IT'S easy to think that money rules the world and some times it does. But NHS money often seems curiously unreal. Like a drunk we stagger from one annual funding crisis to the next, drinking each watering hole dry, but never quite being called to account.
Despite appearances however, money does not count for everything in the NHS. Maintaining the give and take between organisations is often more important in the long run than the current financial position. And ‘must do's’ just have to be done regardless of the deficit. So, along with the usual market economy the NHS also runs a barter economy and a centrally planned, must do, economy. Barter and centrally planned economies govern relationships between organisations at local and national level respectively whereas markets are the national aggregate of individual decisions. Least known, and most interesting are gift economies that are governed by individual decisions made locally or across groups who know each other.
The market economy
In market economies the flow of goods is determined by the sum of individual decisions acting according to nationally defined rules. In the NHS the new financial flows regime and the future of foundation trusts all turn in large measure on market mechanisms. Markets within the public sector are zero sum — more hip replacements here means less chiropody there.
Because market mechanisms are so familiar, everyone tends to assume that the market/consumer model is the gold standard most likely to deliver quality to consumers. In fact, the place for markets is strictly limited within health care, not least because the ‘goods’ are usually not at all good — unlike a Rolls Royce its always better not to own a radical colectomy.
The barter economy
Barter economies exist whenever local organisations work out local deals. Barter is the default economy for all partnership working and is mediated through relatively long-lasting relationships sustained by mutual obligation — you scratch my back and sometime soon I'll scratch yours.
When you are talking to your PCO you will be largely in barter mode. Even with something as apparently specific as the Quality Framework, asking yourself what the PCO wants will probably get you further than sticking rigidly to a ‘points means prizes’ mentality.
By and large organisations in barter mode don't care very much about individual patients. Being passive recipients, patients are important only as the currency by which partnership organisations estimate their mutual obligations.
The centrally planned economy
The centrally planned economy is the world of evidence-based medicine, needs assessments, epidemiology, NICE and public health. Centrally planned economies love standards, inspections, targets, star ratings, external inspections and protocols. The centrally planned economy announces its presence with the steady thud of external dictats landing on your desk. Its appetite for data — relevant or irrelevant — is legendary.
Centrally planned economies are often beloved by academics since they see themselves as rightfully being the technocrats, deciding what the ‘correct’ response for the system should be.
So far as patients go, all those Czars and others who labour long and hard at the centre to keep the ‘Five Year Plan’ on track do perceive the need for patient involvement, but routinely fail to progress beyond tokenism. In this, patients are only slightly worse off than other players since no one outside the central citadel feels they have much power in a centrally planned economy.
Choice like everything else is defined by central authorities. Henry Ford's ‘You can have any colour you like provided its black’ becomes ‘You can have any procedure you like provided it's approved by NICE’. As for choice, the dictats of the centrally planned economy slip comparatively easily into the mindset of local barter economies — anything that limits consumer choice makes organisational bartering easier.
The gift economy
Competition makes people strive against each other. In gift economies that competition is directed to how much one can give. The higher the quality of one's offering the greater one's reputation.1 In our scarcity-driven, money-focused world, gift economies sound improbable but once recognised are found in the most unlikely places. If you are lucky enough to work in a practice where partners help each other out doing the extra visits or seeing emergency patients, then you are probably benefiting from a gift economy. Mild competition to be the best — or at least not to be the meanest — reinforces the pride and respect inspired by reciprocated giving. Functioning beyond money and scarcity, in a gift economy one's status and self-worth are measured by what one is perceived to give to others in the network. What is important is the esteem of one's peers.
One of the best known creations of a gift economy is the Linux operating system which evolved with no budget and no central plan.2 Linus Torvald successfully channels thousands of hours of unpaid work by hundreds of computer geeks around the globe into a self-sustaining system where gifts (pieces of programming) are exchanged for recognition and approbation from peers. Bad work is removed because it is perceived as being poor quality, so someone volunteers the time to create something better and in exchange gains recognition and plaudits within the community of hackers who own Linux.
Gift economies drive much of medicine. The system of peer review runs in part as a gift economy: being asked to referee a paper is both an acknowledgement of present reputation and a gift to the wider scientific community. Participating as a reviewer is rewarded because key others — notably the editorial staff — respect the gift of your time and opinion. Similarly the official positions, rewards and fellowships of many professional colleges can be seen as gift economies. One's status in the profession — how much one has given over and above the normal — is here calibrated and made public. And the best general practices and hospital departments almost always run in large measure as gift economies.
We need to understand how to create and run gift economies. Anyone who has worked in a practice where the gift economy is disintegrating, where everyone is moving from maximising gains by saying ‘Yes, of course I will!’ to minimising losses by refusing to help, can testify to what a soul-destroying experience it is. We know how to destroy gift economies: all we need to do as GPs is to take all the income generated through quality points by nursing colleagues and never share it. Such rampant taking will undoubtedly be toxic to the mutual gift economy which underpins all teams that deliver high quality, complex care. But we know next to nothing about how to build and maintain organisations where giving rather than hoarding is the norm.
And could we use gift economies to overcome some of those perennial financial deficits in the NHS? Many patient support groups — Alcoholics Anonymous is perhaps the most memorable — are based around gift economies. Ask most people with chronic disease if they would like to give something back to the NHS and they jump at the idea. But as yet we do not understand how to make it happen.
At some point between 9/11 and the Madrid bombings trust between communities became deeply problematic. We have yet to fully understand the ramifications of this for race relations, security, social paranoia — let alone primary care. Yet understanding gift economies and finding ways to increase reciprocated giving between individuals from different beliefs is perhaps one way of avoiding a decline into the gated community versus the ghetto.
The idea that people, ordinary everyday people like us, routinely give substantial amounts of anything seems ridiculously naive when viewed from the rapacious depths of the market economy. Altruism is an unfashionable idea, a contradiction for the economist, a puzzle for the neo-Darwinist. Yet as GPs we know that it is far from rare. Altruism is a virtue that dares not speak its name in our cynical age yet it abounds in the face of illness, distress and death. Gift economies offer a way of understanding this bounty, a way to unpack the black box of altruism and make it go further. In this year's Reith Lecture,3 Wole Soyinka talks about the ‘I'm right, you're dead’ mindset of the fundamentalist. In these darkening days of mistrust, where the fear of the other and the random mutations of terror are just beginning to debilitate all communities everywhere, we need all the gifts we can get.
- © British Journal of General Practice, 2004.