Inconsistent and Incongruent Messages

The King’s Fund have just released an excellent video to help explain how the NHS works and some of the complex things going on in it at the moment. It doesn’t shy away from making it crystal clear who is in charge of the money, nor the difficulties we’re facing in staffing and resource allocation. Have a watch of it and then keep reading!

 

 

What is particularly important to understand, especially where we are learning to work in new ways together, like here in Morecambe Bay, is just how inconsistent and incongruent the messages are that we receive from the leadership structures of the NHS.

 

So, here in the Bay, we are forming an Accountable Care System, which brings together different health & social care commissioners and providers to work more effectively together. We are forming great relationships, breaking down walls and barriers to work together, whilst tackling significant budget issues as we try and ensure that we deliver care in the most excellent, safe and sustainable way for our population (whom we are trying to include fully in the co-design of the services we provide).

 

One might think, as we are being actively encouraged to reorganise ourselves in this way, that the Department of Health, NHS England, NHS Improvement and the CQC would all be pulling together to support these changes. One might presume that they would ensure the various contracts and ways of paying and assessing us would enable us to do this important work – the opposite is in fact the case!

 

On the one hand we are encouraged to ensure we work more efficiently and “cut the waste” out of our system, but when we do so, the contracts in place are working against us!! we literally being told to work one way and then penalised if we do! It is an entirely schizophrenic existence and creates an extraordinary amount of wasted time and energy.

 

I’m not exactly sure what it is that is causing the disconnect between the different regulatory bodies. However, as they require of us a new collaborative way of working that ensures greater efficiency and improved models of care…..perhaps it could be better modelled and enabled by those in the “centre”. This would give the entire reorganization a great deal more integrity. Cultural and behavioural change is talked about a great deal and we are enacting it despite the perverse drivers working against us. I wonder if the same is true at HQ, Elephant and Castle. This mixed messaging needs to stop and those of us leading systems, working with great complexity, need to be given the permission, support, and enablers to really flourish.

 

 

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Healthy Schools

Last week, I had the privilege of being at Morecambe Bay Community Primary School. The school is a beacon of hope in this area. I found it extremely moving to walk round, with Siobhan Collingwood, the visionary and big-hearted headteacher and see the incredible love displayed by all staff towards the amazing children there. It made me realise again how centrally driven targets often make no sense for so many of our children and communities, especially when the base from which they start is so very different. Siobhan and her team are doing the most incredible job at caring holistically for the children here, dealing with complex behavioural issues with such kindness and brilliance that it brings tears to my eyes, even writing about it. Not only so, but the standard of teaching to then try and help these kids come up to the ‘required standards’, being creative with the resources available, is nothing short of miraculous. I would defy any school inspector to rate this school as anything else than ‘outstanding’.

 
Siobhan and I had a great discussion about the need for health, social care, the voluntary and faith sector, the police and education to work more closely together for the wellbeing of children and young people in our communities. This is already happening in part, through our health and wellbeing partnership and ‘better care together’, but there is far more we can do. We thought about what it might be like if we parachuted fresh into the community now and had to start from scratch, what we might do together…….

 

We would start with stories – we already have many, from the conversations we’ve had in the community, but we want to really listen and be changed by the responses that we hear. We’re so grateful for the work of the ‘poverty truth commission’, helping us to do just that. We would also definitely pool our resources and prioritise key services that would not be taken away once the community begins to thrive, such as parenting classes, cooking lessons, early support services, a radically caring housing sector, preventative policing strategies (now emerging powerfully in partnership with our town and city councils), social care, mental health champions (something Siobhan has already been part of recruiting 150 locally!), children’s centres and adult education centres as a starter for 10. We would overlay this with the things that are working now – there is so much goodness happening and we don’t negate this. We want to ensure that we could see the health inequality gaps close.

 

In order to build on this idea of ‘healthy schools’, we would see kids being active every day – despite, limited grounds space, this school, like many others locally are running a mile a day. There is a great scheme here in which all the kids are learning to cook healthy, nutritious food, building vital life skills needed now and in the future. The breakfast and after school clubs are providing many healthy meals each day for the kids and throughout the summer holidays the schools cook – another woman with an incredibly big heart, opens the hall to feed families, who cannot afford to eat during the long breaks. A huge amount of work is being done around gender equality (have you seen the amazing documentary series “No more boys and girls: can our kids go gender free?” On BBCiplayer?). Kids are also given a huge dose of self esteem and know that they are loved and belong. If only the same level of caring support could be afforded through the transition to high school…..

 

Over the coming months, we hope to co-host some conversations with the community, not on our terms but shaped together with them. Siobhan spent years trying to think of great ideas to get the parents to come into school and interact with her. It wasn’t until the parents set up their own coffee morning in the old garage of the school playground, that she went to meet with them on their terms and started to build some staggeringly life-changing relationships. We know we are changed every time these kind of conversations happen and it blows our world view up so that we can collaborate effectively and co-design services with them. We want to share data with them about health and educational outcomes in order to create a passion for change and do some appreciative enquiry about all the great stuff already embedded in the community. Through these conversations, we want to connect people together and see a social movement for positive change.

The future of Morecambe is bright and full of hope. The communities are strong, the place is beautiful and the people are amazing. Siobhan is just one of many incredible headteachers in this area, committed to one another and this geography through bonds of friendship. If a genuine partnership between health and education can develop here (and it’s part of my vision and ambition to see this done) then who knows what might be possible over the coming months and years?

 

It is time for Morecambe to find its joy again. It has been the joke for too long, but soon it will become the place where the joke is found and everyone will want to know what we’re laughing about.

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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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Who is Responsible for Your Health?

Who should take responsibility for you health? Sounds like a straightforward question, doesn’t it? But I get so frustrated when complex issues get squashed into simplified, silo-thinking, ready for twitter or media sound bites, or the under-girding of political ideologies.

So….just as the economy is not just made up of the interplay between business and the household, but is in fact far more rich and complex, so too the interplay of responsibility for our own health.

Kate Raworth, really helpfully uses the following diagram to help us rethink the components of the economy. I would like to suggest that we use it to think about health, also.

So…who is responsible for your health and wellbeing?

  1. Your Family/Household
  2. Society/The Commons
  3. The Market
  4. The State
  5. You

In some ways, I feel like all of these are obvious, in their own way, but I will just unpack each one a little bit more.

 

Your Family/Household

We all have needs. We need to know we are provided for (water, food, clothes etc), safe, loved, welcome, encouraged, disciplined and given place to dream and live those dream out. It is the role of our families or the household to which we belong to ensure those things happen as we grow. So much of our ill-health, our brokenness and our long term physical and psychological pain is because these basic needs were never met and left us without a sense of wholeness. The lack of met need, has a huge impact on the development of our personality and character. When we speak of ‘personality disorders’, each type has it’s roots in early life when needs were unmet and therefore parts of the personality remained undeveloped. Let’s face it – no family is perfect! And so, I would argue, that all of us have ‘disordered personalities’, and until we confront the shadow parts of ourselves that are trying to overcome this sense of loss or inadequacy, we continue to project an ego version of ourselves to those around us. We do so to cover over this pain, but facing it head on and allowing ourselves to fess up to our deepest needs, would actually lead to us being a great deal more healthy.

When I work with head teachers and ask them what the biggest need they have in their school, the answer is almost always ‘parenting classes’. However, there are very few providers of this available (due to cuts at a county council level) and the classes available are often very ‘middle class’ in their approach. We need to completely rethink parenting classes in the context of the poverty-truth commission and think about less twee ways to really engage with communities about how we raise happy and healthy kids. The truth that Adverse Childhood Experiences are our greatest public health crisis is not going away. Grasping this nettle is going to be painful but really necessary if we are to breathe health and wellbeing into our society.

 

Society/The Commons

Just as we get our needs met by those in our immediate household, the same is true of society. The way we treat children, the things we expose them to, the way we love them and educate them has a massive impact on their current future health and wellbeing. It’s becoming clear that social media is causing significant harm to our mental health as a nation, particularly our young people, and yet we don’t know how to curb our enthusiasm for all our technology…let alone the rise of the robots…

The commons is fast disappearing, too easily privatized and made available to those who can afford it. How do we safeguard the commons and use it for the benefit of all? What would the Diggers say to us now? The breakdown of our communities, with increasing isolation and loneliness is having a detrimental effect on our wellbeing. What can we do to recover the spaces that belong to us all and help us rediscover the joy of connecting and being together?

The commons is also about our corporate voice. It is only really vast people movements, speaking with one voice that can really cause governments to sit up, listen and take heed of the needs of the people. It is only together, that we will make enough noise to change the health and wellbeing of all of us for the better. How might we speak and act together in a way that will take corporate responsibility for all our health and wellbeing?

 

The Market

Oh the benevolent hand of the market! If only…. But the Market plays an absolutely key (though currently over played) part in our economy and our health and wellbeing. We know for a fact that advertising is deliberately trying to misinform us so that we make irrational decisions. A key component is to make people feel worse about themselves so that they buy things they simply do not need. Supermarkets are being challenged for the ways they deliberately place products and arrange their stores to cause people to buy more unhealthy things and food chains are constantly trying to ‘up-sell’ their unhealthy products and downgrade our health in the process. They evangelize the masses with the idea that we are all free to make our own choices, but if this were so, they would not spend the billions of pounds involved in socially engineering our choices, so that we ‘freely’ choose that which harms us! Oh for a market that might redefine it’s moral code! The market could do SO much good, but unharnessed and left without true accountability or consequences, it serves to damage our health – something it is truly responsible for.

 

The State

The state has a vital role and responsibility in caring for all of our health and when it washes it’s hands of that responsibility or tries to pass it over, we see a massive rise in health inequalities and overall worse-health for all. The NHS in the UK is one of the great triumphs of the state. Providing brilliant healthcare for those who need it whenever they are unwell is truly amazing. Imagine not being able to afford this because it depended on keeping up with insurance bills. It is not uncommon for us to see people in General Practice, who literally cannot afford to feed their families any more and are having to make some incredibly difficult choices (made far worse by long school holidays). Easy to point the finger and start creating a narrative about how it’s “all their fault”, but far harder to hear the truth of what it is really like to be a lived-expert in poverty and the trap it creates and harder still to look to alternative solutions, rather than believe the austerity narrative. There is clear evidence that the more unequal a society becomes, the worse the health outcomes – both physical and mental. When the market is allowed to behave exactly as it wants, we also see the health of people suffer. It is only through the right kind of government that the market can be tamed. It is only with the right kind of legislation that the economy can be skewed towards redistribution and regeneration of the resources needed – this would need to include a radically feminist approach that works on behalf of women, in particular, for equal opportunity, pay and recognition of just how much the ‘household economy’ contributes to the overall wellbeing of the nation. It is only the right kind of leadership that will tackle the inequalities we see and refuse to be wined and dined into maintaining the status quo. It is only brave leadership that will take the ecological issues, like plastic in the oceans, massive over antibiotic use in animals, and ongoing air and river pollution that will give us a healthy planet and human population in the future.

 

You

And where possible, and for some given various health issues, this is more possible for some than others – we do not all have an equal starting place or a level playing field – where we can  – we do have a responsibility to ourselves and to the wider society to care for our own health and wellbeing, so that when the health and social services are needed, they are available for all. It also means using the health and social care services in a way that creates sustainability, being grateful for them and ensuring they and the people who work in them are not abused.

 

It’s complex, but it’s vital that too much emphasis is not put on any one area. We must not play the blame game, especially not towards individuals when we haven’t taken the time to hear their story, nor understood the wider context of the role of the other vital players on the field. Each aspect of the economy plays a massive role in the health and wellbeing of the nation, and it is high time that each plays it’s relevant part to its fullest ability.

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Building Healthy Towns and Regions

The other week, I was phoned by a BBC producer to ask if I would take part in a discussion on the Victoria Derbyshire show about how we can build healthy towns. It’s partly due to the work we’re doing here in Morecambe Bay with our communities around being more healthy and well, especially working with schools. Unfortunately, I was away on holiday and missed the call and so didn’t get on the show! But it did get me old grey cells thinking about this whole idea. Here at Lancaster University, we have the Health Innovation Campus, which is helping to design a new ‘healthy town’ in Lancashire. The “Imagination Team” are also hosting a conference this week called “Does Design Care?” But what do we mean by a healthy town and what ingredients might we need to see in our cities in order to say that they are, or are becoming “healthy”?

 

We must get beyond thinking that a healthy town is simply one where there is clean air to breathe and everyone is out jogging, smiling at each other and eating quinoa salads for lunch – it’s all a bit middle class! I would like to make some fairly radical suggestions of what it might mean for a town to be truly healthy, especially having been so inspired by the amazing ‘Doughnut Economics’ by Kate Raworth. I think if we don’t have a vision for what we want our future towns, cities and regions to be like in 50 years, we will not build them! I am often told that you cannot eat an elephant in one go, and we must focus on the small things we can do – eating it one bit at a time – true enough, but we need to hold both things in tension. We need a vision big enough to inspire us to change and then we need to pick up the knives and forks and begin the process of eating it!

 

So, what might healthy towns of the future be like?

In healthy towns:

There are no homeless, not because of social cleansing, but because everyone has a home in which to live.

Design cares enough to ensure that spaces are built which encourage communities to spend time with each other, connecting and collaborating, breaking down isolation and loneliness and facilitating new political space.

There is a creative commons, with plenty of space that belongs to all.

The economy of the town/region is designed to ensure that resources (including land) are redistributed, breaking cycles of poverty and enabling all to flourish. This increases the happiness and health of all and allows a society in which the wellbeing of all matters to all.

The economy of the town/region is designed to ensure regeneration, thus taking care of the environment for future generations. Towns like this will not only be carbon neutral, they will in fact, as Kate Raworth says, become generous in their approach to humanity, other towns and the planet itself.

Children will be nurtured, as part of communities, not as fodder for the economic machine, educated as socially adaptable human beings, understanding their place within the ecosystem of which they are a part.

There will be a culture of positive peace, made possible through non-violence, in which architecture is used to enable communities to live well in the midst of and celebrate difference. Facilitation and mediation will be normative practices when relationships become strained or difficult and the lust for competition and war will be quelled.

There will be a culture of love, in which all are welcome and accepted for who they are. This does not encourage selfishness, nor does it mean that there is no challenge. In fact, love, at its best, is self-giving and others-empowering (Thomas Jay Oord).

There will be a culture of kindness, displayed through humility and respect.

There will be a culture of joy in which people know that they belong and are trusted.

Justice will be restorative, rather than retributive, something which does not negate the need for discipline, but hopes for a better future through grace.

Refugees are welcomed, cared for and also allowed to flourish.

Equality and diversity is celebrated as a norm.

Farming practices are kind to the land.

Business is changing it’s goal, becoming agnostic about growth, but obsessed with how it plays it’s part in improving the wellbeing of all through regeneration, redistribution, repair, reuse, refurbishment, recycling and restoration.

People are valued in their work place and the workplace is a healthy place to be in.

Physical activity and healthy eating are a normal part of every day life. (Thought I’d better add that one in!).

Wherever possible, people die well, surrounded by community who love them.

 

Wouldn’t you love to live in a happy, healthy, wholesome town?! It’s not beyond our grasp. We simply need to adapt the ones we have and build the ones we want! Building together a future that is good for all. Which bit shall we eat first?!

 

 

 

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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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Perspective

Earlier this week I wrote another blog about the health inequalities we face in the North, compared to the South. Then I spent some time with a good friend of mine, who has spent much of his life in other countries. In what I’m about to write, I’m not negating the injustice that exists between North and South in the UK, or belittling the struggles that many of us face. But it did make me reflect again about wider issues of justice, not just locally but globally. Perspective is everything.

 

There has been much in the press over recent months about the rise of food banks – I do agree that this is shocking. But how amazing it is to live in a country where food banks are possible! Currently, 1 child dies every 10 seconds in the world today from HUNGER! Can you pause to imagine that?

 

It is true that some of our most economically deprived communities still have outside toilets. But those toilets are connected to a mains sewerage system that keeps disease far from us. 500,000 people (most of them children) – die every year from DIARRHOEA! That is like the entire population of the City of Leeds being wiped out every year from something entirely preventable. Clean water and sanitation – think about it.

 

The so-called childhood diseases of measles, rubella, pertussis (whooping cough), tetanus, and diphtheria are responsible for several hundred thousand deaths per year. Fortunately, all of these diseases are preventable through inexpensive vaccines.

 

Can you imagine for one minute if children across the UK were dying of hunger, diarrhoea and preventable illnesses? There would be uproar and rioting. But the poor suffer what they must.

 

Why am I writing this? Because we must constantly challenge our perspectives. It doesn’t mean that we should not tackle injustice at a local level. But, I think it does mean that if we challenge injustice at a local level, let’s not just be satisfied to stop there. We must tackle injustice at every level, wherever we see it and keep pushing ourselves to look further and deeper, beyond our own borders.

 

 

 

 

 

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The Rules of Engagement

I am increasingly concerned by the use of the word “customer” to describe people who use the NHS and social services. I hear it often in meetings and it is, in my opinion really dangerous. It is dangerous for 2 reasons: firstly, it assumes that people “buy” services, which they do not (because our services are not and must not become based upon ability to pay); and secondly it creates a very unhelpful understanding of how we expect people to behave in relation to their own health and the health service i.e. as consumers, rather than participants.

 

I heard recently about a practice in Columbus, Ohio, in which before beginning an operation, each member of the team: the patient, the surgeon, the anaesthetist the nurse, the ODA and the recovery nurse all stand in a circle and agree who is responsible for which bits of the healing process. It takes into account the ‘checklist’ idea of Atul Gawande and expands it further. Each person, including the patient (except in emergency settings when they are unconscious) have some responsibility to take for the healing that is about to ensue. It is vital that the patient themself understands that they have a key role to play in their own recovery.

 

If people think of themselves as the ‘customer’ or we think of them that way, we can all too easliy exclude them from taking an active part in their own health journey. The NHS is not a sweet shop or a passive experience in which you have things done to you – at least it shouldn’t be. Creating a ‘customer base’ is the antithesis of a social movement for health and wellbeing and we need to stop this really unhelpful language now!

 

There is a step-ladder approach to thinking about engagement and participation which is really helpful. I’m not exactly sure who first drew this, so can’t give credit where it is due:

 

 

We are actively producing and encouraging a society of passivity and consumerism and we need a sizmic shift in our thinking to create a totally different approach to how we think about our health and wellbeing.

 

If we think of, or encourage people to think of themselves as customers of our health and social care services (and this applies across the public sector, so this could equally be written about education, the cleanliness of our streets etc) then we assign people to the bottom two rungs of the ladder as victims and consumers. It is no wonder that we are facing some of the issues we are. It has created an incredibly unhelpful and unhealthy power dynamic and has caused an enormous strain on our services.

 

I’m not talking uncompassionately here. I know that many people have to live with long term conditions that can be utterly debilitating and difficult to cope with on a day to day basis. What I’m talking about here is how we respond to people who live with those complexities every day. We don’t have to treat them as victims, nor as consumers. Surely, we want people at least to be able to translate what their choices are – what’s possible for me or even what is in this for me? It would be one step better for people to be able to actively participate in their own care – this can be both active and reflective. But what about people being able to shape or co-produce the kind of care they would like to see and what might their role be in this?

 

Co-production calls for a double accountability. What is the responsibility of the person who has a certain condition and what is the response ability of the service to work with that person or group of people around that condition/situation? It is not for us to be taking power away from people. We have to learn to work differently and to work with people.

 

People using the NHS and Social Services are not customers and we must stop talking about them in this way. They are active participants in their own health and social needs, who should be able to shape and co-produce the kind of services we all need to improve our health and wellbeing. This kind of approach is vital if we want to see an end of the consumer mentality and an embracing of a greater sense of corporate responsibility.

 

That is why I am so passionate that we take our financial difficulties and conundrums out to community conversation. It is not for those of us in positions of power to make decisions on behalf of our communities, (even though this is our statutory responsibility) because if we do, we will only deepen the victim/consumer mentality. No, we must be honest, change our language, share our problems and engage together to recognise that the future of the NHS and Social Care belongs to us all and is our shared responsibility.

 

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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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Social Movements and the Future of Healthcare


As the crisis in the Western World deepens, and the growing reality sets in that business as usual simply can no longer continue nor solve our problems, our systems must change the way they view, deal with and hold onto power. The NHS is no exception. If we want a health and social care system that is of the highest quality, safe, sustainable and economically viable for the future, we need to understand the power of social movements, both within our systems and through the wider society. This is something we are really committed to in Morecambe Bay and so it was with great delight that I listened to the excellent Helen Bevan, talk about just how vital social movements are for the NHS and healthcare, worldwide at the recent IHI conference in London, Quality 2017. This blog will be an amalgamation of what Helen shared and my own thoughts about our early experiences with social movements.

 

 

A social movement in health and social care involves us all learning to connect, collaborate, cooperate, cocreate and coproduce at a level we have never done so, until now. But our circumstances are forcing us to reconsider the ways in which we work. We need the creative substance that is within our teams to be heard and harnessed so that we cut our waste and work more effectively together. The issues we face, need facing by us all, together; not by some board in an isolated room, making decisions based on diktats from on high, on behalf of us all.  But even this will not be enough. Those of us stuck in the system have become too homogenized in our thinking for us to do this exclusively from within. We need our citizens to help us re-imagine what it means for us to be healthy and well. We must stop designing things for our communities or doing things to them, instead we must design and do things with them. We must analyse, create and enact together and to do this, we must learn to solve the issues of power.

 

Helen Bevan, with her background in social science, demonstrates the great debate about the interplay between our organisational structures (rules) and agency (freedom) when it comes to effecting change. Where does the “permission” come from to enact the change we need to see? Is it externally generated by those in positions of power, or is it internally generated by a personal motivation? Our experience in Carnforth and Morecambe in community conversations has been a bit of both. There are many people of incredible heart and goodness, waiting to do something new and good that will positively affect the health and wellbeing of society, but are perhaps waiting for that sense of community backing, support, encouragement or indeed permission. With a bit of coaching or spurring on, we have seen some amazing initiatives begin that are bringing transformational work into our area and causing us all think differently. We need both individual agency AND corporate agency. Helen describes individual agency as being when people get more power and control in their lives – we see this in patient activation, shared-decision making and self-care – a greater sense of autonomy and responsibility. Collective agency, on the other hand, is where we see people act together, united by a common cause, harnessing the power and influence of the group whilst building mutual trust.

 

 

We have seen this used powerfully, in just one example by our maternity liaison service committee, who together have challenged our system to think more carefully about how we communicate to women, especially at key or stressful moments of their obstetric care. These stories are now a compulsory part of training for all who work in our maternity service and have significantly improved both our skill mix and ability to provide excellent care.
What is absolutely vital to understand is that we do not become transformed alone. We are transformed when we are in relationship with others (Hahrie Han). The problem is that we don’t really encounter the “other” enough to be changed. However,  when we let go of the kind of power that is held by the few, pushes others down, uses command and control, that is closed and transactional, and instead embrace a power that is held by the many, shared, open and relational, then we can begin to see the change we need (Hirschman and Ganz).

David Holzmer says that we are witnessing the collapse of expertise and the rise of collaborative sense-making. I would suggest that this has been going on for some time, but our systems have been incredibly slow at catching onto the change around us.

 

Now, what is hugely encouraging is this: research by Kollectif shows that you only need 3% of people in an organisation/society to drive the conversations with 90% of other people. In other words, you don’t have to get everyone on board from the word go. You find your passionate people with a sense of agency, infect them with the virus and watch it spread. These people need to be a mixture of ‘lone wolves’, mobilisers and organisers. Lone wolves are people who have been trying to help change happen for a long time but can sometimes feel like an annoyance to the system, so they are given tokenistic positions, patted on the head and patronised into exhaustion. Mobilisers build power by calling large numbers of people to contribute, engage in change and take action. Organisers build power by growing leaders in a distributed network, building a community and protecting its strength. We need all of them, though mobilisers and organisers will be the most effective in creating agency and bringing about lasting change  (Hahrie Han).

Joe Simpson says that ” great social movements get their energy by growing a distributed leadership.” The cult of celebrity can be powerful, but is not effective. The beautiful thing about a social movement is that is depends not on money, materials and technology but on relationships, commitment and community, and as the movement grows, these resources increase, rather than diminish. The problem, as Don Berwick puts it, is that leaders in position of strategic influence, are simply not seeing the resources available to the biggest problems we are facing.

 

Jason Leitch and Derek Feeley have powerfully shown that performance management (keeping the power), based on targets, sanctions and inspections can only get us so far. Quality improvement (sharing the power) gets us a little further, but mobilising social action, or co-production (ceding power) has a far greater potential to bring lasting change and far better outcomes for all.

 

So, how do we catalyze a social movement and how would we know if the movement was being “successful”? Well, our experience in Morecambe Bay is that you start with the 3%. You start with those who are drawn to the conversation, who recognise the need for change and who want to be part of it. You start with transparency, with openness, honesty and vulnerability about the mess we find ourselves in and the truth that we no longer have what it takes to solve the problem. And you start with really good questions and then deeply listen to the conversation which is emerging so that we ourselves are changed and can therefore be part of the emergence of something new, which operates on an entirely different kind of power.

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. That is what we must measure!
And so we need disruptive co-creation, which breaks through the top-town/bottom-up approach and causes us to see and hear like we have never done before. It is hugely exciting and enables managers to stop feeling like they have to extract as much performance as possible from the system, flogging the workforce, blocking change and innovation and inadvertently driving down the quality of care in the process.

The invitation is instead to become part of the change that we all long for. If we’re going to have an NHS in the future, we have to give it back to the people and work with them. In order to do this, we have to deal with and change our relationship with the very notion of power – something I will turn my attention to on the next blog!

 

 

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