We Have a Power Problem!

NHS – we have a problem! This blog forms a hiatus in the middle of a 4 blog mini-series about what I call the four rings of leadership (in the context of healthcare). I have been musing on some statements made at the IHI conference in London, Quality 2017, and before I go any further, I want to take a pause to reflect on the notion of power. Helen Bevan says that the number one issue facing our health care system is the issue of power. I would suggest that unless we seriously reflect on power and how it manifests itself in our systems and in us as individuals, then we will never be able to co-create health and well-being in our society.

 

In my last blog, I mentioned an excellent talk that I heard Derek Feeley of IHI and Jason Leitch, the CMO of Scotland, give together about our need to “cede” power, if we are to build safe, high quality, economically sustainable health systems. They contend that we need to move from keeping power, to sharing power and then ceding power. To cede power, means to transfer/surrender/concede/allow or yield power to others. I do believe this is correct. I believe that true leadership is absolutely about being able to ’empty out’ positions or seats of power, so that all are empowered to effect positive change and build a society of positive peace. However, my contention is this: ceding power is not helpful unless we first deal with the very nature of power. Once we have dealt with its very substance can we truly cede it through our organisations and systems to bring increased well-being for all.

 

I have talked many times over the dinner table with my great friends Roger and Sue Mitchell about the nature of sovereignty and power. Sovereignty is a dominant theme within our political discourse at the moment, at a national and international level. It is worth reflecting that sovereignty (the right to self-govern) is utterly intertwined with our understanding of power, and we need to pull the two apart if we are ever to cede the kind of power that can transform the future. If we do not recognise (have a full awareness/deeply know) this, we will continue to inadvertently create hierarchical dominance and systems that become the antithesis of what they are created to be.

 

 

We see the issue of sovereign power at work every day in the NHS. We see it in terms of power edicts from on high, without understanding the local context or issues worked through in a relational way. We see it in the way these edicts are then outworked through leadership and management styles, which are very top-down and hierarchical in nature, eating up people like bread in the process – what Foucault calls “Biopower”. We see it in the way wards are managed and in the way GP surgeries are run. Sovereign power says “I’m in charge around here” and “we’re going to do things my way”. We see it in individuals who choose to practice autonomously without thinking about the wider implications on the system, prescribing however they would like to, without thinking about the cost implications. We see it in the attitude of some patients, when it becomes about “my rights” with an unbearable or unaffordable pressure put onto the system. If we multiply sovereign power, we simply end up with lots of  kings and queens who defend their own castle, creating more barriers, walls and division in the process. Sovereign power is defunct and dangerous and it is this which is currently destroying our ecosystems and wider society. The “I did it my way” approach is rooted in self preservation and ambition and does nothing to help us build health and well-being in society. Sovereign power stands in the way the very social movements we need to see, because Sovereign power is based on fear.

 

Sovereign power has its roots in certain streams of theology and philosophy which have in turn laid the foundation for a way of doing politics and economics based on the supremacy of the state and within that the individual. However, the damaging effects of this are seen on our environment and on community, with utterly staggering levels of inequality, injustice and damage to the world in which we live.

 

If we are to truly cede a power that is effectual in changing the world, then it is not enough to simply reconfigure (rearrange) it, or reconstitute it ( i.e. give it a new structure/share it). First of all, we must revoke it! In other words, we must look ‘Sovereign power’ straight in the eyes and reject it, cancelling it’s toxic effects on our own selves and on that of others. We must change our minds about it and embrace instead a wholly different kind of power. Sovereign power has not changed the world for the better so far, and I hold no hope of it doing so in the future. No, we don’t need Sovereign power and we certainly don’t want to cede it. Instead, we need kenotic power. Kenotic power is based in self-giving, others empowering love (Thomas Jay Oord). It empowers others, not to live like mini-dictators, but to also dance to a very different beat.

 

I used to play the card game bridge, with my Grandpa (he was an amazing man, who invented Fairy Liquid!). In bridge, to revoke something is to fail to follow suit, despite being able to do so. Kenotic power refuses to play the game of Sovereign power. It embraces an entirely different approach. And as many through the ages have found, this kind of power is truly costly, and can even cost you your career or life; but it is the only kind of power that truly changes the world for good. Jesus, Rosa Parks, Emmeline Pankhurst, Gandhi, MLK, Malala Yousafzai, Nelson Mandela, Florence Nightingale and Mother Theresa are just some, who have embraced this ‘self-giving, others empowering love-based power.’ This is the kind of power we need now. We need it in healthcare and in every other part of our society.

 

Kenotic power is vulnerable but it is not about being a door mat. It is like a beautiful martial art, in which we can say “I won’t fight you and you can’t knock me down, unless I let you” In other words, we lay down our rights and power freely, they are not taken from us by force. So, even when energetic attacks are launched against us, this kind of power allows us to move out of the way, allow the attack to pass through and then to come along side the person and help them see another point of view. Switching to this kind of power is far more creative, less combative and far more fruitful in creating a way ahead full of possibilities without the need for making enemies in the process. We must challenge the deep structural belief that our political and economic systems must be built on and can only be held together by Sovereign power. What if we developed systems based on love, trust, joy and kindness, aiming for the peace and wellbeing of all (including the environment?) – what might such a health system be like? It will take a social movement for us to get this shift, and as I wrote in my previous blog: You might call this a re-humanisation of our systems based on love, trust and the hope of a positive peace for all. But this social movement is not aiming for some kind of hippy experience in which we are all sat round camp fires, singing kum-ba-yah! This social movement is looking to cause our communities to flourish with a sense of health and wellbeing, to have a health and social care movement that is safe, sustainable, socially just and truly excellent, serving the needs of the wider community to grow stronger with individuals learning, growing and developing in their capacity to live well.

 

 

I agree wholeheartedly that the most important role of leaders is to cede their power, so that all can truly flourish, where there is a far greater sense of cooperative and collaborative agency within our (health) systems. But if we do not examine the nature of this power, we will only perpetuate our problems.

 
Martin Luther-King said these famous words – they are seriously worthy of our reflection:

 

Power without love is reckless and abusive and love without power is sentimental and anaemic. Power at its best is love implementing justice, and justice at its best is power correcting everything that stands against love.”

 

 

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Floods, Fire and Fresh Thinking in the North

imgresAs I was driving along the A6 today, between Carnforth and Morecambe, on my way to visit an elderly patient, I experienced in the space of a few moments both exhilaration and dismay. I was exhilarated by the magnificent view of the mountains of Cumbria, just across the Bay in the beautiful sunshine and felt very grateful for living in such an inspiring and spacious place. And then onto my radio, came the voice of the Prime Minister in response to Jeremy Corbyn at PMQs. He was asking David Cameron about the lack of government response to the floods in Cumbria of 2014. This direct lack of action across the North of England (despite clear warnings) contributed to the appalling flooding that thousands of people have experienced over the last month. That, coupled with de-forrestation and the clearing of land upstream was a recipe for disaster once the storms hit us. Mrimgres Cameron, however, seemed to think it more important to mock Mr Corbyn on his shadow cabinet reshuffle rather than address the very serious questions in hand. The floods have been no laughing matter for the North. They have been devastating and could have been avoided had the North been treated with equity to the South.

The North is a remarkable place, filled with people of great heart and courage, a people who have historically had the ability to unite at a level to bring about significant change. As one example, it was a petition of the people of Liverpool, Manchester and Sheffield that saw the end of the slave trade in the UK. So, when the people of the North get a fire in their bellies, you can guarantee that change will come.

imgresWell, the floods are serving as a catalyst for this fire. The floods are only another indication of the injustice the North suffers in favour of the politically lucrative South. The South is not to blame and nor is this post intended to be divisive in any way, but it is high time that the North stood up to be treated as an equal partner and not a poorer brother. In my area of passion, health and well-being, the differences between the North and South are completely unacceptable and indeed detrimental when it comes to making effective change to health outcomes.

As already stated on this blog, despite all the worst health outcomes being in the North, 94% of all health research money is currently spent south of Cambridge. We have conclusive evidence from the Academic and Health Science Network, that health outcomes are significantly better in places where research is carried out , because funding follows the research.

We also know, from Health Education England, that when a direct comparison is made head for headimgres between the North and South when it comes to recruitment and staffing levels there is a £17million deficit in the North. It’s not that we can’t attract people to work here, we’re just not given the money to pay for them in the same way.

imgresWhen it comes to council cuts, again we see the North punished in comparison to the South, even though the need is greater here – which area has the highest use of food banks? The answer is the North West! If you study the map on council cuts (deep red = heaviest cuts, blue = increase in spend) – you will see just one blue area in the North, but major areas of protection and even significant growth in budgets for the South.

 

In Lancashire alone, the county council has to cut £262 million from their budget in the next 2 years. This is going to have devastating consequences to public health provision and social services, which is in in effect a cut to the NHS also. We are already seeing severe bed blockages in our hospitals and without social workers to support our elderly citizens, the crisis will only deepen.

 

imgresMy hope is that the North harnesses the emerging fire to come to a place of equal partnership with the South, raising its voice for justice and love rather than in vindictive, competitive vitriol. I hope that the North will together decide what it is to become a “Northern Powerhouse” rather than being prescribed what it will mean via the ideas and ideals of the Chancellor in Westminster. From my perspective, the North is about a different way of doing things. The North stands for a more equitable and co-operative society. In this moment the North can stand for a forward looking culture in which:

Men and women are equal.

Children are prioritised.

The environment is stewarded well.

Hospitality is an art form, practised and adhered to, where all are welcome and all can find a home.

Inter-culturalism thrives as mutual respect for difference is a core value.

The elderly are honoured and cared for with dignity.

Justice involves much more restoration and less retribution.

The rich do not become ever richer whilst the poor become ever poorer, but cycles of poverty and deprivation are broken through hope and aspiration.

Work is done, not simply to earn money and pay debt, but to create more joy, beauty and care in the world.

Well-being is more important than economic growth which involves people being used as fodder to drive the ever hungry machine.

People take responsibility for themselves and each other leading to more sustainable systems (health/education/social services etc) for all.

Healthcare and education is free and accessible to all.

The North must rise up, not to dominate but to become a different kind of “powerhouse”. A house in which power is poured out for the sake of those who need it most in order to create a more fair, just, loving and peaceful world. This is the new politics, not the farce we are seeing in the corridors of power. People learning to live together differently, having important conversations together to create a future that is more beautiful. Come on the North – let’s use this passion for good!

 

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