High value care
Or how we learned to apply management approaches developed by the Nazis to modern-day healthcare
In his 2023 book Free to Obey: How the Nazis Invented Modern Management, historian Johann Chapoutot traces the origins of the modern manager’s desire to delegate decision-making, innovate through competition, and demonstrate empathy by nurturing the wellbeing and resilience of workers, to innovations in ‘people management’ pioneered by the Nazis in the early years of WWII.
Contrary to the idea that the Nazis favoured strong, centralised, and strictly hierarchical forms of disciplinary control, Chapoutot shows how the Nazis hated the idea of centralised bureaucracies, which they saw as “artificial and lacking dynamism” Link. Instead, the ruling National Socialist party favoured forms of social control that mirrored their belief in Social Darwinism, racism and eugenics.
The Nazi ideology espoused that the same kinds of competition that (they believed) governed the natural world should decide human social affairs. They believed human competition should be based on biological, racial distinctions, and that ‘desirable’ inherited traits should be promoted whilst eliminating undesirable ones.
A central motif of these new forms of government — pioneered by Reinhard Höhn, ‘one of the Nazi regime’s leading organization theorists’ Link — was the idea of ‘Germanic liberty’. Here, members of the community could act on their own volition in the spirit — rather than slavish obedience, which was considered anathema to the essence of the true German — to the will of the Führer.
Multiple ad hoc social agencies were established and set in competition with one-another. Workers were actively ‘empowered’ and participation in horizontal decision-making was incentivised. Organisation leaders were encouraged to improve the ergonomic working conditions of employees, as well as organising concerts and team holidays.
‘Höhn also promoted the idea that workers should not be guided by commands but be given freedom to choose for themselves the means to best achieve their assigned objectives. His work was so greatly appreciated by the Nazi elite that he was appointed a general (Oberführer) in the SS in 1944’ Link.
Chapoutot shows just how influential Höhn’s innovations were in post-war German reconstruction, with his Academy for Economic Leaders (Akademie für Führungskräfte der Wirtschaft) becoming ‘the largest executive-education institution in Europe’ Link. By the time of his death in 2000, Höhn’s Academy had trained more than half-a-million managers.
We see all sorts of echoes of this logic playing out in healthcare management today, with some logics operating in more subtle ways than others. Take the concept of high-value care (HVC), for instance.
The concept of high-value care has been widely embraced across healthcare in recent years (See 1, 2, 3, and 4, for example). But what is striking about HVC is how successfully it sublimates its true purpose beneath an image of person-centred care.
On the one hand, HVC makes little attempt to hide its true purpose as being to achieve the best possible care at the lowest possible cost. After all, who could realistically argue with that? Are we not operating in a healthcare environment in which the public no longer seems to want to support publicly funded healthcare through personal taxation, thereby throwing the entire sector into the same kind of anti-bureaucratic, small-agency-led competition so much favoured by the Nazis?
But making the case for high-value care simply on the basis of its economic necessity would still seem mercenary and unappealing, even in today’s straightened times. And so, it comes ready-veiled in the language of patient care.
When we dig into this language, however, it’s nuances become a little problematic. Five of the seven major tenets of HVC, for instance, really run the risk of increasing the complexity and cost of care.
Here are its seven major tenets:
Cost-Effectiveness
Reducing Overuse and Waste
Patient-Centred Care
Evidence-Based Practice
Improving Quality and Safety
Health Outcomes
Access and Equity
Only the first two are overtly about cutting costs. All of the others carry the possibility of much more diversity, inclusiveness, clinical and managerial complexity. Utilising the best available research evidence through the conduct of rigorous scientific studies, for instance, isn’t cheap, and neither is the desire to address disparities in healthcare delivery and promote health equity.
Patient-centred care is perhaps the most obvious trojan horse here. Prioritising the needs, preferences, and values of patients in all aspects of care; involving people in shared decision-making; communicating effectively; and tailoring treatments to individual patients sounds well in principle, but everyone knows in healthcare that achieving this in practice can often put the goal of care at the lowest possible cost in serious jeopardy.
(Note here, also, how the language of modern-day patient-centred care mimics the ideals of Reinhard Höhn’s Nazi management ethic.)
The crux of the issue is, of course, that patient-centred care, health equity, improved quality and safety and the like, are only allied to HVC for their ability to mask the fundamental operating discourse of economics. But why should this be the case? Surely, what constitutes high-value care depends entirely on context?
High-value care for a biomechanist would surely mean more bodily function and tissue adaptation to injury and illness. For an existentialist, it might equate to enriched intersubjective relationships for patient and therapist/carer. For a social activist, it might imply improved social determinants, or more group inter-connection.
So HVC, as it’s currently articulated in the healthcare literature, only makes sense as the best possible care at the lowest possible cost from the perspective of the economist and the health service manager, whose primary interests have always been greater productivity at lower cost. But their voice should not — can not — be the only one driving this idea.
Foucault, who died 40 years ago last week, showed us that the most effective technologies were those that hid their power and true purpose in plain sight; trading on their taken-for-granted obviousness to cajole a docile populace into complicity.
This gives us a very powerful tool of analysis because what it shows us is that the very things that are succeeding as social discourses, are those that correlate most closely with the current economic, political, and social zeitgeist. And what could be a more apposite metaphor for the globalised, neoliberal, biopolitical world we live in today than high-value care?