Category: NHS

Health Spending in The North vs The South

A few months ago, I wrote a couple of blogs exploring the social justice issue that is the vast difference between the health spend in the North, compared to the South.

 

This week a graph was produced by HM Treasury to show how overall spending has changed across England since 2012. Here is the evidence:

 

 

So, in the North, we already have the worst health outcomes in England with an underspend of around £800m per year, per head of population, compared to the South. Yet, over the last 5 years we have seen further disinvestment here at a time when we’re also being asked to make substantial savings! Why the Northern MPs do not seem to think this is worth making much noise about, I’m not quite sure. This is an economic issue, a political issue, a social justice issue and a humanitarian issue. As I take the conversation to our public about the difficult choices ahead of us, here in Morecambe Bay and Lancashire over the coming months, I wonder what the response to this information might be?

 

 

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Creating a Great Culture – Part 2

In the last blog, reflecting on the book “Legacy”, by James Kerr, I started to explore how the All Blacks have managed to create such an excellent culture; reflecting on what we can learn from it in the health and social care system (or indeed any environment).

 

Of the 15 principles outlined, I looked at the first 8 (the pack) and now I will look at the back 7.

 

9) Stay Focussed under Pressure – The eighth principle is to practice under pressure and learn to keep a cool head. This ninth one is about individuals and the team keeping their focus and attention on the task in front of them when the pressure comes. There are times when the stress is on. We are hard pressed from every side. The powers are breathing down our necks, the crisis is in front of us, we feel under resourced, over stretched and at the end of ourselves. Keeping our heads, and not losing them at such times, is the mark of a team who know how to manage themselves and take care of each other. This is really about learning to be mindful, to be present in the moment and to centre ourselves well. At times of real pressure, psychologists recommend three key things: 1) Slow your breathing down and focus on the breath flowing in and out of your body – this calms the mind and brings you into the present. 2) Find a repetitive action, like tapping your foot, scrunching your toes or clicking your fingers to help your body connect to the moment you are in. 3) Rehearse some mantras, which you can repeat back to yourself, over and over, to remind you of the basic things you need to do. That is what we use ABCDEF for in resuscitation – it’s why we need the automatic pilot. It also makes us far less likely to snap at team players and hurt relationships when the proverbial hits the fan.

 

10) Authenticity – the best leaders stay true to their deepest values, no matter what situation they find themselves in. Honesty = Integrity = Authenticity = Resilience = Performance. Be taken at your word. Say what you mean and mean what you say. Be true to who you are, no matter where you are. To be lovely at work and a terrible person to your spouse or family lacks integrity and authenticity. Good people make good leaders.

 

11) Sacrifice – now, I would offer a word of caution here. We work in environments in which sometimes we sacrifice our own wellbeing or our own marriages/families due to the pressures and expectations that we put ourselves under, because we are good hearted people who often have the need to be needed or the need to be heroes. However, there is definitely a balance, because without some sacrifice and having the kind of love, which as Thomas Jay Oord puts it, is “self-emptying and others empowering” we will lack something vital in our culture.  Buckminster Fuller says we must wrestle with these questions: ‘What is my job on the planet? What needs doing, that I know something about, that probably won’t happen unless I take responsibility for it? What extra mile will make us extraordinary?’

 

12) Language – Sing your world into existence. I hosted a conversation  in Morecambe recently, in which I shared that I often sing to places as I drive or walk through the streets (weird, I know!). But I asked everyone there, that if they were to sing a song to Morecambe, what that song would be. There was nobody without a song! Leaders are storytellers. All great organisations are born from a compelling story. Words and values really matter. Organisations need their own vocabulary, mottos, mantras and metaphors. The food of a leader is knowledge and communication. In Morecambe Bay, we are beginning to develop a language and a narrative around ‘The Bay Way.’ We want our vocabulary and our dialect to reflect the vision, values, culture and behaviours here.

 

13) Ritual – now, it might be pretty awkward if we all started to try and do the Haka at the start of our meetings! Not only would be awkward but it would make little cultural sense! Even for the All Blacks, the Haka has had to change. The team is no longer predominantly Maori, but a mixture of many cultures. They have had to go on a journey together of how to keeep and adapt a ritual that really means something and connects the team together. Ritual makes the intangible real. It can take many different forms, but it really is vital. It might be a daily team check in, but my sense is that it takes some bravery to establish and continue. In the West, we are so much more detached from our sense of corporate history and identity. Perhaps we feel embarrassed about it or no longer know what it means for us now. What might ritual look like in our work places and teams now? There is a Maori phrase which says: “Tell me and I’ll forget. Show me and I may remember. Involve me and I’ll understand.” This is why I am so keen for our teams to experience things together, like the Art of Hosting. It is in the partaking, the encountering of the ‘other’, the immersion in the experience in which we find ourselves changed.

 

14) Whakapapa – this is the principle of being a good ancestor. What are you sowing into those around you. The All Blacks make it really clear that becoming an All Black is a privilege not to be taken lightly. When you receive the jersey, it comes with a weight of history and a responsibility that you take it to the next level. The challenge is not to aim for something nice to be written on your grave stone, but for your fingerprints to be left in the lives of those around you, so that the thread of your story is continued. Here are some good words: Care for the land, care for the people. Go forward. Grow and branch forth for the days of your world.

 

15) Legacy – This is your time. What will you do with it? What will your legacy be?

 

There is so much to reflect on in the chapters of this book. We are in danger of rearranging the systems in which we work, without dealing with the issues of the heart. I will keep on saying this: Culture is vital. If we do not get our values and our culture right, we build on very shaky foundations and our house will not stand. Taking the time to reflect and build our culture together will enable us to create a legacy for the future that will be beautiful and life giving.

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Creating a Great Culture – Part 1

I’ve recently finished reading the extraordinary book, “Legacy”, by James Kerr. It is a book about the culture of The All Blacks, the most “successful” sports team in the world. If you are involved in leadership, at any level, especially if you are passionate about developing the culture of your team, I would heartily recommend that you buy yourself a copy – it serves as a great manual! As you might expect in a book which flows out of Rugby Union, there are 15 principles to align with the 15 players in the team. I will therefore make this a 2 part reflection, to make it more readable!

 

I’ve written a few blogs on here about the importance of culture (of joy and kindness) in health and social care, and indeed, the IHI so clearly show that building a “Culture of Joy” in healthcare is one of the core pillars to creating a truly excellent, safe and sustainable health and social care system. If we get the culture right, everything else follows. We spend so much time focused on vision, process and measurement, but nowhere near enough time to establishing a really healthy and flourishing culture. So, how do we do it? How do we build a really good culture? Well….I am no expert, but I want to share what I’ve learnt from this book and am learning through the work we are doing here in Morecambe Bay.

 

1) Character – it is everything. Team is not built on good players, it is built on good character, which is far more important than talent. Good character starts with humility. No one is ever too important to do the most menial of tasks. This has to be modelled.

 

2) Adapt – Darwin said, “it is not the strongest species who survive, but those most able to adapt.” In a target driven system, like health and social care, with edicts handed out from on high, we need to develop the kind of culture that is able to take the strain, to bend, to mold and not lose focus at the whim of every new government initiative. Adaptation means we need a compelling vision for the future and the investment in our teams to move well together, especially at times of pressure.

 

3) Purpose – My coach, Nick Robinson, asked me a great question the other day. I have been really struggling with the idea of ambition. For me, ambition is a word that is tied up in negative ideas like selfishness and arrogance (that isn’t true for everyone – just carries those connotations for me!). So, we explored what a better word might be to help me think about the future. The word we agreed on was purpose. So then he asked me, “So, what is your purpose? Who are you here to serve? And where in the world does that need to be manifest?” At one of the lowest points in their history, after crashing out of the World Cup in the Quater Finals – a match they really should have won, a group of the All Blacks shut themselves in a room to rediscover their purpose. One of the coaches spoke 6 words and it began to change everything. “Better people make better All Blacks.” This is true in every context. Better people make better doctors. Better people make better nurses. Better people make better managers. Better people make better receptionists. Better people make better leaders. We spend an inordinate amount of time developing the skills of our teams, making sure they can ‘deliver the goods’, but we invest precious little time, space or energy in ensuring that we develop better people. Do we help people confront their own ego issues? Do we enable people to get to grips with their shadows, their struggles, their root issues? It really matters who people are, far more than what they can do. Perhaps our development days should focus far more on tools like the enneagram and strengths finder than on some of the “mandatory training” we always make the priority.

 

4) Responsibility – this forms so much of the ‘culture of joy’ I have blogged about before. People need to know they are trusted to do the work they have to do. We have to create a culture of ownership, accountability (not micromanagement) and trust. The All Blacks talk about a collaborative culture in which individual talents can rise and flourish. Are we crushing the creativity of our teams by not allowing people to really come into their own?

 

 

5) Learn – for people to be at the top of their game, they need space and time to develop their skills. In a global landscape, we need to look beyond our own boundaries, discover new approaches, learn best practices and push the boundaries. It’s not OK to just settle for something a bit rubbish – learning allows us to strive for excellence in our work. There is wisdom in this Maori saying: “The first stage of learning is silence. The second is listening.”

 

6)Whanau – Rudyard Kipling wrote: “For the strength of the Pack is in the Wolf, and the strength of the Wolf is in the Pack.” The being of team comes from within. In the All Blacks, there isn’t space for “dickheads”. Team is everything and those who want the glory for themselves will not find a place within it. The All Blacks build on this principle. It is better to be punched in the stomach than stabbed in the back, or as the Arab proverb says: “It is better to have a thousand enemies outside your tent, than one inside.” We need to create a healthy culture of being able to challenge damaging attitudes and behaviour so that when we move, we move as one in adaptable formation, like the spearhead formation of birds as they fly.

 

7) Expectations – There is a saying the All Blacks use: “Aim for the highest cloud, so that if you miss it, you will hit a lofty mountain.” Why aim for something a bit rubbish? If we benchmark ourselves against the best practices, we will strive to be the best we can be. It’s OK to fail – that’s what a learning culture is about. But it’s also ok to not set your standards low and expect failure. Let’s expect the best from our teams so that we create a culture of excellence in the way we work.

 

8) Practice Under Pressure – I think this is especially important in a geography, like ours, in which we may not see some things very commonly. Simulation labs are vital and exposure to other working environments, so that we learn how to deal with serious situations with a calm head. When the heat is turned up, as it so often is in our working environments, we need cool heads and steady hands. Ensuring our training is as robust and pressured as possible, makes us ready for the times our skills are needed most. For this reason, we must not mollycoddle our medical, nursing and therapy students too much. We must expose them and our junior staff and help them be prepared for our times of greatest pressure.

 

In the next blog, I will focus on the other 7 principles of building a team culture. Plenty to think about above though, eh?!

 

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Authentic, Loving Leadership

Over the last year, I’ve had the privilege of spending some time on a leadership programme with the NHS Leadership Academy. One of the things it has helped me to do is talk more openly and honestly about what is important to me, what shapes me, what makes me – me! I have spent a great deal of time thinking about the word ‘authenticity’ and how I can be true to my deeply held values, no matter where I find myself, or whose company I may be in.

 

I did most of my ‘growing up’ at University with an incredible set of friends, who have remained at the core of my life. One of our founding principles as a bunch of mates was that we would not do fear or shame, but that we would be honest and open with each other about whatever we were going through. I found myself being able to talk about stuff that had been bottled up for years and making me feel rubbish about myself and as I did so, I found I was loved, not for what I did or performed but for who I was – just me, as me.

 

This kind of open and honest vulnerability sits as one of my core values in leadership because I believe it keeps me humble and permissions others to open up also. For some, there is a fear that if you show weakness, others may turn it against you – but that is a voice of fear that I personally will not succumb to. The depth of relationship that we form in any team is determined by our own ability to open up and show our true colours. I believe that being honest about where we are failing or weak allows others to be honest too and it makes us more human, builds connection and allows us to build team with real integrity.

 

Personally, I am continually influenced and changed by that man, Jesus. In the Gospel of John, we are told that any time anyone questioned his identity, his legitimacy or his authority, his answer was simple: I am, who I am. For us to be authentic, we need to know who we are, so that whoever we are with, we remain true to our core values. Throughout our life’s journey we are continually challenged to decide which way we will walk. Will we walk the easy way of life, in which we allow our ‘ego’ to remain in tact and have people see a projection of ourselves? Or will we choose the more difficult but life-giving way, of letting our ego be stripped back, so that our true self can be seen?

 

What I have witnessed over the last few years, is that leadership can rob people of their humanity. The structures we work within can end up dehumanising us, as the ego becomes puffed up and we find ourselves protecting the image we have projected. As we climb the ladder of responsibility, we can begin to modify our behaviours and as we do so, we begin to subtly let go of our core values. Perhaps we forget where we came from, or we feel the need to protect our position. Perhaps, we’ve never dealt with our own sense of entitlement or the privilege of our background which helped to propel us into positions of influence in the first place. Perhaps we never really confronted our own shadow and have carried on building our own ego project, which somehow permissions us to act in very unhealed ways.  Perhaps we get proud and lose the humility to accept that we don’t know the answer to many of the questions thrown at us, but instead of opening up the conversation towards a collaborative process, we lock down the control and increase the demands on our teams. Whatever the reason, hierarchy so easily dehumanises us, unless we work really hard to subvert it.

 

There is a real art to leading in the midst of complexity, due to the interplay of mechanistic structures and the living systems of which we are a part. The ability to resist the the demanding expectations of the behavioural norms of the machine, whilst ensuring the job gets done and setting a culture of kindness, openness, trust, honour, joy and dare I say it, love, takes bravery, time and audacity. All too often, especially at a regional and national level, I am seeing that people seem to forget who they are and begin to behave in ways that lack authenticity, treating those who were their peers, only a few months previously with disdain. I tire of seeing people talk down their noses at others, or gather people into a room to shout at them, as if this is an effective means of communication. When we see it, we must call it out. We must subvert it before submitting to it. Only by doing so, will we expose it for the phony, imperial nonsense that it is and find a way through to a kinder, more human way of leading. As my great friend, Roger Mitchell says, “Love is the purpose of everything.” A great question for leaders is, “How much love am I loosing here?” If the answer is, “not a lot!”, then maybe think about why on earth you are leading and how you might do it a whole lot more authentically!

 

 

 

 

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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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Please get your Flu Jab this Year!

We are heading for a massive flu outbreak this winter across the UK and Europe, USA and Canada. Australia have had a seriously nasty outbreak of a strain of flu called H2N3. It held their health care service to ransom over their winter and we need to be ready for it. The best thing you can do is have your flu jab – free on the NHS, here in the UK for those who are most vulnerable. If you get flu this winter, don’t worry, we’re on it! Public Health England are masterful at making sure we are ready and in partnership with the NHS, we will be armed and ready. But the best medicine is preventative. So, PLEASE, get your flu jab as soon as possible and make sure it is the QUADRIVALENT type that covers the strain we are most at risk from! Let’s stay healthy and well this winter.

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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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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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NHS or IHS?

The commonwealth fund (an influential US think tank) recently declared the NHS to be the best healthcare system in the world, for the second year running!

https://www.theguardian.com/society/2017/jul/14/nhs-holds-on-to-top-spot-in-healthcare-survey

 

Many think of the NHS as the Jewel in the UK Crown, more popular, as it is, then our own Royal Family. Andrew Street (professor of Health Economics at York) tells us why, and compares it to the US Insurance-based System:

http://theconversation.com/why-the-british-love-the-national-health-service-66314

 

We spend less of our GDP, per head of population, than almost any other developed nation and yet continue to have the best service there is.  It clearly is not unaffordable. It is something to be extremely grateful for! Why on earth would you spend over 18% of your GDP on health, as our friends in the US do, and still not be able to provide great health care for every person in your nation, no matter of their ability to pay? I do not understand why the NHS (or any “social model” of healthcare) is vilified from the other side of the Atlantic Ocean, when it is the most cost effective and clinically safe health system that there is anywhere in the world.

 

So, I’ve been wondering – why keep it to ourselves? Why just stop at a National Health Service? Why not go International (but not in an awful old-school Imperial Way, but rather a life-giving, loving kind of a way?). We have some of the best public health knowledge there is. We are learning to work creatively and differently with our population for prevention of illness and self-care. We know how to manage complex systems and budgets and we are able to adapt to new challenges relatively quickly. We know what it is to limit our spending and not allow it to get out of control and we know how to regulate corporate giants who would love to turn it into a profit-making machine.

 

The issues of global justice, when it comes to healthcare are insane. We keep talking about wanting to ‘lead the world’. Well – that old style of imperial dominance is thankfully dead and buried and will never be recovered. But we can humbly offer what we do know onto the table and see if we could all learn together about how to have a more globally just health care system. Why stop at the NHS? Why be satisfied with only a National Health Service? Let’s stop wasting time, money and resource on space exploration, projects which destroy the environment and building ridiculous weapons. Instead, let’s imagine a world with an International Health System in which we really get to grips with the kind of issues that are needlessly destroying millions of human lives every year. The possibilities of an IHS are endless and there are multiple ways it could be stewarded. If every nation contributed 8.9% of its own GDP towards it (as we do in the UK), I wonder just what might be possible and how much more connected we might become as a family of nations. Do we still dare to dream these days?

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