Does Design Care?

Earlier this week, I had the privilege of sitting in some conversations at ‘Imagination’, Lancaster University as part of a conference, hosted by Prof Paul Rogers, entitled ‘Does Design Care?’ It has left me with much to think about in terms of how the health and social care system is currently being redesigned here in the UK.

In Morecambe Bay, we have been set a target to save £85 million over the next 3 years, learning to live within a smaller budget than we have had previously. In order to help us consider our options, we were encouraged to have the consultancy firm, PwC, come and work with us for a number of weeks. They met with many of us from across our system and worked with us to subsequently bring some recommendations to us as a leadership team about how they perceive we can tackle the problems facing us. When I met with them, I asked them to consider coming with me to walk through some of our most “deprived” communities, to talk with the people here, so that their proposals did not become detached from those who need our services the most. Unfortunately, they were unable to make the time to do so. I wonder how often consultancy is done and recommendations are made without the involvement of local communities. I wonder if the concept of co-design is anywhere near being at the core of our values. I wonder if design really cares very much at all. I know it does but maybe it has lost its way a bit.

A wonderful challenge was brought to ‘Imagination’ by Saurabh Tewari from India, to embrace the Gandhian principle of ‘Sarvodaya’ as a framework for design. Sarvodaya means ‘the upliftment of all’. The idea flows from Ruskin, of Cumbria in his work ‘Unto This Last’ and from Christ and his teaching from the Parable of the Vineyard. Our design or re-design of systems could easily forget that part of its call is to ensure that this is outworked. Many of the interventions tried through the redesign of services often does nothing at all to tackle health inequalities and in fact can often widen the gaps we see. This idea of ‘Sarvodaya’ has so much synergy with the concept of a ‘redistributive’ and ‘regenerative’ economy. There is little point designing something that does not carry the blatant goal of trying to improve the life of everyone, but especially those who find themselves at the bottom of the pile, or suffering, the most.

The priorities of Sarvodaya are: care for the environment and care for the weakest… so similar to the politics of Jesus – care for the poor, the sick, children, women, prisoners, refugees and the environment. These seem like really good foundational things to be careful about when we think about design of any sort.

Dr James Fathers, Director of Syracuse University School of Design, delivered a powerful paper about this whole area of co-design. He ended with a beautiful quote from Lila Watson an Aboriginal Elder, activist and educator from Queensland, Australia:

“If you have come to help me, you are wasting your time.
But if you have come because your liberation is bound up with mine, then let us work together.”

Design at it’s best, if it is to work for the health and wellbeing of all, means that all are redesigned, re-configured and changed for the better within the process, because all are included in the design process i.e. Co-design. Together we find we need each other and so are all transformed independently and corporately into something more beautiful and whole.

At the heart of ‘Sarvodaya’ is the idea of ‘Khadi’. Khadi is a hand-spun and handwoven cotton cloth, representing both a non-violent protest against the British products, but also a sign of a community learning to be self-reliant, self-sufficient and to use village articles only when and where available. I wonder if we’ve thought about the redesign of our health and social care systems based on the values of caring for those who need it most, uplifting the whole of society (but in so doing, ensuring the closing of the inequality gap), using our resources thoughtfully not wastefully and doing so together, with a spirit of non-violence. What might our systems be like if we held true to these values?

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The Ethics of Health Economics

The ethics of Healthcare is about 2000 years ahead of the ethics of Health Economics! All doctors in the UK take an amended Hippocratic oath when we qualify, in which we promise to:

 

  • Do no harm
  • Prioritise the patient
  • Treat the whole person, not just the symptom
  • Obtain prior informed consent
  • Call on the expertise of others when needed

 

We also have our ethical code:

 

  • Benficence – i.e. seek to do good
  • Non-maleficence – i.e. don’t deliberately do harm
  • Justice i.e. treat everyone equally
  • Autonomy – i.e. respect the wishes of your patient

 

Kate Raworth argues in her simply marvellous book, Doughnut economics (in the Chapter “Get Savvy With Systems”), that the discipline of Economics simply does not have any such moral or ethical code. In fact, as George Di Martino puts it, “it is entirely cavalier regarding its responsibilities”. But in a world, based on theories (most of which are entirely outdated and impotent in solving the global issues we face today), it is vital that an ethical code is written on which economic decisions can be based. She makes the following suggestions:

 

  • Act in service to human prosperity in a flourishing web of life, recognising all that it depends upon.
  • Respect autonomy in the communities that you serve, ensuring their engagement and consent.
  • Be prudential in policy making, seeking to minimise the risk of harm -especially to the most vulnerable – in the face of uncertainty.
  • Work with humility, by making transparent the assumptions and shortcomings of your models and by recognising alternative economic perspectives and tools.

 

In some ways, I think you could take the ethical code of the medical world and simply apply it that of economics, but the four principles above give us a good starting framework.

 

The reason I want to explore this whole idea and will give some further blogs to this area of health economics is that, to my mind, it is ludicrous to be talking about ‘reimagining health’, if we are not also in the same breath ‘reimagining health economics’ or indeed ‘reimagining economics’. Much of what is happening within the world of health and social care at the moment is being driven by an economic model that lacks a moral compass or an ethical frame work. It is high time that this changed! Decisions made about how a health and social care system is organised and governed hugely impacts on how that health and social care is subsequently delivered. We cannot afford to separate our ethical principles from our commissioning strategies. There must be far more synergy between the two.

 

I love this quote from Donella Meadows:

 

“The future can’t be predicted, but it can be envisioned and brought lovingly into being. Systems can’t be controlled, but they can be designed and redesigned (emphasis mine). We can listen to what the whole system tells us, and discover how its properties and our values can work together to bring forth something much better than can ever be produced by our will alone”.

 

Plenty to think about there!

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