Adam Smith Was Wrong!

I have recently been at a brilliant gathering of people, down in Sussex, called ‘Sparks’. I always find it to be one of the more helpful imaginariums which I spend time at and love the diversity of the people who come. What follows is some learning I’ve taken from my good friend, Mark Sampson and his fabulous PhD thesis.

 

Adam Smith famously stated: “It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest.”

 

Like Mark, I disagree with him! I do not believe that self-interest is the basis for individual interaction and whatever we are told, the unrestrained free market is not benevolent!

 

We have allowed economic language not only to inform reality, but to create it. The language and vocabulary of economics is performative – it creates the world around us. Why would we think that self-interested economics will lead to goodness in society when we do not believe that in other parts of society or our own lives? It is not true of our relationships in our families nor in our friendships, so why do we allow a split mindset in how we think about work?

 

Some economists (Robertson and Summers) have argued that we should promote self-interest in policies and act out of this same motive in business, but altruism in other areas of our life, like our family and charitable work. This is ludicrous!

 

As Kate Raworth has so eloquently demonstrated, this current model of economics is dividing us, isolating us and slowly destroying us. It may, in some ways have gotten us to where we are, but it is neither capable nor kind enough to give us the future that will lead to a more connected and healed society and a more sustainable planet. Enlightenment thinking holds very little light for us now. And so, it is time to let it go, to lament its failure and discover together a new language and a more sustainable model for a reimagined future. Some of this requires exchanging the language of scarcity to one of abundance, renouncing the doctrine of growth for one of equilibrium, repenting of our obsession with competition and embracing relationship and collaboration and replacing self-interest with the notion of gift, reciprocity and mutuality.

 

This requires us to dig deeper into a spirituality and a paradigm shift in our thinking which embraces incongruity! The beauty of mutuality is that it recognises that there is personal benefit to the giver as well as the receiver in any gift-exchange interaction and it strengthens the bond of relationship. Since I watched the Christopher Robin movie, I’ve been thinking quite a bit about upsidedown triangles. Our current economies are built in pyramids, with those at the top “earning” and holding absolutely vast sums of money. What if we gave our most and prioritised those considered at the bottom as the most important? In the NHS we think a lot about ‘equality and diversity’ but often do little about it. For example, most of our waiting rooms and clinical environments are incredible unfriendly for people who have an autistic spectrum condition (ASC). What if, when designing these spaces, we didn’t tag on some kind of tick-box exercise afterwards to show we’ve considered people with ‘disability’ in a vague sense, but actually put them at the forefront of our thinking and planning? What if people living with ASC were at the very forefront of our planning decisions? Incongruous, perhaps, but a different kind of economy, which feels to me to be altogether kinder.

 

In my last blog, I explored how it is isolation (and competition caused by our need to try and overcome our human limitations) which cases poverty. What might we imagine together of an economy in which we prioritise relationships first, and worked together WITH those often left at the bottom of the pile or tagged on as an after thought? What might our planning cycles be like, if we slowed things down and really collaborated WITH our communities and truly considered all the benefits of mutuality? I believe we are at a moment in which the facades are well and truly down. We can see more clearly than ever just how broken our current economic system is, the true effects of putting our faith in the ‘free market’ to create a fair society and a sustainable planet and the realities of allowing our policies to be shaped on the notion of self-interest. It would be insane for us to continue with such a broken model, but it will take ongoing bravery to undo it’s myth in our minds, breakdown the strongholds of the many vested interests and to be part of a corporate reimagining of something based on mutuality and even incongruity!

 

In the end, I believe that when we deal with our root issues and become more healed, we are far more motivated by love than self-interest – and I see this every day! We are made in the image of God but allow ourselves to believe much less of ourselves. To quote Charles Eisenstein, “it is time for us to tell a more ancient and far more beautiful story which our hearts tell us is possible.” What if Milton Friedman was wrong and the business of business is not business? I know that may seem ridiculous, but what if the business of business is to ensure that every life matters, that we are more connected and living in a more sustainable way? What if it was the business of business to make real what really matters to us all? What else might a reimagined business of business be? And what effect might that have on how we think about economics and how we collaborate for a more mutually beneficial society and planet? I think we see this in many models and forms of business already. There are some wonderfully ethical and gentle businesses – I think this is especially true of smaller businesses where relationships are both vital and strong. It is the impersonal banking sector in particular, built on an economy of debt, with multi-lateral corporate giants that holds us prisoner.

 

The reason I am writing about this on this blog is that so much of our health and wellbeing is governed by our philosophy of economics and it is the language of economics which shapes so much of our thinking and reality. So, be careful how you speak about it, find some better words and let’s begin to shape a new future together for the sake of the wellbeing of humanity and the planet!

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Population Health and the NHS 10 Year Plan

https://www.kingsfund.org.uk/publications/nhs-10-year-plan

 

This is an excellent blog from Sir Chris Ham and Richard Murray at the Kingsfund and highlights some important issues that deserve real consideration and debate. Get a cup of tea, reflect on it and then join the discussion. Here are my reflections on it.

 

Improving population health and closing the health inequlaity gap are the two most important things for the NHS to focus on, if we are to have a heath and care service that works for everyone and is sustainable long into the future. It is not an easy nettle to grasp and is full of complexity, which is highlighted in this paper, but fundamentally, if we do not see a cultural shift, and ownership of these issues across the public sector, with population (and environmental) health written into every policy combined with a collaborative social movement for change, we will still be talking about this in another 15 years.

 

The reorganisations of the last few decades have been exhausting at so many levels and have not achieved what we have needed them to. It is indeed vital that we learn from these lessons and commit to at least a 10 year focus on improving population health, tackling health inequalities and integrating services, ensuring that we embed a culture of joy, kindness and excellence as we do so. We have reached a pivotal moment and we must break through our silos and see things tip towards a new commitment to improve the population’s health, together.

 

The funding question will not go away and it is really important that we are honest and open about what is actually going to be possible within the new funding agreement for the NHS and what will not be, especially if there is not a substantial investment into Social Care. Much of what we mean by prevention in Population Health relies heavily on other public sector partners, like Public Health, Education and the Police and the reality of their funding decline will make the transformation we need to see, especially in young people’s mental health very difficult, especially as the new deal for the NHS is not what it needs to be. For many Integrated Care Systems, the savings still required are so colossal that doing the simulataneous transformational work of population health and tackling the widening health inequality gap is a very hard task. It is a huge ask of finance directors to meet the constant demands of the regulators whilst also trying to be brave and shift resource towards more long term gains that do not meet the short termism of yearly budget requirements. The increase in demand due to more frailty and complex health issues, eye watering cuts to local government budgets (with profound knock-on effects to social care and public health), a target driven environment and low staff morale is making this all very difficult. It is not impossible but it is going to need realism and pragmatism about what can be achieved, by when. The choices being made about the funding of our public services are ideologically driven, and we need to ensure that feedback about the reality of austerity leads to necessary changes, so that we can have truly evidenced based policies.

 

Here in Morecambe Bay, we have recently launched the ‘Poverty Truth Commission’, one of several around the country. Many leaders from across our region sat with tears streaming down our faces as we heard story after story about the reality of poverty and destitution for people in our area. We heard from one young man, Daniel about how the closing of the youth centre on his estate and his local high school (both the only places where he knew he belonged and was safe), left him and many of his friends vulnerable to gangs. Moved, again and again through private rented housing, in order to provide for his siblings, he ended up selling drugs and guns, simply to put food on the table, ending up street homeless, with serious addiction problems himself. Many of us wondered how often we think about the short and long term consequences of the cuts being made and what kind of risk assessment is done in these situations. In her very powerful book, ‘Radical Help’, Hilary Cottam writes of need to put relationship back into the heart of our public service care provision, as we grapple with the joint issues of funding constraints and human need.

 

The points raised about improving productivity are important. Where we can be more efficient, we must continue to be so. Let’s pause to recognise, though, just how much has been achieved already. Culturally, we must learn to celebrate the positives and recognise the great work already being done in this area, which will inspire more of the same. The sharing of best practice and creating environments where we can learn from one another is absolutely key. This will most effectively happen through collaboration not competition. So, yes – integration must be a priority, but it comes with a health warning – if we don’t get culture right from the start, everything else will ultimately fail.

 

A Population Health approach is the only game in town. Wigan have achieved some really wonderful things, but there are some important things to understand about the context of Wigan that have made it more possible there. Firstly, there is clear political unity. The idea of population health is owned across all spheres and levels of government, and “safe seats” have led to a political continuity that has made long term planning far more successful. The ongoing politicisation of health and social care in other contexts makes this kind of transformation much more difficult. Secondly, there is a real humility in style of leadership that has been willing to a) openly share the complex issues and choices being faced, with the people of Wigan and b) deeply listen to the communities and therefore find a way through the problems together with a profound sense of joint ownership. It is this two-edged sword of necessary culture change and brave leadership with a social movement that makes it possible to cut into new ground together. We must be brave in talking to people in our local communities about the choices ahead of us and understand the importance of agreeing together who is going to take responsibility for the various pieces of th jigsaw which need to occur.

 

We know that 40% of our health depends on the every day choices we make as individuals, for example around what we eat or how much exercise we take. However, it is not as lovely and simple as this. There is far less choice available for our most deprived communities. Supermarkets do not stack the same amount of healthy food in their shops in our more deprived areas. Children have little choice over the adverse experiences they go through, how much sugar is in their breakfast cereal nor what is pushed at them through targeted advertising. The number of junk food outlets is far higher in areas of greater deprivation (see Greg Fell’s excellent analysis of Sheffield). So, when we talk about choice, especially in the context of poverty and education, we need to take a reality check and not simply point the finger of responsibility. This is where a people’s charter can be really powerful. Those in leadership play their part in taking care of the needs of the population and bringing in appropriate governance and a fair distribution of resource, whilst citizens commit to playing their part in staying healthy and well, and learning about conditions which they live with, so they can play an active role in being as well as possible, dependent on their circumstance.

 

Given the lessons from Wigan, or from global cities, like Manchester, and Amsterdam and what they are beginning to achieve around population health, there is a powerful argument, not only for combined health and social care budgets, but also for increased devolution of budgets. If we see what has been achieved in the Black Forest of Germany, with a very holistic transformation of services, including the connecting of communities through far improved transport links, we begin to reimagine what might be possible at a larger scale. Devolved budgets though must be a fair deal and not an opportunity for central government to make further cuts and then leave the blame in the locality. Devolution, if it is to work well, must come with new and fair legislation around taxation and proportionate allocation of resources.

 

All of this is only possible with the right workforce. I completely agree that we need both short-term and long-term strategies. I am not yet confident that enough work is being done at a predictive analytical level to really work out what kind of workforce we will require, if we shift to a fully integrated, population health model. This is the kind of workforce we must then build and it will by its very nature, be much more community and relationally focussed. This will allow us to build culture from the ground up and create the kind of working environments that are healthy and well, enjoyable to work in and therefore with a high retention level of staff. Perhaps our short term solutions need to be less reactionary and more proactive in building towards the future we need. Perhaps there are also more short term international opportunities and partnerships to be built whilst we plan for our reimagined future.

 

In making all of this happen, I think we need a little caution in too much over-comparrison with the American insurance-based systems. The ICS development we see there is based on a very different model and can look very appealing, because it overlooks too readily the 50million Americans who cannot afford a decent level of care. Yes, there are some impressive things to learn and some very data savvy things we can apply into our systems, but the fundamental differences between our ideologies and practices must cause us to pause and think about what is transferable and what we can do diffferently to ensure that everything we do works to close the health inequality gap, rather than widen it. This is where our greatest test will be. It is too easy when creating new agreements with the public to work with those who are already highly motivated to change. In so doing, we might actually make things worse, rather than better in terms of inequality. It is going to take determined effort and brave focus to ensure this doesn’t happen.

 

In short (!) I am very grateful for this paper and the issues it highlights. It deserves real contemplative reflection and a commitment by all to embrace this future together. We cannot achieve population health and the tackling of health inequalities alone, but together, we can.

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Healthy Schools

Tweet 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. [Continue Reading …]

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Building Healthy Towns and Regions

Tweet 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 [Continue Reading …]

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Hosting Conversations That Matter

Tweet In my last blog, I was exploring how some of the biggest determinants of our health and wellbeing have very little to do with healthcare at all. They are societal issues, with huge implications on how we live together. Issues like poverty, homelessness, loneliness and adverse childhood experiences are far greater drivers of health [Continue Reading …]

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A 3 Fold Approach to Population Health

Tweet Here in Morecambe Bay, we are trying to develop a strategy around Population Health – by that we mean we want to take a much broader view of the health needs of those who live in this area, ensuring that we try to tackle the disparities we see in the health of our population. [Continue Reading …]

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Social Movements and the Future of Healthcare

Tweet 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 [Continue Reading …]

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Turning To Each Other

Tweet Here are some excerpts from a speech I gave recently at Lancaster City Hall about how in a time of crisis, we can either turn on each other, or turn to each other (my friend Mike Love gave me that line!). When we turn to each other, unimagined possibilities become the fuel of hope [Continue Reading …]

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What Every Northerner Should Know About the North/South Health Gap

Tweet Everybody knows about the Gender Pay Gap – it’s well publicised and very much in the public domain for discussion – and too right! – How is this even still an issue? It it is quite simply wrong that women should earn less than men, any time, any place, end of discussion.   Well the [Continue Reading …]

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How do You Solve a Problem Like………..£50,000,000?!!

Tweet On Friday night, watching comic relief, I got quite excited as the total neared £50 million – I turned to my lovely wife and said – ha – there now, we can plug the gap in our local health economy for next year! (Obviously the money is desperately needed in many situations across the [Continue Reading …]

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