Health reforms where next: private influence/public voice

A few days ago I met with the chairman of a large health promotion and education society. Over the course of the conversation it became clear that he and several others in the society were making progress in influencing health policy at the highest level. As is often the case this was behind the scenes with access conditional on confidentiality. However, to those on the outside, by which I include the rank and file members, there was largely silence, which could lead to questions such as: ‘what are they doing?’; ‘how are they giving voice to my concerns?’; ‘what do I pay my money for?’ So, the very mandate that gave them access and legitimacy to influence was bound by another condition, that of secrecy that in turn risks undermining the original mandate.

The circle is of course broken (or ‘managed’) by on-going carefully crafted communication, ‘listening exercises’, leaks and informal briefings so as to give some public voice to provide conversation.

What becomes worrying is when this cycle breaks down. In the current health reforms we have seen the Royal College of Midwives, Royal College of Nursing and the British Medical Association disengage from discussions. Also, the all-party Health Select Committee has openly voiced its clear objection to the endeavour.  And today we have the Nursing times, Health Service Journal and the British Medical Journal united in in the view that the reforms are an ‘un holy mess’.

The hope is that somehow the processes of private conversation and public engagement will continue and the latest distractions will be seen as an uncomfortable but important part of the process.

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Choosing Choice

The King’s Fund and Nuffield  Trust’s paper to the Department of Health and the NHS Future Forum titled ‘Integrated care for patients and populations: Improving outcomes by working together’ makes encouraging reading reflecting increasing evidence of a maturing attitude towards choice.

Here they recognise that choice should be intrinsic to the provision of care.  However, they have reflected that we need to move from simply offering a number of providers to the patient and towards using choice as a way of facilitating better outcomes, more innovative ways of working and how this can be integrated through the entire patient pathway.

To facilitate this they righty suggest in my view a single assessment process covering all patient needs within health and social care.  Each patient will be the centre of his or her own array of care that will be unique to them with budgets to match centred on the wellness of that individual.  Choice in this world will encourage innovation and put the patient at the heart of matters but it will require us to think differently about targets and performance.  Here, there is less ability to simply aggregate activity to form an overarching commentary on health.  This may be unsettling for many existing providers and funders, but we should not lose sight of the potential benefits on offer to all.

Empathy by numbers

A few days ago a friend sent me the following You Tube link. Here a very sincere medic describes the problems that doctors have in communicating with their patients, particularly in demonstrating empathy.
He goes onto describe how doctors have too little time to work on this in face -to-face training with other doctors or patients. The solution that he offers is a computer program that identifies those “empathic opportunities in a conversation”. He then goes onto say that having “learned how to recognise [empathic opportunities] … to give them the tools for how to respond”.
Just to stress, I don’t doubt his sincerity in addressing the problem, what saddens me is how we seek to use the world of IT to find solutions to problems that essentially are the bedrock of human nature. For example, the words used such as “opportunity”, “tools” and “respond” imply a staid and linear form of communication devoid of feeling, empathy and “deep connection” with the other person. This point was emphasised for me when the medic then went onto say that a patient/doctor conversation could be “coded” and used for a number of purposes including “maintenance of certification and practice”.
For me it questions the remit and scope of IT. Perhaps IT should be there to free time for doctors to have those face to face conversations rather than for its codification and regulation.

Welcome the NHS Commissioning Board and the promises it will bring in a sea of uncertainty

With today’s launch of the NHS Commissioning Board I notice that Sir David Nicholson,  NHS Chief Executive, was quoted as saying: “Building this new system over the next two years, while delivering for our patients, increasing productivity and improving the quality of care, is a major challenge. But I firmly believe that what we are trying to achieve – a stronger, more innovative and more coherent commissioning system – will be critical to sustaining the NHS in years to come”: a realistic balance between the realities of today and the challenges of tomorrow. (http://www.dh.gov.uk/health/2011/10/commissioning-board/).

It seems a long time ago since the Coalition Agreement of 2010 was signed that set the tone for the changes we are now experiencing, particularly in health (http://www.cabinetoffice.gov.uk/news/coalition-documents).  In order to “… free NHS staff from political micromanagement, increase democratic participation in the NHS and make the NHS more accountable to the patients that it serves” it
aspired to:

  • …  stop the top-down reorganisations of the NHS that have got in the way of patient care
  • ….  strengthen the power of GPs as patients’expert guides through the health system by enabling them to commission care on their behalf
  • …  ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT)
  • …  act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs.

The NHS Commissioning Board will be holding Clinical Commissioning Groups and others to account for their promises.  And the public will hold the politicians to account for theirs.  In all of the uncertainly of change we shouldn’t lose sight of these important pledges whilst keeping the NHS working.  The challenge reminds me of what Otto Neurath (1944) once said about everyday life, sociology and the messiness of change:

Imagine sailors who, far out at sea, transform the shape of their clumsy vessel… They make use of some drifting timber  to modify the skeleton and hull of their vessel. But they cannot put the ship in dock … to start from scratch.  During their work they stay on the old structure and deal with heavy gales and thundering waves.  A new ship grows out of the old one, step by step … [they] may already be thinking of a new structure, and they will not always agree with one another.  The whole business will go on in a way we cannot anticipate today.  That is our fate (p47).

Although change will be difficult in these uncertain waters, I daresay there will be little forgiveness from the voters if promises are not kept.  And then as Otto pointed out new ideas and demands will take us on ventures new.

Ref: Neurath, O (1944) Sociology and the Practice of Life, International Encyclopaedia of Unified Science – Foundations of the Social Sciences, Vol 1, No 1, p 42 – 47, University of Chicago

The CQC Reports – Our role in the repetition of failure in health and social care

Today the Care Quality Commission published its findings of 100 unannounced inspections of hospitals in England focusing on how we care for the elderly in hospital.  It identified 55 as “alarming”, the examples cited made disturbing reading.  This comes in a long line of deep concerns including the Castlebeck care home scandal, Mid Staffordshire NHS Foundation Trust, Bristol Royal Infirmary children’s cardiac surgery unit and Alder Hey.

Common features included an institutional “acceptance” of poor practice leading to untimely death, suffering.  A common response to these events seems to be: “how can they have done this …”, or “how can this happen …?”

In asking the same question I thought it might be useful to take a different stance and to consider the work of Hannah Arendt.  In doing so I sense that somehow we are either asking the wrong question or we have not thought of the assumptions that lie behind it.

Arendt was a political theorist whose work and personal life was influenced by the many tragedies of the 20th century, notably the treatment of the Jews in Europe and World War Two.  But it is her insights of people that I would like to draw on as opposed to any abstract theory.

It was in 1963 that Arendt found herself in Jerusalem reporting on trial of Adolf Eichmann, the person who largely was held responsible for administering the extermination of millions of people in the concentration camps, the majority of whom were Jewish, a community of which Arendt was a part.  In drawing on Arendt’s coverage of the Eichmann trail I am not attempting to compare the scope or the nature of suffering (after all how can such events be compared with each other apart from
in the most crass numerical sense).

Instead I am considering Arendt’s insight into the interconnectedness of people and how we are all involved, in some way or another, with each other.  In this sense the question “how can this happen …?” changes.  It moves from implying a separation of the “disgusted” from the “disgusting” towards one whereby we all have a role to play, along with personal responsibility.

In Arendt’s account of the trial there are several relevant themes that occur to me.  In raising them here I inevitably do not do justice to her argument or the detail of her description.  I would urge readers to take the time to read her account.  The first thing that resonates with me is Arendt’s description of Eichmann.  He was someone who was keen to progress in his career, not particularly bright, and made the most of the opportunities presented to him.  I get no sense that Eichmann started his life as inherently evil.  Instead Arendt points out that he developed a thorough knowledge of Judaism and had friendly acquaintances amongst the Jewish community.  This quality was recognised by his Nazi party colleagues who came to see him as an expert in such matters which in turn was recognised with promotion and additional responsibilities.  Secondly, as the war progressed, the whispers of the horrors of the concentration camps tacitly filtered into the German community.  This resulted in the camps being moved further East beyond the border.  Thirdly, and controversially (an issue that I will come back to), was the participation of the communities most disastrously affected by the camps being party to the implementation.  All of this started several years before the start of the war whereby there was an interconnected “slow boil” of changing attitudes, particularly for Eichmann, his Nazi colleagues and more widely in society.  I am not suggesting that all parties had an equal voice and ability to change the course of those events, that is plainly not the case, but there was interconnectedness between people.

So how does Arendt’s account, help with the question posed?  It is important that we recognise that we all have a role to play, albeit with differing power and knowledge to
change the course of events.  For example, if one looks through the Francis Report in the Mid Staffordshire case, it is clear that many knew something was wrong, both amongst staff and the wider community.

With this in mind we cannot, in response to such events, set up and rely on detached approaches of inspections and checks run by appointed inspection Quangos.  By this I mean the application of systems whereby we are not constantly holding them to account as well as those communities of which we are all part.  In other words, the setting up of an inspection system should be seen as an addition to, not a replacement of, a continued challenge and questioning; a challenge and questioning by all, and
for all to have their voices heard.   For example, if we visit or work in a care home, we must all be constantly alert to the sights and sounds, smells that might speak to our intuition that something is not right.  An inspection report of “acceptability” has little relevance to the lived experience of what is actually happening at the time.  As for those inspection bodies we need to constantly hold them to account – how they work, how they listen to issues being raised, the resources that they can deploy and how much time they actually spend on the ground, experiencing the world of those being cared for.  In addition, any form of self regulation of institutions wholly inspecting their own services needs to be challenged.  Failure to do so would risk missing the deteriorating norms and cultures to which people can become blinded to, even in good faith.

What I’m describing, in practical terms, is how we are all part of an ongoing process and we all have power and responsibility, albeit not in equal measure; the implied separation of the “disgusted” from the “disgusting” is false and dangerous.  This brings me back to Arendt and the reaction to her comments on the Eichmann trial.  The idea that the parties had interconnected roles and responsibilities was not well accepted, although she made her case meticulously.  It seemed to benefit most people after the event to draw a clear distinction between those who “did” and those who were victims. Perhaps this is not unreasonable given the events she was commenting on.  However, to do likewise in health and social care would do all a disservice; patients, the cared for, and staff communities alike.  It was Arendt who coined the phrase “the banality of evil” to describe its constant presence in the mundane ongoingness of everyday life, a presence that we all have a role in combating.

Further Reading

Arendt, H (2000) Banality and conscience: the Eichmann
Trial and its implications, in Arendt, H (2000) The Portable Hannah Arendt,
London: Penguin Classics

Francis, R (2010) Independent Inquiry into Care Provided
by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009, Department
of Health, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113018

Healthcare Management: Is There Anybody Out There …

In looking though the HSJ and other industry journals it struck me that, compared to other  professions or areas of work that I have been involved in, the voice of the practitioner is almost silent. By practitioner I mean the ward manager, the general manager, the operations director all working hard to deal with the day to day problems of delivering healthcare effectively, safely and efficiently. Instead the void is largely filled with range of well informed commentators, journalists or occasionally the “great and the good” making a point on a specific policy issue. What is obscured are those voices that have to make these issues a reality and have to juggle competing demands. It could be that the practitioners do not have anything to say or want to make a contribution.

However, a quick glance at some of the message boards on HSJ will tell you that this isn’t the case – as soon as an article is posted anonymous comments flood
in. Occasionally someone is brave enough to put their name to it. My question is this – what is it about health service management that quells exchange of
ideas, views and comments at all different levels in the trade press and
elsewhere? I’m not saying that there are no pockets where this occurs, but
drawing on my experience in other sectors there is a deafening quietness in the healthcare management. Why is this?

An insight from poetry …

Today I opened the door.  Amongst the post was a newsletter from The Connection at St Martin-in-the-Fields.  St Martin’s provides support to homeless people in London, this includes a night centre, outreach for rough sleepers, career advice and training.  It also has a creative writing group.  In amongst the newsletter was a small booklet featuring poems from this group.

One caught my eye, titled 10 Thousand Pills from Rachel Vidal, it goes as follows:

I saw them
sitting there
on the shelf
so equal and perfect

I saw them
every day
But I saw you
less and less

I tried to leave
the house
and play with
my friends

The door was locked
every time
And every time I kicked
and screamed to be let out

A homely prison
you made for me
segregated me from
those who loved me

All the while everyday
those gems lay in wait
for my growing Hatred
toward you

Now I’m just an
inconvenience
and you’ve set
me free with
nowhere to go

For me to slip every last one
all ten thousand
of them and watch
you slowly disappear

You brought me into
this world
And after what you’ve done
I’ll help you leave

I don’t know Rachel or have never met her, but she evoked a number of thoughts.  The uniformity of medicine (and health) “so equal and perfect”, present, but at a distance.  How this contrasted with tense and deteriorating relationships between loved ones and the angst and guilt created.  And, the destructive possibility of how they both may come together.

For me this poem tests the assumed “goodness” of medicine health and social care more generally.  The application of medicines and care according to pathways, set interventions and the “system” comes at a risk.  We lose sight of the individual.  There is a person who has unique needs for whom those who work in health and social care may be able to provide some help and care, but so too others beyond these boundaries for example in housing, work, their friends and family and so on.  Taken together, seeing the individual as a person, progress can be made to achieve what they want from life.  By doing this touch the lives of others, for example relatives, friends, work colleagues and society more generally.

This is a call for the individual to be at the centre for those who work in health and social care.  Whilst talk of pathways, interventions and the “system” may help us understand the resources and how they can be provided, they are provided for the benefit of the individual, a person who is unique.

This poem and others (as well as the work of The Connection) can be found at: http://creativewritingconnect.wordpress.com/