Beyond Bentham (S) and Taylor (F)

[chickenfeet]

Just finishing up Peter Linebaugh's The London Hanged. This is a very worthwhile exploration of some of the themes first mooted in Albion's Fatal Tree (Hay, Linebaugh et al) and Whigs and Hunters (Thompson). Central to the argument is the apparent paradox of 18th century criminal law; on the one hand the enormous increase in the number of capital statutes and on the other the steady decrease in the number of hangings, despite a rising population.

Various explanations have been put forward for this over the years including the ruling elite using the great drama of Assizes and gallows and , crucially, the ability of local magistrates to obtain reprieves, to reinforce local networks of subordination and clientage. I have always found this explanation particularly unconvincing as local magistrates and prosecutors had far more tractable tools for achieving the same ends. (eg not prosecuting or bringing a lesser charge).

Other explanations turn on the new statutes giving the state the power to target dangerous areas of social upheaval. This, to my mind, is more convincing and can be fairly convincingly demonstrated for rural unrest. It doesn't seem to hold for London though where unrest followed the imposition of new legislation as much as preceded it and where, frankly, the metropolis was in a pretty constant state of barely contained lawlessness.

Linebaugh's thesis is that the new legislation and its highly selective employment was a critical element in transforming various sectors of the economy from a traditional mode of production to a fully capitalist one. Based on a statistical analysis of the occupational backgrounds and crimes of the total population of these hanged in London in the 18th century he is able to show that, indeed, the new legislation was used specifically to criminalise customary perquisites and practices that workers traditionally used to control the both the material and the process of production. Targetted prosecution for the new offences was then used to facilitate control of the production process by the employer, often leading to automation, deskilling and an increase in the rate of exploitation.

Industries covered include silk, tailoring, coal heaving and shipbuilding. I found the latter extremely interesting as shipbuilding was far and away the most complex industry of the time. The methods used by Sam Bentham (Jeremy's brother) to 're-engineer' the ship building process are uncannily reminiscent of those used by Taylor and Ford 130 years later.

At this point I diverge from book reviewing to bring up a few parallels of my own. Bentham and Taylor's 'discovery' that before automating one must first take control of the production process is one which is constantly forgotten. A million misbegotten IT projects stand witness to that simple truth and a few fortunes (Mike Hammer for example) have been made out of rediscovering it.

Much of my own work in last few years has been concerned with the automation of the practice of medicine which is truly one of the last outposts of a traditional mode of production. The work process (and to a large extent wages and prices) are controlled by the master craftsmen (physicians and surgeons), training is by apprenticeship and regulation, such as it is, is in the hands of 'guilds' controlled by the master craftsmen. Now everybody knows that much of what physicians do could be replaced by lower skilled technicians of various sorts (nurses, nurse practitioners, midwives etc, a class described to me by a former president of the Ontario Medical Association as 'physician wannabees'). Given imaginative use of knowledge based systems further improvements in productivity, prescribing practices, reduction in adverse drug interactions, reduction in unnecessary diagnostic tests etc are very feasible. It doesn't happen to any great extent though because for the most part physicians dig their heels and refuse to cooperate (unless handsomely bribed!).

So, pulling my two threads together, perhaps what we need is legislation outlawing, say, the practice of physicians referring patients to labs in which they have a pecuniary interest followed by some exemplary prosecutions. I will concede that in our kinder, gentler age that hanging might be seen as a touch severe though the irony of post-mortem dissection at Surgeons' Hall would be delicious.

Comments

[oursin.livejournal.com]

much of what physicians do could be replaced by lower skilled technicians of various sorts
I'm not sure 'lower skilled' is quite the expression wanted here. For example, in the case of midwives there is extremely strong evidence (from countries such as the Netherlands where they never underwent the erosion of their status particularly characteristic of N America, and even the UK) that they are better at managing the normal childbirth than intervention-happy obstetricians. (Semmelweiss had it right in more than one sense.)

[chickenfeet2003.livejournal.com]

I buy that. Substitute 'cheaper and less expensively trained'.

[avicenna697.livejournal.com]

Yes, but why are they cheaper?

If medicine becomes an assembly line process/ Taylorised then many of its activities can be substituted by less highly-trained staff with a narrower focus of expertise working to strict algorithms. Of course they cost less to train, the barriers to entry are lower so pay will inevitably be less, individuals within the assembly line have less autonomy and therefore less responsibilty for the final product, hence again less pay.

Even the medical profession

[avicenna697.livejournal.com]

(stupid trackpad, where was I ... )

Even the medical profession is not immune to this process, hence the increasing use of 'non-consultant career grade' posts at the senior level and 'non-training grade' posts at the more junior level. There isn't much outcry at this at the moment as these jobs are often being filled by doctors from third world countries.

[chickenfeet2003.livejournal.com]

At the risk of stretching my already dubious analogy of today's healthcare system with Walpole's London way beyond its reasonable limits... shades of the Irish in the silk trade?

When I look at Ontario's healthcare system, I am struck by the fact that resistance to change is not coming from the docs in academic health sciences centres. Indeed they have just willingly accepted a move from 'fee for service' to salary for clinician/researchers. Their position as elite knowledge workers is reasonably secure. The opposition is strongest among sole practice GPs, much of whose work could be taken over by other 'trades', who have proved reluctant to move away from 'fee for service' which gives them more control over the labour process.

[avicenna697.livejournal.com]

I'm not sure what you mean by GP in this case (or by the Irish in the silk trade for that matter, is it analogous to the role of the Chinese, ie trying to monopolise production by keeping the source secret?).

In the UK each GP has to be a generalist, able to converse with physicians of any specialty, make appropriate referrals (incuding a working diagnosis to determine which specialty is appropriate, and managing less severe cases in-house) etc. For that a lot of responsibility and experience is required. As gate-keepers to the NHS they are the single feature which keeps our costs lower than other countries.

On the other hand, they are only too keen to hand over responsibility for vaccinations, regular check-ups (blood pressure, peak flows, etc) and so on to specialist nurses. It cuts out the drudgery for them and the nurse can always refer any complicated cases.

[chickenfeet2003.livejournal.com]

My understanding is that UK GPs (in the NHS anyway) are paid a salary for managing health care for a defined patient population. The behaviour you describe is then one that one might expect and, given appropriate support (resources (human, information etc) is a good way of maximizing the skills of the GP.

We don't have that. Essentially, anybody can go and see any doctor who is then paid for the transaction. There is little incentive for docs to maximize the population they treat rather than the number of transactions. Strategically, Ontario wants to move closer to the UK model but its an uphill struggle.

To get back to my original point, to maximize the return on information systems investment it is necessary to have an appropriate work process. The UK one seems more likely to facilitate the desired result than ours.

[avicenna697.livejournal.com]

Okay, I didn't mean 'less highly-trained' I meant more narrowly-trained.

Consider the simpler case of phlebotomists (the ones who take blood from a patient's vein). I would argue that most are more skilled at taking a blood sample than most doctors. However, their protocols tell them not to take blood from patients with hepatitis or AIDS, not to take blood from CVP lines in-situ (a less skilled job since this means there is already an available conduit into a vein), and not to make more than two attempts if it is proving difficult to obtain the blood sample. In all these instances a junior doctor is then expected to do the job. Final responsibility still lies with the physician, hence the continued disparity in pay.

[avicenna697.livejournal.com]

I don't know much about the Canadian system. I know the USA orders far more tests than the UK partly because the centres are paid for each test and intervention but also driven by the fear of litigation. In the UK, there is considerable pressure not to order unnecessary tests, driven by the departments themselves and by the waiting list (eg for a CT scan or ultrasound).

It is generally the consultants who drive the rationing process the most, as they have the most experience. The most junior doctors, and the staff following rigid protocols, will order the most unnecessary tests since, to quote Donald Rumsfeld, they fear the unknown unknowns (I'm happy as a doctor to manage the known knowns, refer the known unknowns to someone more experienced or in the appropriate specialty, but it's the unknown unknowns that keep me awake at night, ie the things that I didn't know that I didn't know).

I hope that made sense.

I'm not sure what you meant when you quoted the term, 'physician wannabees.' I assume what the former president meant was those individuals whose jobs were starting to take over the traditional roles of doctors. I don't know a politically correct collective noun for them. The umbrella term for nurses, radiographers, phlebotomists, pharmacists, midwives etc would perhaps be 'professions allied to medicine.'

Perhaps between us we could come up with some acceptable, less unwieldy alternatives?

I keep meaning to read back to find out exactly what it is you do, or precisely what project you are working on. We would certainly welcome an integrated IT system in the UK.

[chickenfeet2003.livejournal.com]

don't know much about the Canadian system.

We have a bizarre hybrid system. Essentially the sole payor is government but most docs are independednt contractors paid on a 'fee for service' basis. Similarly, hospitals are independent not-for-profits with their own boards but are financed by block grants from MoHLTC. Most hospitals do not employ docs (except as managers). Even in a hospital most docs are 'affiliated' and paid on 'fee for service'. The most NHS like part of the system would be the academic health sciences centres where increasingly the physicians (who almost invariably hold university posts as well) are on salary.

What this means is that consistent, protocol driven, practice is pretty much confined to the AHSCs.

I'm not sure what you meant when you quoted the term, 'physician wannabees.'

I think its a lousy term. I used it to illustrate the dislike and disdain for such people that the docs' official representative displayed.

I keep meaning to read back to find out exactly what it is you do, or precisely what project you are working on. We would certainly welcome an integrated IT system in the UK.

I'm a business and technology strategist who has done a fair amount of work on clinical information and related systems. I have also been very much involved in the debate in Canada between 'big bang' approaches to clinical automation versus 'start small, grow and (eventually) connect'. Everybody is in favour of integrated information systems until they have to change their ways of working! One of the points I was trying to make in my original post is that automation is only effective when the work process is redefined for automation. That is usually what gets resisted.