
for operationalising rationalities and governing from a distance).
Governance therefore involves the responsibilisation of autonomous individuals, the
encouragement of self-governance and the establishment of indirect control from a distance
rather than overt or direct intervention. In rendering individuals or collective groups responsible
for a particular social risk (in this case failing healthcare productivity or an economically unvi-
able healthcare service), the problem is transformed into one of self-governance. Lemke
explains,‘thekeyfeatureoftheneo-liberalrationalityisthecongruenceitendeavourstoachieve
betweenaresponsibleandmoralindividualandaneconomic-rationalactor’(Lemke2001:201).
Thisisthesuggestionthatprofessionsneedtorelegitimisetheirpositionbyincorporatingmarket
criteria into their accountability as professionals (Fournier 1999). In doing so, professionals are
effectivelyalignedwithparticularpoliticalobjectives(Doolin2002). Encouragingindividualsto
pursue such a project has potential symbolic and material benefits for the individuals involved,
includingtheperceptionofkeepingexternalcontrolatarm’slength.
A governmentality perspective therefore allows the exploration of the contours of power
within reforms (Doolin 2002) and a critical examination of the rationalities and technologies
that endeavour to connect the lives of the actors to the aspirations of the authorities (Rose and
Miller 2010, Winch et al. 2002). Following Miller and Rose (2008), the pertinent analytical
questions for this study relate to the rationalities and technologies of government utilised in
the construction of professional rights and responsibilities via productivity discourse; in
particular, how the state aims to exert influence over the professions; how such wishes are
articulated; what sort of knowledge claims underpin schemes for intervention; what
professional understandings have been acted upon and how this may shape or reshape the way
in which professionals construct and enact their identity.
Methods
The methodological objective of this study was to explore the development of productivity
discourse and the construction of professional responsibilities therein via analysis of key
documents from a noted turning point (Table 1). The concepts of efficiency, productivity and
resource management or allocation are not new to NHS policy (Lapsley and Schofield 2009).
Indeed Pollock (2005) states that one of the main drivers for hospital policy after 1991 was
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the perpetual quest for efficiencies. Around the early years of the 21st century, however,
healthcare productivity became a much more widely mobilised concept in policy and in the
professional literature. This was evident both in terms of increasing frequency and potency.
Many documents were dedicated solely to this issue of productivity. This watershed appears
to be marked by a synergy of factors, including the government’s unprecedented investment
in the NHS, the onset of the fiscal crisis, the Nicholson challenge and the improved accuracy
and sophistication of national efforts to collect healthcare output data (Street 2009). Conse-
quently, public policy documents, influential reports and minutes of House of Commons select
committee meetings published between 2006 and April 2012 were selected for their direct
reference to NHS productivity, efficiency or value for money as a major theme. While the
King’s Fund and Nuffield Trust reports do not originate from the NHS it is acknowledged
that, as authoritative, independent think-tanks, both organisations are influential in shaping
policy and transforming services. Such an approach is also consistent with the conceptual
framework, as the concept of governmentality acknowledges the existence of multiple sources
and agents.
All documents were coded by thorough and repeated reading for both implicit and explicit
constructions of productivity. Of primary interest were the productivity discourses that bore
relevance to the responsibilisation of healthcare professionals. Attention was paid both to
recurring themes and any inconsistencies or deviations from dominant discourses. The data
were subsequently analysed via an interpretative discourse analytic approach as discourse is
the system of action through which government is orchestrated (Rose and Miller 2010).
Analysis
Productivity as a problem
A key discursive construction of productivity in the selected texts is a pejorative one, whereby
recent productivity in health care is presented as being generically problematic. This is the
process of problematisation identified as a starting point in the governmentality conceptual
framework. The documents refer to ‘ten years of almost continuous decline’ in hospital
productivity (HoCCPA 2011: 7) and ‘a tragic missed opportunity’ to secure value for money
(HoCCPA 2011: Ev1). In the minutes of the HoCCPA, the state of hospital productivity is
repeatedly referred to as ‘depressing’ (House of Commons Committee of Public Accounts
2011: Ev2) with the chair asking ‘why has it gone so bad?’ (HoCCPA 2011: Ev6). It is
suggested that transforming healthcare productivity is viewed as a necessary discipline
(DH 2010b: 43).
How healthcare productivity becomes an object of possible knowledge is more complex.
Professional productivity is made quantifiable in a number of arenas, being depicted in terms
of statistics, charts and graphs and discussed in the terminology of economists and
accountants. In this way, health care becomes permeable to other bodies of expertise (Miller
1998). Information is accumulated and compared and NHS institutions are league-tabled. This
focus on quantification emphasises the pre-eminence of commercial accounting practices that
underpin the NPM approach (Lapsley 1999). Within the data also lie repeated references to
the difficulty of measuring healthcare productivity (NHS Confederation 2006, NAO 2010).
There is a belief that the DH and the Office for National Statistics are embroiled in a ‘quarrel’
over the definition of productivity (HoCCPA 2011: Ev2) and the productivity dilemma is
framed as one imbued with considerable uncertainty (HoCCPA 2011).
This position is supported by the King’s Fund (Wanless et al. 2007), who claim that
depending upon the assumptions made, changes in productivity may have ranged from minus
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7.5 per cent to plus 8.5 per cent between 1999 and 2004. Consequently they propose that
because of the ongoing debate over how productivity can be measured, it is probably ‘not
sensible to draw definitive conclusions about changes in productivity’ (Wanless et al. 2007:
26). One could argue that in governmentality terms the measurement of productivity
constitutes a calculative technology of government, but is problematic in its own right and
therefore potentially contestable. However, despite the acknowledged ambiguity over the
measurement of productivity, the key message from these documents is that the financial
deficit will not be resolved without a marked increase in hospital productivity, and that failure
to secure it could jeopardise the long-term future of the NHS (Wanless et al. 2007).
Having problematised healthcare productivity, the scene is set for ascribing responsibility to
some aspect of conduct, and developing the rationalities and technologies necessary for
government.
Healthcare professionals as part of the productivity problem
In the primary data there are numerous examples of healthcare professionals who have been
implicated as the contributory cause of the productivity problem. A notable theme is the
perceived requirement for a fundamental cultural change in the NHS both in terms of the ways
in which professionals work and the ways in which they are managed. It is recognised that a
significant proportion of hospital costs can be attributed to pay (Hurst and Williams 2012):
Where does the NHS spend its money? It spends it predominantly on people… If the NHS
is going to become more productive, it has to employ its people more productively and in
different ways. (HoCHC 2010: Ev2)
Since 2005 a series of pay reforms have increased these costs further and yet it is claimed that
staff have not been managed in such a way that performance manages their productivity
(House of Commons Health Committee [HoCHC] 2010, NAO 2010). The NAO states that
there is no evidence of a widespread cultural change that would have been essential if these
reforms were to be used to optimise productivity. As a consequence, the changes made
‘employees richer and the NHS poorer’ (HoCHC 2010: Ev33).
This criticism is also applied to healthcare professionals more generally, as it is claimed that
the standardisation of professional and clinical performance across the NHS would liberate
substantial savings, exceeding those that are deemed achievable by reducing management
costs, back office support functions and procurement (£1.8 billion per annum) or by transform-
ing the management of chronic conditions (£2.7 billion per annum) (DH 2009). As such,
productivity is presented not just in terms of failing, but also in terms of what could be
achieved. This reflects the notion of government as both a representation and an intervention
(Miller and Rose 2008). NHS staff are reminded that poorer quality care during periods of
financial challenge is ‘indefensible when the scope for improving quality and productivity is
still so great’ (DH 2009: 11). This constitutes a pre-emptive strike intended to counter
arguments that driving productivity will inevitably be detrimental to quality and safety. The
evidence is presented as being indicative of a missed opportunity, particularly given the period
of growth in the NHS following considerable financial investment:
When I [chair HoCCPA] look at the headcount numbers from around the country, it doesn’t
reflect the sort of reductions we would expect from developing new ways of working, from
moving forward in the way we had planned to be more productive and more efficient.
(HoCCPA 2011: Ev2)
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There is also a suggestion that there may be professional obstruction that requires conquering
(House of Commons Committee of Public Accounts 2011: Ev2). These discourses become
more overt in terms of the attribution of blame. For example, in evidence provided by a
professor of economics to the HoCHC (2010: Ev32), it is proposed that methods to reduce the
variation in practice (and therefore improve productivity) have been advocated for at least
30 years and that it ‘is time to challenge the dinosaurs that resist contract enforcement,
challenges to clinical practice variations and innovative and potentially cost effective changes
in skill mix’ (HoCHC 2010: Ev38).
The issue of skill mix is also highlighted elsewhere (Appleby et al. 2010) with claims
that inflexible role demarcations between professional groups have obstructed patient-focused
care and perpetuated inefficient practice. In this context professionalism is depicted as being
self-serving and relatively resistant to strategies based on command and control. As a result,
professionals are depicted as knaves, rather than professional knights, who have resisted
policy alignments and reform in favour of their own interests (Le Grand 2010). It is
noteworthy that while some of the critique is directed specifically at doctors (in particular
consultants), in general the discourse suggests that the membership is professionally
undifferentiated. This appears to be a departure from the traditional assumption that it is
predominantly doctors who possess legitimated clinical autonomy and jurisdiction over what
work is undertaken and how resources are used. This conflation of clinicians with doctors is
also reflected in specific projects, such as the productive series, which have been directed
towards a very wide professional group and not just doctors. In particular, the designers of
The Productive Ward explicitly created a strategy that was framed in ‘nurses language’,
driven by aspirations of having the ‘time to care’ and embodied in a spirit of collective
involvement (NHS Institute 2010: 21). Such conflation may represent a rhetorical tactic
intended to diminish the perceived power of the medical profession or alternatively, a unify-
ing tactic intimating a shared collective purpose. Arguably, the professional implications of
responsibilisation for productive health care would be quite different for the less dominant
professions. Indeed, it is suggested that productive ward participants have perceived it as a
professional opportunity for nurses to ‘reassert their role in the organisation of care’ (NHS
Institute 2009: 24).
In this debate, productivity improvement is described as a tool with which to repair,
demolish or rebuild the NHS services. When asked why strategies associated with
productivity improvement cannot be enforced, an NHS Institute representative responds that
he cannot ‘imagine a world in which external regulation will be able to become more
significant than the professionalism of services’ (HoCHC 2010: Ev4). It is at this nexus
that healthcare professionals become identified not only as contributors to the problem, but
also the potential solution to it. Specifically, the notion of professionalism is conceptualised
as a rationality of government.
Healthcare professionals as a solution to the productivity problem
The emergence of new discourses over productivity can be seen in the data where healthcare
professionals are identified not only as part of the problem of productivity but also as its
potential solution. For example, healthcare professionals, as the frontline teams or ‘clinical mi-
crosystems’, are identified as having the ‘greatest potential to unlock productivity’ (Appleby
et al. 2010: 26). These discourses are framed by three interwoven themes namely duty, indi-
vidualisation and engagement. Improving productivity is presented to healthcare professionals
as both essential to the cause (DH 2010b) and an obligation:
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As clinicians we make the decisions that, every day, have an impact on how the NHS bud-
get is spent. Our duty is to do this in a way that makes the best use of NHS resources and
taxpayers’ money. (DH 2010a: 7)
In this there is an implicit threat that if healthcare professionals fail to ‘respond to this chal-
lenge there is a real risk that the need to cut costs will overtake all our best intentions to
improve care for our patients’ (DH 2010a: 19). Linking productivity and efficiency to the
notion of care is a persuasive rhetorical tactic in advocating individual and organisational
change. This discourse is specifically directed at individuals:
You may think that money is someone else’s business but we believe that addressing
financial inefficiencies is a key personal, professional and moral responsibility.
(DH 2010a: 5, emphasis added)
The ideal-type professional is depicted as possessing the personal capacities with which to
achieve the socially desirable goal of increased productivity and therefore to be the
salvation of the NHS. There is an emphasis upon the alignment of personal and organisa-
tional priorities with a perceived need to incorporate cost reduction and value for money
into individuals’ objectives in order to drive the desired behavioural changes (Appleby et al.
2010; HoCCPA, 2011). Furthermore, productivity is portrayed as being compatible with
notions of social justice and good citizenship. This moralistic construction is characteristic
of political rationalities (Rose and Miller 2010). The challenge for driving productivity
improvement is presented as a matter of ensuring both the rapid dissemination of
information and innovation and the active engagement of professionals in programmes of
direct change (HoCCPA 2011):
It is they who decide the length of stay, treatment and care options, they spend 80 to 90 per
cent of our costs. So we need them on board, hearts and minds. (Hurst and Williams 2012:
36, emphasis added)
This approach was exemplified by the productive series, an NHS Institute programme intended
to improve healthcare productivity and increase clinician–patient contact time, where
professionals are supplied with a series of tools to redesign care in a locally relevant manner
(HoCHC 2010). The chief executive officer of the NHS Institute describes the power of
implementing productivity improvement in this fashion:
It has two names, this piece of work. It is known as The Productive Ward, Releasing Time
to Care. The nursing profession told us that they find that their members find the word
‘productivity’ has negative connotations, that a focus on releasing time to care created far
greater ambition to be involved. (HoCHC 2010: Ev9)
This quote clearly demonstrates the perceived importance of staff engagement and ownership
and the implementation of more subtle strategies for aligning staff with organisational policy
(such as strategically renaming the project to avoid potentially unpalatable connotations with
Taylorism).
The call for a ‘new professionalism’?
What do these discourses set out to achieve? Clearly, the technologies of government involve
the construction of productivity and fiscal responsibilisation as an individualised professional
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SociologyofHealth&Illness©2013FoundationfortheSociologyofHealth&Illness/JohnWiley&SonsLtd