In the final discussion at the Stockholm conference we tried to synthesise what participants had learned from the conference, with their own experience and understanding.
We produced three themes: a description of health care systems, in terms of their complexity; a critique of health system managerialism; and an agenda for change in European health care systems.
COMPLEXITY. We concluded that:
1. Health care systems are complex, because:
- They are embedded in society, and rooted in culture
- They are whole systems, not simple mechanisms
- They reflect economic change
- They are politically driven
- They are about social relationships
2. This complexity is:
- Sometimes a problem for individuals using services,although there is often a high level of public satisfaction with health services (except in the USA)
- A source of stability but therefore of resistance to change
- A management problem, that leads to managerial attempts to simplify the complexity.
3. To understand a part of a health care system you must understand the whole system.
A CRITIQUE OF MANAGERIALISM. We concluded that:
4. Current managerial approaches to system complexity define health and social care in terms of products (Fordist commodification), with the following consequences:
- The development of panoptic control systems, and blaming the workforce for system failure
- Pre-occupation with costs & prices, and with productivity
- Itemisation of work tasks and outcomes
- Concern with defining and measuring quality
- Codification and standardisation of knowledge
- Actual needs of service users are not met
- The system becomes more complex, not less, and management becomes part of the system�s problems.
5. There are two other features of the current situation that are important. This type of managerialism emphasises the importance of regulation, but in practice this tends to be weak. There is a clear lack of vision within the system.
AN AGENDA FOR CHANGE
6. An agenda for change in European health care systems should include:
- Basing all health care on not-for-profit institutions and organisations, and creating clear distinctions between the not-for-profit sector�s activity and that of commercial interests. This is distinctly different from a stakeholder approach.
- A return to an understanding of whole systems, both for service users and for service providers.
- Promotion of an awareness of common interests, as well as individual and national interests, through a continuous process of dialogue (for example, about the social implications of medical care)
- Democratic and multi-disciplinary norm-setting, with needs defined and prioritised in a transparent process. The process of engaging citizens in policy decisions is the most problematic issue for those opposed to current managerial approaches. Norm-setting identifies priorities that will determine investment needs, and prices can be derived from this.
- Strong regulation, using qualitative rather than quantitative �contracts�& professional training for self-regulation and self-evaluation, as mechanisms to create a system that develops dynamically.