Wednesday, 22 July 2009

Efficiency or Triage?

People in Jersey could see cuts in public services and a possible increase in taxes over the next few years. That's according to the latest States Business Plan. Falling tax revenue will lead to a public debt of 51 million next year and 70 million the year after. 156 million pounds from the rainy day fund will be injected into the economy, but that alone won't be enough - all States Departments are being told to cut spending by half a percent. The business plan will debated by the States in September. (1)

Listening to the presenters going through the business plan, it seems to me that what we will be getting is a form of selective triage. Triage was originally defined as a medical model:

Triage is a process of prioritizing patients based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate, sort, sift or select.(2)

But it has been taken over to a business model:

Within each category, the desired outcomes and goals are ranked based on the "threat" presented to the company if the outcome or goal is not achieved and the level of "outrage" that will occur should the threat be realized.(3)

Within the business model, as it could be applied to public services, we can see how those least able and most vulnerable can be isolated, segregated, and have services cut back or curtailed. There is no threat from these groups, and they can be treated as insignificant; there is little or no threat to politicians, especially with three years until the next election.

Against simple poverty, the States of Jersey has in place the income support scheme, which - however much it has defects - attempts to keep people above the breadline. This is in part a matter of justice, but also a means of averting confrontational politics. The Trade Unions often represent the poorer workers in society, and their ability to take industrial action, and withdraw labour, and for it to escalate into a general strike, is always a potential threat.

The recent strike at the Airport in Guernsey was potentially very damaging to the Island's image as a well-run finance centre, and the Chief Minister, Deputy Lyndon Trott, intervened extremely rapidly to concede to enough of the strikers demands to defuse the strike.

But other minority groups, such as carers of those who are mentally handicapped, or suffer from varying forms of dementia, or the elderly on meagre State pensions, but owning their own home, can find and have found services cut back or means tested (another way of cutting back), because they don't have the same pressure that they can put upon the States.

The easy option, then, is to remove respite care, or provide it only as a paid but subsidised service ("user pays"), or provide services free only to those who get above a threshold, which may include not owning one's own home. It is the easy option, because the groups it targets can be vocal, but they pose no significant threat to the States. I have been in touch with several people, and it is clear that this is happening now. It may be curtailed to a few hours respite, or one morning per week, which actually is little use, because what these people need is a decent break from the stress of being carers, and a longer time provided less frequently would be a better option.

Support for people wanting to give up smoking is another area under threat, according the report on BBC Radio Jersey. The logic is clear: if people want to give up, why should this be subsidised by the tax payer? The fact that this may lead to less of a burden on the health service in the long term is forgotten, and like Yes Prime Minister ("The Smoke Screen"), there is also the income being generated by taxes on tobacco which would be lost which is probably also lurking in the background.

The buzz word for all this is "prioritise". I think it should be "triage", as it would provide a better description of what processes of thinking are taking place. Hard decisions are being made, and the essence of these is - where can cutbacks be made without meeting significant opposition and the threat of massive social disorder. That may seem unduly cynical, but I will argue that it is built into the model that works with terms such as "efficiency" and "prioritise".

Robert Halpern provides a warning from the great depression of the 1930s:

As relief budgets shrank and demands on those budgets increased, the differentiated responses to different family situations and the balance of responsibility for relief among public and private agencies that had just begun to be worked out, collapsed. New, often harsh, and in some cases bizarre rules for providing relief were created. Some local rules required social workers to wait until families were completely destitute before approving relief In New York City, a rule called "Skip the Feed" required local offices of the Department of Welfare to skip every tenth family seeking relief (Hall 1971:12). Casework was also rationed. Agencies struggled constantly with whom to select for relief-related monitoring and follow-up. Some developed triage systems for deciding who could benefit most from supportive casework services-for instance, families at neither too high nor too low risk, with neither too many nor too few problems. (4)

Harry Moody has also questioned if this is the way to go with regards to the aging population:

As more and more professionals provide services to the aging, the expense grows greater, yet there is dissatisfaction with the services provided. Is there a way out of this dilemma of greater needs and limited capacities, or must we face a "politics of triage" that leads either to privatization, on the one hand, or rationing of services, on the other? (5)

Fundamentally, where the use of the words "efficiency" and "prioritise" can be so bad is that they conceal the moral choices, and instead it seems more like putting a mechanic to work on fine tuning the machinery of government. The moral values behind the words is lost, and the drive for efficiency - in effect a form of triage - can lead to picking targets where there can be seen to be substantial (and often quick) results for the finance and manpower used, which is not necessarily the right thing to do. This is brought out very clearly by Christopher Hudson in his discussion of prioritisation of mental health provision:

The seeming conflict between the principles of triage and need is one of the philosophic bases for many of the policy discontinuities involving the community mental health movement interest in primary and secondary interventions and recent state efforts to provide tertiary and rehabilitative services... Those in most need should always be given service priority, but priority should be given to those most able to benefit from service when persons of similar disability or need are considered. For instance, if a mental health center has developed effective services for their most seriously disturbed and has resources to program for either their moderately disturbed children or adults, a persuasive argument can be made to then concentrate on a program for those children, considering their longer remaining life span.(6)

The UK government's introduction of targets for hospital waiting lists is a good example of how "efficiency" can fail to provide a good service. The unintended consequence was that instead of concentrating on patient welfare, strategies were evolved to meet targets, which meant that the quick and easy result took precedence over the long term with uncertain outcomes. It was the absence of thinking about real goals, and assuming that a technical "fix" would provide a solution that ultimately led to the policy failing.

The same kind of strategy, of looking for visible effectiveness in the public sector was subjected to a very clear critique by Lipsky in his 1980 book "Street-Level Bureaucracy: Dilemmas of the Individual in Public Services.". Again, he points out that when "effectiveness" is the target, that is precisely what the public service worker wants to deliver, and this can easily lead to a worse outcome for many people.:

Public service workers stereotype clients as a reaction to an unstoppable stream of demand, determining who is worthy enough to receive service or attention-as in the case of a public defender who pushes a few cases to trial, while many other cases languish. Yet as Lipsky states, by modifying goals to best serve a few clients upholds a public image of effectiveness, but is not truly representative of a public benefit (Lipsky, 1980).

Triage and prioritising strategies ask: "How can we get best value with limited resources?" But the question implicitly assumes that "best value" is obvious, or can easily be measured in financial terms, or in terms of the results (with their short-term bias and quick fix mentality). But it may be the case that we should spend on something not because there are visible results, but because it is the right thing to do. A good example of this would be environmental values:

Environmental problems have an ethical dimension. They are not just about the efficient use of resources. Justice in the distribution of environmental goods and burdens, fairness in the processes of environmental decision-making, the moral claims of future generations and non-humans, these and other ethical values inform the responses of citizens to environmental problems (8).

We are told that "all States Departments are being told to cut spending by half a percent", which may be a worthwhile target given the state of the economy, but the debate on where to cut and why, and the moral justifications for doing so - which should have been part and parcel of the Strategic Plan - has yet to take place.

In English, the word "economy" has three meanings: avoidance of a waste of money; control and management of money and other community resources; a social or household a system of political economy; these have nothing to do with ethics. But in Chinese economy, "jing Ji" (Ching Chi, in the old alphabetic system of writing), is related to ethical value for it means "governing the world in harmony to bring about the well-being of the people."(9)

(4)  "Fragile Families, Fragile Solutions: A History of Supportive Services 
for Families in Poverty." , 1999
(5) Abundance of Life: Human Development Policies for an Aging Society,
Harry R. Moody, 1988
(6) Dimensions of State Mental Health, C. Hudson, 1991

1 comment:

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