The Hospital is a Factory
If we scrape away the patina of modern healthcare practices, we can see the ways in which the factory model still structures hospitals. Is this a good thing?
My partner recently spent several nights in hospital for an unscheduled, serious, but straightforward medical intervention. Trapped in “Hospital Time”, with hours to while away as we waited for the next step in the process, the two of us got to thinking about the edifice of the modern hospital and what it is like to be a small patient in an enormous machine.
The Modern Hospital
While we’ve had centres of medicine for thousands of years, the hospital that developed between roughly the 1750s and the 1970s is a distinct and fascinating institution.
We think of the industrial revolution as primarily transforming the nature of economic production. In direct parallel - and with surprisingly little lag - hospitals were transformed in Europe over 200 years from religious hospices and charitable dispensaries to high-capacity centres of research, of technological innovation, and of medicine at scale. The hospital of the twentieth century represented a triumph of the industrial age, and a jewel in the crown of socialised healthcare. Its structure has enabled what I would call miracles. Where once they were places where people mostly went to heal themselves or die, the social benefit of a hospital is giddying.
Structurally, we can consider the hospital as branching pipelines in a factory that transform the raw material of unhealthy people via a series of specialist stations into outgoing healthy (or at least, recovering) people. The A&E and admissions process act as differentiated buffers and sorting facilities that lead into the factory proper. Wards represent holding platforms for "works in progress" in-between expensive and constrained stations such as X-ray facilities, MRI machines, and operating theatres. Through this lens, the lens of a factory floor, what matters most is efficiency and efficacy - ensuring that this incredibly complex system of systems continues to work without interruption, day and night.
The ideal patient-as-work is passive, uncomplaining, engaged enough to confirm life but no more than that. A patient that demands, that insists upon their own participation in the process is experienced by the system's workers not with pleasure but with irritation and for good reason. They are disrupting the necessary flow of the well-oiled machine.
The hospital of the twentieth century, the Modern hospital, guiltlessly enjoyed this mechanistic reality, and the patients, understandably, might feel alienated by a system that primarily treated them as work to process. Monty Python's satire of what childbirth is like in a 1970s hospital remains one of the more succinct summaries of the potentially distressing subjective experience of being in hospital.
The Changing Patient
Note the way in which the father is excluded from the theatre as "not involved" and the isolation of the newborn child. A lot has changed in hospitals in the last fifty years, especially in ways in which the hospital has opened up to families and recognised the traumatic potential of isolation in an intimidating and alienating process. The enforcement of visiting hours has become less draconian and more humane.
Quality of care has improved massively, as well. Hospital teams practice active process improvement, in fact, there is a whole science behind how to effectively bring research findings into health practices. Hospital teams proactively track and develop areas of improvement, and the result can be demonstrated in measured improved outcomes.
Medicine has embraced ideas of patient consent; Cole's Medical Practice in New Zealand, the Medical Council's standard guide for new doctors, suggests that the person must have the necessary capacity to consent or refuse an intervention, must be appropriately informed, and must give consent voluntarily and without pressure. It also talks a lot about "Patient-Centred methods", or the "biopsychosocial model" of health (the idea that health exists at the intersection of biological, psychological, and social factors, natch).
It's no longer considered cool to talk about patient "compliance"; instead the subtly different "adherence" is preferred, alongside the decision-making "concordance" of the patient-practitioner partnership.
As a result of these sea changes, the modern hospital is a much gentler experience. Nurses and health assistants are empathetic and attentive. Everyone is very sorry about the delays and issues caused by nearly two years of particularly ruthless budget cuts, and understands how frustrating it must be. A soft duvet of patient comfort has been laid over the purely mechanical operational processes.
Limits to the duvet
But the reality of the factory persists. What we have is a kind of double disavowal: first the patient is reduced to work in a pipeline, and then the patient is told that they are an active participant, that their informed consent is vital to the process.
Instead of moving towards treating the patient as human, this redoubling increases the distance from recognition. How can a patient complain that they have not consented to a procedure when there is signed paperwork declaring precisely that they have!? Never mind that the majority of interventions - injections, dispensing of drugs - are only implicitly consented and rarely well-informed, or that valid alternatives are basically never raised as topics of discussion, or that formal consent often occurs too close in time to the procedure for a patient to feel comfortable declining it.
The reality is that the factory structure of a hospital is a kind of gravity. Efforts can, and should, be made to humanise the experience but they will always be pulling against forces whose priorities dominate the system: economic necessity, operational efficiency, worker convenience, what we might call Realprioritäten. The purpose of a system is what it does.
We see this demonstrated everywhere. These days, patients are no longer immediately stripped and forced into gowns upon admission, not for the benefit of their dignity and privacy, but because it is cheaper to save gowns for when the hospital knows they'll need them.
Similarly, toilets need to be openable from the outside, in case of patient collapse or other emergency. But the solution has been to break the locks such that they no longer secure the space from accidental intrusion, nor correctly indicate vacancy.
Doctor's rounds are another example where patient needs are bypassed. A dozen professionals surround a bed, reviewing history and status, conferring mostly among themselves and asking the patient intermittent questions. Of course, the patient can theoretically ask questions important to them - when might I be operated on, at what point will I be allowed to leave - but every element of the process makes it clear to the patient that this will be, at best, an obligation and more likely an irritant.
Privacy is also mostly symbolic. It is impossible not to hear every detail of a fellow patient's intimate history in a four-bed room, and patient details are made legible even from outside the room in the form of feeding charts posted to the room window.
It is telling that, while there is a strict protocol for dispensing of medicine (and for good reason), there is no established protocol for entering a patient's curtained area. Should the nurse make a noise, put a hand in the gap, come straight on in? The lack of consistent approach demonstrates that it is not considered particularly important, or not relative to other priorities.
Perhaps the most frustrating aspect of the patient experience is the haphazard sharing of information. Will the operation happen today? Shrug. There exists a dynamic theatre schedule for the day, and nurses do have access to it, but this information is only available to the patient in drips and draps, and only ever mediated through request. The patient must wait in limbo, but be prepared at any moment to be whisked away to be worked on, an anxiety-inducing state that little effort has been made to systematically mitigate.
The Hospital is a Factory (complimentary)
What we experience is something more akin to the vibe of dignity, privacy, and consent. The illusion is maintained inasmuch as it does not impede the necessary reality of industrial work. Is this bad? Perhaps not necessarily.
Let's consider an understated truth: it is not always unpleasant to be an object in a factory. When one feels tended by capable, effective practitioners, there is a pleasure to letting go, to getting whisked along the conveyor belt and smoothly handled. Hospitals are at their best when one is in motion, trundled steadily through the machine, confident that the system has evolved over millions of patients to treat one with the loving indifference of a machine.
This pleasure breaks down in the liminal waiting spaces, when one has an interminable time to sit and think, when one is acutely conscious of being an item in a buffer, shunted to the side as more urgent cases steam through. Then one begins to desire to insist on being treated as a person, to be catered for, to be recognised, to invent difficulties that will force an individualised response from a blank-faced system.
We could think of issues of consent and partnership in a hospital like travelling on a train. Once a passenger has boarded, they are bound to the strictures of the train's schedule. They can get off at fixed points, they can expect some tailoring of the experience on board to their needs, but once on board they are committed to seeing at least a leg of the journey through. Pulling the emergency stop is still available but doing so for anything less than life or death reasons is frowned upon.
If we embrace the industrial model in this way, we can reduce the mystified efforts to improve the patient experience. We accept the contradiction between the Hospital as factory and as partnership, and focus our efforts for the latter where they actually make a difference.
We also open the possibility to recognise an unrepresented worker in the system: the patient. The patient has a kind of dual character, but there is no doubt that they perform labour, even as their unconscious body responds with healing to the traumatic violations performed upon it. Why then do they often only have an occulted say on the work floor?
Perhaps what we need is a Patient's Union - something akin to our renters union and Australia's unemployed worker union - a kind of advocacy group for the atomised and isolated individuals that are subject to the Hospital. It could demand a seat at the table of maintenance and process improvement, raise to first class the voice of the beleagured patient in a way that neoliberal customer satisfaction forms cannot (how likely is one to recommend the Hospital to a friend, indeed!)
For many people, a visit to the hospital is a rare event, one that they simply hope will pass quickly and without complication. For the disabled and the chronically ill, or families and friends thereof, the Hospital looms large. It cannot be avoided and its many indignities accumulate visit after visit. For the parent or guardian of a sick child, the unsteady supply of information multiplies the feelings of distress and helplessness. They are asked to trust a system that shows in a thousand ways that their social and emotional needs are an afterthought. This is, of course, multiplied if one is not a white cis man or is unable for whatever reason to advocate fiercely for oneself.
Unlike many other institutions, we do not need a revolution of the Hospital. It represents millions of person-hours of thought, research, refinement, and implementation. Even under decades of economic pressures,even accepting the need to tackle its enormous baggage of patriarchy and colonialism and white supremacy, a world without the Hospital is unthinkable, and unwelcome. What we need is to more openly acknowledge these inherent tensions and contradictions and take hold of them as the engine itself by which we forever make it more fit for our purpose, more human.