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Dangers of McDonaldisation in NHS healthcare

We live in an age in which bureaucratic and market logics are transforming all kinds of expert work. The term “McDonaldisation”, which American sociologist George Ritzer coined to depict a culture with the characteristics of a fast-food restaurant, is now frequently used to describe this shift.

McDonaldisation encompasses the cornerstones of hyper-rationalisation. It stands for homogeneity, extreme efficiency, quantifiable objectives and complete control. Few would deny that such attributes are increasingly to the fore in healthcare, where the streamlining and standardisation of practices and identities is becoming as quotidian as a Quarter Pounder.

Inevitably, a key concern is whether McDonaldisation offers a recipe for success. A recent study by researchers at Nottingham University Business School’s Centre for Health Innovation, Leadership and Learning suggests the concept is much more to the taste of some than it is to others.

It is important to stress first of all that this was “on the ground” research. The findings that emerged were based not on theory but on observation and analysis. Over the course of three years we spent time alongside healthcare professionals on the frontline of McDonaldisation, engaging with them in various settings, from wards to team meetings to rest areas, and interviewing scores of medics and managers.

What we discovered is that responses to McDonaldisation not only vary but also reflect individuals’ standing in terms of the power they wield. In essence, it seems fair to conclude that in this brave new world, with its greater emphasis on viability and profit, some healthcare employees – with apologies to Orwell – are more equal than others.

By way of illustration, let us start with one manager’s description of the modern way of doing things: “Medicine always has this human aspect to it, but in general, of course, it’s a production process – the same as every product and process.”

This, by any standards, is an unflinching articulation of the hyper-rationalisation credo.

Similarly, executives habitually referred to doctors as “technicians” whose work needed better organising to prevent waste. Timeframes and targets were writ large. “Throughput” was a key objective. Backlogs were not to be tolerated. There was talk of “100% commitment” and “outperforming the NHS on its own terms”.

Tellingly, it was doctors holding management or leadership roles who almost inevitably demonstrated such a level of enthusiasm and absolute dedication. Thus the rise of “McMedicine”, as we might call it, appears to be creating a corporate elite of healthcare professionals whose elevated positions have their roots in financial investment and ideological alignment.

By contrast, those with limited influence and esteem suggested they had little choice but to embrace the spread of commercialisation and bureaucracy in the absence of a realistic alternative. For them McMedicine represented the “least worst” option in an era of economic uncertainty.

As one noted: “The whole NHS is changing. I guess I should feel quite lucky to have this experience.” Their attitude was typified not by passion and determination but by weary acceptance and, perhaps above all, a sense of powerlessness.

Naturally, there can be no doubt that a mixed economy presents private companies with a chance to transform the organisation and delivery of public healthcare. Ideally, everyone would benefit as a result. But a crucial question is whose interests are truly being served by the fashioning of an “elite” whose status and motivations sometimes appear inextricably entwined with McDonaldisation’s core philosophies.

Top-down control and bottom-up resistance may play a part in shaping future responses, but this is ultimately a matter of position, resource and opportunity. What we really have to ask ourselves is whether it is right to encourage a healthcare arena in which “technicians” are regarded principally on the strength of their contribution to accumulating capital.

Worryingly, there is a very real risk that the schism highlighted by our research will grow wider if the corporatisation that ineluctably attends the advance of McMedicine continues to engender a hierarchy in which certain professional resources are more prized than others.

A system that allows some doctors to find themselves hopelessly beholden to ever-starker forms of McDonaldisation while others reap ever-larger commercial benefits can only expect to be defined by inequality and segmentation. It is not an easy prospect to digest.

Professor Justin Waring is a Professor of Public Services Management at Nottingham University Business School and director of CHILL, its Centre for Health Innovation, Leadership and Learning.

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