Criminalising clinicians is not the answer to care failure or neglect

November 18, 2013

It has been widely reported in the last few days that doctors, nurses and managers will face jail if they neglect patients (see for example http://www.theguardian.com/society/2013/nov/16/doctors-face-jail-if-patients-mistreated). Press coverage has suggested that this links back to both the Francis Report into Mid-Staffordshire and the Berwick Report into patient safety (the former is correct, the latter, not really, as I’ll come back to). The idea is that, by putting in place criminal sanctions, a deterrent will be put in place to prevent the wilful neglect of patients. I think this is the wrong way to go about this.

The NHS does have a problem in terms of care provision. Part of this is sheer scale – when you have that many organizations all of which are providing NHS care, there will be some clinicians somewhere not doing a job. They may even be engaging in wilful neglect. But sadly, there will be poor care somewhere. The question is, how can minimise poor care as much as possible?

The government plan to make neglect a criminal offence depends upon such an offence being a deterrent. But just about the most robust finding we have in psychology is that, if you want people to do things better, you should appeal to their intrinsic motivation rather than by putting in place extrinsic rewards or sanctions. In more everyday language, if you want people to do a good job, you should appeal to people’s pride in doing a good job rather than trying to pay them to do it, or by threatening them if they don’t. This finding applies double when you are dealing with highly-qualified professionals. We want our clinicians to do a good job, so we need to have systems in place that appeal to their pride in caring, not trying to pay them to do it better, or threatening should their care standards fall. Of course we need systems in place to hold clinicians to account for the care they provide – but threatening them with jail really isn’t the answer.

A key question for me is why does bad care happen? How is it that people who became carers with probably the best of intentions end up neglecting patients? The answers are not straightforward. It can be the result of having to work in dreadful circumstances, brought on by a lack of resources and dreadful leadership. It can be the result of gradually falling standards due to the tolerance of poor care from others. We need a great deal more research to really understand what happens when care fails. But threatening people with jail should they fail to provide good care on the grounds that it will act as a deterrent ignores how and why bad care was being provided in the first place. It assumes that carers are making rational decisions to neglect patients, when the real situation is always more complex and difficult than this.

A second key question is whether the principle of prison-based deterrence ought to apply to our policymakers. If we are going to prosecute carers, then why aren’t we prosecuting government ministers for neglect in policymaking, leading to an NHS reorganization that was not based on research, which wasted billions of pounds, fragmenting care, and demoralising staff? If the government are so sure that deterrents work, why aren’t they making themselves subject to them too? Or is it, perhaps, that by sending a few lowly-paid nurses to jail (as has happened at Mid-Staffordshire, under existing health and safety laws) we can pretend we have dealt with care provision problems and move on, rather than looking harder and thinking this through more carefully?

Francis did recommend that neglect of basic standards be a criminal offence. Berwick was much more circumspect – I read his findings in suggesting that, only in extreme cases should criminal proceedings be used, as expressing the bare minimum agreement with Francis rather than supporting the earlier report. Berwick talks instead about the collective responsibility of care teams, and about supporting carers – the language of punishment isn’t really a part of his report. I think he was right in this. By appealing to the reasons why people became carers in the first place, by supporting them in their jobs, and making sure they have the resources they need to do their job, then we have the best chance of minimising neglect and reducing care failure. Sending people to jail won’t help.

Targets, performance management and the NHS – what happened at Colchester?

November 14, 2013

Last week, we received a report from the Care Quality Commission that showed that cancer care records at Colchester hospital had been tampered with. Inspectors went into the hospital in August and September, and found 22 of the 60 records that they looked had been compromised in some way. It seems that senior managers were alerted last year (2012) to what was going on, and carried out an internal review, but this did not stop the practice. By way of context, Colchester was one of the 14 hospital trusts with high mortality rates that was included in the Keogh review, and although 11 of those trusts were subsequently put into special measures, Colchester was not. It is worrying that, even under increased scrutiny, the tampering with care records was not picked up earlier. It also seems that Unison and the RCN were trying to raise alarms, but that managers dismissed their concerns. The CQC only seems to have picked up the problems when – in the words of BBC correspondent Nick Triggle, they were told ‘exactly where to look’ (www.bbc.co.uk/news/health-24833412). The trust is now in special measures.

What does all of this tell us?

One view is that this is just what happens when you impose targets on staff in a particular way. Where staff have no ownership of targets, and will be blamed for not achieving them, then they have good reasons to try and ‘game’ them. I don’t know who the originator of the pithy phrase ‘hitting the target but missing the point’ is, but that seems to go on a lot in performance management systems. Targets make us narrow our focus, and the danger with that is, if we forget why we are chasing the target in the first place, we can end up behaving rather perversely. I can manipulate the figures to make it look like I have met the target (as seems to have been the case at Colchester) or I can hit the target and stop – saving my effort for the next time period or going to other activities instead. Or I can stop engaging with activities that don’t have targets attached to them, even if those other activities are worthwhile too. In other words, narrowing focus can be extremely useful, but it can also lead to problems where we forget all the other things that presently aren’t being measured, but are important in our job as well, or where we decide, for whatever reason, to simply lie in the statistical return for the target.

So, if targets cause problems, should be abandon them? There was an interesting discussion around this on twitter, where several people suggested that target-based systems are inherently flawed, and so we would be better off without them. I was interested to see several clinicians, however, suggest that targets are both important and can be useful. They made two main arguments.

First, that we need targets because without them we wouldn’t have seen the improvements that the NHS has achieved in recent years. Think of waiting lists – imposing maximum waiting time targets has meant that managers and clinicians have found ways of driving down waits, and surely that has to be a good thing. Provided that the reductions in waiting time are genuine, and that we haven’t ended up distorting clinical priorities, that seems a good argument. Effectively, we are saying that by finding a target that is in an area that is important, and focussing on it, then they can be a means of driving improvements. This can come through diverting resources into areas we need to improve, or by reviewing care pathways to find bottlenecks or efficiencies. Wherever it does come though, a target can be a means of focusing attention and driving improvements.

A second argument in favour of targets is that they can act as a means for clinicians to be able to challenge managers to provide additional resources. The logic is that, if a trust looks like it is going to fail to meet a target, then clinicians can go to managers to get more resources to try and improve performance against the problem target. If the point I raised above was about focus, this was is about diversion – about diverting resources and attention from one area to another – another area that looks like it has a target that won’t be met. Again, provided the diversion of resources is justified, this seems to me to be a good thing. But of course, if the target being chased is not as important as the area losing the resources, then this isn’t really optimal.

What I’m struck by is that you don’t need centrally-set targets to focus, and you don’t need them to allocate resources sensibly either. Surely it’s the job of our managers and clinical leaders to work out what the staff working with them need to be doing? Targets can help us focus on what is important, but do we really need them to be centrally-imposed us to treat them seriously? I would hope that clinicians are more than capable of working out what they need to do each year to make things better, set targets for themselves to that end, and be held to account for them. I’m not clear why the government needs to be involved. Equally, if the health needs of an areas are such that resources need diverting, then surely we can expect clinicians and managers to work through that debate and come to sensible conclusions. This won’t be easy, as decision about what to prioritise are also as much about politics as they are about evidence, but the alternative, where government sets the targets for us, isn’t the right way forward either as this ignores the importance of local context. What health services in Durham (where I work) need to prioritise is very different from health services in York (where I live).

What I’m arguing for here is for targets to be decided in a bottom-up fashion, by clinicians and managers working out what needs doing, and then being held to account for doing it. And those targets need to be understood as goals rather than fixed measures that we can simplistically tick off once achieved. Patient care isn’t like that. If we get our clinicians and managers to agree goals together, and hold them sensibly to account for their achievement, then we have a way forward in improving services that people will have bought into, and which will be about improvement rather than punishing people for things that they believe they have no stake in.

 

The closing of the walk-in centres

November 11, 2013

Warren Buffet once said that the difference between a conversation and commitment is a cheque. There’s certainly something in this. If you believe in something you should pay for it, right? So, if one in four walk-in centres are closing, that would suggest that this is because the NHS doesn’t value them sufficiently to keep them open. The NHS isn’t willing to pay for them, ergo, then don’t have value.

But this logic only works if all funding decisions are made rationally. There are at least two reasons why this isn’t the case with the walk-in centres. First, because it seems that many people are waiting longer than want to (or sometimes should be waiting), to get a GP appointment. I don’t have a problem getting a GP appointment in a reasonable time, but understand this isn’t always the case for others, especially those in big cities. If the walk-in centres are providing extra needed capacity, then it would suggest that closing them isn’t right – especially if, as Monitor report, the people using them will end up in A&E instead. That isn’t going to help anyone, and is going to cost a lot of money. We have been told that the walk-in centres are ‘popular’ in press coverage this morning, but I haven’t seen good research examining whether their case-load is made up of non-urgent cases, or whether they are providing a valuable additional service. It seems we don’t really know enough about walk-in centres actually do, and that is half the problem.

A second problem with the idea that, if walk-in centres were useful, then the NHS would pay for them, is that is assumes a market-based rationality. It assumes that patient need and patient choice is driving the system, and I’d be amazed if that were the case. We have been told that the walk-in centres are ‘popular’ as I mentioned above – in which case they should be getting the funding they need, and it seems this isn’t the case. And even if the walk-in centres were popular, that still doesn’t mean they are actually serving a clear health need – we ought to be asking deeper questions as to why people who go in them aren’t visiting their GPs – whether they can’t be bothered to book an appointment, or can’t get one. Whether they actually need to see a doctor, or their needs could be better met through seeing someone else (or perhaps even, no-one at all). Healthcare isn’t a consumer good, as individual patients are usually not in the position to know if the person seeing them knows what they are talking about or not.

So closing the walk-in centres may or may not be a good thing in terms of providing better care. It may be that CCGs don’t want to pay for them because their members aren’t working in walk-in centres. It may be that commissioners don’t have the research to show whether walk-in centres are valuable or not. It may be that we’d all make greater use of walk-in centres if they were more convenient to get to than their own GPs – especially for us commuters.

What the closures do show, however, is the deep irrationality of the purchaser-provider split. If the NHS needs the extra service and capacity that the walk-in centres offer, it should be making the funding available. This shouldn’t be about the localised purchasing decisions of CCG, which seem to be largely unaccountable and unjustifiable here, as these decisions don’t appear to be being based on any particular evidence.

 

What kind of market is the NHS market?

October 20, 2013

This week a merger between two hospitals in Dorset was blocked by the competition commission, on the grounds that the move would be anti-competitive (http://www.bbc.co.uk/news/uk-england-dorset-24559766). The two hospitals aren’t happy, especially Poole hospital which is apparently in a pretty bad financial state, and was depending upon the merger acting as a kind of financial bail-out for it. What are we to make of this? What can it tell us about the emergent NHS market?

Well, as I keep on complaining, the NHS is not a market. Using the term ‘market’ suggests that we are talking about something like perfect competition, a theoretical model never observed in the real world, in which there are lots of small purchasers, lots of small providers, freedom of entry and exit from the market from both purchasers and providers, and it is cheap and easy to get in and out. There is also perfect information about what is going on, and participants that make highly rational decisions.

Now others (Alan Maynard especially) like to remind me that expecting the world to be this way is unrealistic. And that’s right. But in talking about ‘markets’ we are using the legitimacy of an idea (the perfect market) to underwrite a bunch of arrangements that are nothing like this.

Because over here in the real world, the NHS isn’t like this. We have large providers (both public and private) where we can’t let the public providers exit or go bust (although we might let private managers or even private providers take them over). We have private providers who can duck out, but we’ve still got to provide care so public providers will end up having to take their place (breast implants, for example). We have lots of small purchasers, but when they are up against big providers they will appear weak and disjointed and have little power. And where we have to pay for something complicated, like care, we may need planning and co-ordination – whether it is long-term care for the elderly (which is especially worrying given this (http://www.bbc.co.uk/news/uk-england-sussex-24579496)) or for cancer care.

Now look, I like competition in markets where I think I can make sensible choices. I like it that Samsung and Apple are driving each other on to make me better gadgets. But I still have no idea how I’m supposed to make choices in the healthcare market, and I don’t think my GP does either (and s/he is meant to be doing the commissioning on my behalf). We have put in place a system of buying and selling care that labels some providers as being effectively bankrupt when they may actually be providing really good care, and little or no sensible evidence showing all the effort and expense of having the market mechanism in place actually justified its costs.

So – back to Dorset. Should the merger have been blocked? Well, there’s very little evidence showing that mergers work, anytime, ever. They take years to get over, and just about never live up to the claims made to justify them. Mergers are generally a bad idea. But equally it is ridiculous to force hospitals to merge because they are in financial trouble. Surely the question we should be asking is whether they are providing a good service to their local people? Are they providing high standards of treatment? Are they giving good care? If they are, shouldn’t we be paying for their services rather than forcing them into dubious merger manoeuvres on the grounds of market legitimacies that are based on a theoretical model rather than anything in the real world? And if they aren’t, shouldn’t we be finding ways of driving up their standards rather than assuming somehow that better management can fix it?

The NHS ‘market’ isn’t a market in any kind of sense by which we usually use the term. To use the term market is to confer dynamism and innovation upon institutional arrangements that run directly contrary to providing the long-term, stable, and open-ended care that we need. More importantly, pretending the NHS is a market conceals the need to think very differently about how we can support care by organising things differently, and how we can arrange finances to support good care, rather than forcing hospitals to try and merge to avoid running out of money and being forced into private hands. That way madness lies.

Confronting obesity – a response to Max Pemberton

October 16, 2013

In this week’s Spectator (12th October) Max Pemberton makes the case that Britain must urgently confront its growing obesity problem. He takes us through an anecdote about a patient in a GP surgery demanding a pill that will allow her to not digest fat along with a range of alarming statistics (£5bn a year additional costs to the NHS with 300 hospital admissions a year due to obesity). He writes about other costs – Ambulance services having to replace their fleets to deal with obese patients and hospitals having to buy new operating tables, trollies and scanners. Max points to the failure of public health policy in terms of eating five fruit and veg a day, and suggests we now plan around obesity – assuming it to the both norm – rather than confronting it.

So what should we do? Max suggests we need to confront patients about their weight to get them to confront the reality that they are eating too much and moving too little. He accepts that some people may be genetically predisposed to weight gain, but that changing lifestyle can deal with this. The problem, he writes, is that we aren’t trying to lose weight any more – it’s an attitude problem. We treat patients as consumers (literally here, I guess) and then we are surprised that they won’t take responsibility for their weight any more. Obesity is not a disease, Max writes, – it’s a mindset.

I hope I’ve represented Max’s piece reasonably above. Is he right?

On one level, I think he is. Clearly we can control our weight by eating less and moving more. But it may not be as simple as that. Obesity is important because it is a growing and expensive problem. But it also challenges the way we think about our environments and what it means to be human in a fundamental way. Where we locate the blame for obesity tells us a lot about how we see the world.

We can locate obesity as not being our fault as individuals through two strategies. First, we can say it is down to the toxic food and drink environment we have created for ourselves. It is sometimes hard to move in supermarkets or corner shops for booze and crisp deals, and then you get to the counter and they try and sell you cheap chocolate as well (even WH Smith do this at present – I can’t buy a newspaper without being offered a family-size bar of Cadbury’s). There are studies from the US showing that many local shops offer their local populations huge deals on cheap but largely nutrition-free food and drink, and so little wonder they get fat. Suppliers of sugary drinks and convenience foods pay shops to take their products and display them prominently, crowding out more healthy alternatives. On this view we are having obesity foisted upon us by the food and drinks industry and government turning a blind eye.

Equally, we can blame our genes. Max talks about this in his piece – and no doubt some people do have a higher propensity to store fat than others. Hey – this would have been a genetic advantage not that long ago when food was scarce, but now it’s everywhere (see above), we get fat because our bodies are super-efficient at storing fat for the famine that now never comes (for us in the West, at least). Again then, not our fault.

But these two explanations, as Max points out, take choice and responsibility away from us. But we don’t all deal with choice and responsibility in the same way. Talking about personality types is always a simplification – but work done by Margaret Archer and more recently Graham Scambler points to some of us being autonomous in the way Max describes, some of us depending on others for validation more, and some of us having such jumbled and chaotic personal narratives that we struggle to make and carry through good decisions. Now if I’m autonomous I make my own judgements, and presumably can be held accountable for what I do in the way Max describes. But if I’m more likely to be looking for validation from others, then their views and lifestyles will impinge much more upon me. It’s no wonder that people with weight problems may live with other people with weight problems (be them family or friends). We want to fit in. We don’t want to be the ones not eating crisps or puddings, or seem fussy about what we have for dinner. Equally, for those with chaotic life narratives, who struggle to be consistent or make good decisions, it’s easy to see how eating convenience foods or buying the chocolate when it’s on offer to you, become the everyday decisions. Especially when you are trying to down work (possibly across several jobs).

The key thing is that what we eat and how much we move is a complex mix of the above. I’m lucky in having a job that means that most days I can arrange time to eat reasonably well, as well as being able to afford my own exercise equipment, so I can get up early and try and keep my weight under control. I live somewhere where I can access a decent range of foods without too many problems. I’m also lucky in that my wife is an excellent cook, and so much of the food preparation falls to her (I try and do childcare to balance this up a bit). All of these things mean that I can be held to account in the way Max describes. But many (most?) people aren’t.

Yes, we need to do more on obesity, and adverts with cute plasticine characters aren’t going to fix it. We need to hold those marketing and selling us nutrition-free food and drink to account – hell, let’s tax stuff that is making us fat as we should be eating less of it anyway. But we also need to make sure that better alternative are available, and educating kids better about food at school (I’m appalled at the rubbish they get taught there about nutrition). And parents, yes, need to do more as well about helping their kids be healthier, in terms of both diet and lifestyle more generally. And so do doctors.

So Max is partially right. But in simplifying this down to choice and responsibility, he’s missing out large parts of the story, as well as not questioning how why our health services are treating us as consumers, or asking our governments to act in the better interests either. We need a bigger and more encompassing strategy – leaving all this to markets will just keep making us fatter and more unhealthy where we allow money to be made in that way. But we, and our governments can change the rules to move us more towards the right direction, and to more effectively help those that need more support.

Evidence in health policy? Don’t make me laugh…

July 20, 2013

This week the government told us that they weren’t going to introduce minimum alcohol pricing or plain, unbranded packets for cigarettes because there wasn’t enough ‘concrete evidence’ in the case of alcohol (http://www.bbc.co.uk/news/uk-politics-23346532) or, in the case of cigarettes, that it wanted to wait and see how things went in Australia (who are already doing this), first (http://www.bbc.co.uk/news/health-23288993). Now, if we put aside claims in the media that all of this is really about Conservative links to particular lobbyists it is using as strategists, or that is simply caving in to industry (http://www.guardian.co.uk/society/2013/jul/17/minimum-unit-price-alcohol-shelved?INTCMP=SRCH), then there is the beginning of sensible claim here – that we should be basing our health policy on evidence. Surely that would be a good thing, wouldn’t it?

Well, yes it would be a good thing if we based our health policy on evidence, but there are two problems here. First, if we wait for evidence, especially on public health issues, then we won’t ever do anything new. What we need to do is experiment to find out what interventions have the best chance of working, being aware of how different contexts affect results. If we are actually serious about trying to improve public health, how about we try things, carefully evaluate them, and then introduce them more widely if they work? There will be problems around borders and boundaries (if alcohol is cheaper in one area than another we might expect this), but the extent of this can be over-stated (Scotland is more than capable of doing things differently to England it would seem), and most people, most of the time, won’t be sufficiently motivated to make enough different to jeopardise an experiment. So let’s have a go – if we are serious about improving public health, let’s try out some new thinking and see what happens.

The second problem with the claim that the government are engaged in evidence-based policymaking in health is, of course, that they’ve spent billions of pounds reorganising the NHS at a time of austerity, but based on the very flimsiest of evidence that their plans have any chance of actually making things working. Even the research the government cited in their White Paper as supporting their research (the competition-based work from the LSE) seems to have been misunderstood by them. What we have an expensive, distracting reorganization at a time when the NHS needs to save money, and also at a time when what seems to be becoming clear from the devolution of health policy across the home nations is that what health systems need to improve is stability and continuity – not continual disruption and change. The WHO report on Scotland is particularly interesting in relation to this point (http://www.euro.who.int/en/who-we-are/partners/observatory/health-systems-in-transition-hit-series/countries-and-subregions/scotland-hit-2012).

So, if we are serious about making health policy evidence-based, that doesn’t mean we should sit on our hands and wait to see what happens when other countries experiment with public health measures (where things may be very different culturally and contextually anyway), and it certainly doesn’t mean we should be reorganizing the NHS. As those things are what the government are doing, it is easy to be cynical and suggest instead, that things are being driven instead by the alcohol and tobacco industry, and by simple ideology.

Submission to Labour’s inquiry into the Effectiveness of Health Systems

July 5, 2013

Here is the submission I made to Labour’s inquiry into the effectiveness of health systems. I’ve also published it on the Socialist Health Association’s website at

Xenophobia and health policy

July 3, 2013

Today the government have announced that they are thinking of charging non-EU visitors to the UK £200 a year to access the NHS, or tell them to take out private health insurance. We are told that this is to address ‘health tourism’ and Jeremy Hunt says he is ‘determined to wipe out abuse in the system’. The Department of Health doesn’t really know how much of a cost issue this is, but seem to be giving what is a guestimate at about £30M a year.

So, let’s ask two questions. First, why is this a problem now? Second, what is the government planning to do about it and does it make any sense?

Why is health tourism a problem now? Let’s be honest, it isn’t really. £30M is a lot of money, but is less than 0.3% of the NHS budget, and actually, we have no idea whether the problem is this big because we really don’t know. So if you are going to change government policy, wouldn’t you want to know how big the problem is first? It’s a pretty difficult research issue (I’m supposed to be good at designing research and doing any kind of good research in this area seems pretty fraught to me), but surely some attempt needs to be made to whether this is actually a problem before you spend time and money trying to fix it.

And so this isn’t really about health tourism (or whatever we want to call it) being a problem now, it’s about the government playing to supporters who are keen to show that it is being tougher on foreigners, or perhaps, if we are being cynical, about them trying to distract from the latest NHS reorganization fiasco (take your pick, but the news that there continue to be major problems with the ‘111’ telephone service is the most recent).

Given this isn’t really the most pressing problem (or perhaps even a problem at all – we don’t know), asking what the government plans to do about it, I’m afraid, makes things even sillier. Now in immigration I can see how we can charge people who plan to stay longer than six months, and don’t come from the EU. It won’t be terribly popular, and we already have a pretty awful reputation with many overseas visitors (many of whom, like students, bring in lots of money), but this is just about viable provided that immigration services ever get the resources they need and raise their competence levels (too big ‘ifs’ there).

But then, how are we going to check whether people should be receiving NHS services or not, and then, how are we going to charge people who aren’t. Checking people will fall to health professionals, and frankly they don’t have the time. GP consultations (where most health appointments occur) are already short, and most surgeries don’t have the facilities to be checking people for their immigration status on the way in or out. So we are going to have to invest in new systems and possibly new staff – and they won’t come cheap. And are we really going to refuse people who don’t have the right coverage or can’t pay?

Then we will have to charge people. That’s going to involve investment in new systems, and possibly credit control and debt collection. Again, that’s going to cost money.

Now really, are all these new systems we are going to need to check people and charge them, when applied across the whole country, going to cost less than the guestimate abuse of £30M? Doesn’t seem likely to be me. I used to work in credit control (no, really), and it takes a great deal of time and effort. Don’t the government realise this?

So in all, we have the government making a lot of noise about a problem we don’t know is a problem (on cost grounds), and which will probably cost more to implement than the funds it can raise. This isn’t about saving money – it’s about playing to xenophobia.

Culture and healthcare – what are we on about?

June 26, 2013

Have you noticed that whenever anything goes wrong in an organization at the moment, it is described as being due to ‘a culture of…(something bad)’? What on earth are people talking about?

The Chairman’s statement of the Francis report, for example, says ‘There was an institutional culture in which the business of the system was put ahead of the priority that should have been given to the protection of patients and the maintenance of public trust in the service. It was a culture which too often did not consider properly the impact on patients of actions being taken, and the implications for patients of concerns that were raised. It was a culture which trumpeted successes and said little about failings.’ (p. 3).

Now I have the greatest respect for the process which Robert Francis went through in his inquiries into Mid-Staffordshire, but this seems to me to be woolly thinking. Have you ever worked in an organization (especially a big one, like a hospital) which had only one ‘culture’. All the ‘culture’s in the quote above are in the singular, and this also goes for the other present examples of the term being used as a cause of poor institutional performance. What do we mean by culture? What do we mean by there being only one of them?

‘Culture’ is a messy word, and there are whole books just trying to work out what it means (even when applied to organizations – my favourite is Alveson’s). The most simple definition tends towards something like ‘the way we do things around here’, so let’s go with that. Now, for there to be just one culture, the ‘we’ would have to be everyone, and the ‘things’ and the ‘around here’ would have to be what they do and where they do them. So when we talk about ‘a culture of…(something bad)’ we are saying ‘everyone around here does (something bad) this way’. And we might add – and there is no other way of doing things, and there are no exceptions, and the people who work here have no choice in that. Really? Have you ever worked anywhere like this?

Culture in the singular suggests that everyone does the same thing. That would actually be quite an achievement in itself (have you tried getting everyone to do exactly the same thing?). Now think of this in the context of healthcare, where we have multiprofessional teams who we know tend to regard the world in different ways (we know that different professionals view health reform in different ways, and different professionals prioritise different care treatments as two obvious example). So we have different professionals groupings who ‘culture’ somehow has got everyone to all behave in the same way.

I’m not suggesting that nothing cultural goes on in the case of poor performance. The problem is that describing culture as singular over-simplifies complicated situations and stops us from trying to find what was really going on. If we are to understand how carers can reach a situation, as at Mid-Staffordshire, where they were falling so short of the standards they knew to be acceptable, then we need careful research and not to impose over-simplified ideas on them. Equally, suggesting that we can make things better by creating ‘a culture of (something good)’ is equally sloppy. Well-run organizations are not the result of some magic bullet, but the hard work of those who keep working at making them well-run. This stuff doesn’t happen by itself.

Organizations have many cultures. I’d go further and suggest that particular meetings can have cultures, and that those cultures can vary depending on who is chairing them and who turns up for them. Wards can have cultures, but they too will vary depending on who is on duty (think of night shifts especially, which can be wholly different depending on the particular mix of staff working at a particular time). Understanding how cultures change and when they seem to support good work is the key – not suggesting that there is somehow just one culture and that the people within that organization apparently have no choices in deciding to go with or against it.

So please, next time someone says ‘a culture of (something)’ to you, say ‘really, just one? And the people in that culture had no alternative?’. Only by getting to grips with the detail of how organizations fail (or succeed) can we hope to try and make things better.

Health inequalities and Grimmer Up North

May 24, 2013

Next week I’m participating in a panel at Durham, and organised by Durham’s Wolfson Research Institute and Demos, on the them of ‘Grimmer Up North’, and discussing health inequalities.. Here’s some thoughts.

A good starting point is to ask why health inequalities exist. Is it because some people can’t physically access safe and hygienic food, housing, leisure and work? Well, yes, that is still a problem. Some social housing is terrible, and people are facing some difficult choices as a result of the changes to the benefit system the government introduced (not least the ‘bedroom tax’, which is really a reduction in benefits where people have more space in their houses than the government believes they need). So we still don’t have good housing for everyone, and some people are undoubtedly under considerable financial pressure – turn on daytime television and watch the ‘payday’ loan companies advertise to you at rates which, frankly, I can’t believe are legal. So poor housing and financial pressures – not a good place to start from if you want to live a long, healthy life.

But surely all of this is a matter of choice? If people worked harder (or got a job) and ate decent food, smoked less, drank less booze, wouldn’t the health of the nation improve immediately. Well, yes and no.

The liberal view of us is that we are all (unless the state or something else coerces us) free individuals who make our own choices. Economics takes this one step further in saying we are rational too. Our laws suggest we are responsible for our actions, taking a not dissimilar view – we are responsible for our choices. Now, as a myth to live by, this isn’t a bad one. I can’t imagine a world where I am allowed to do whatever I like to whomever I like – that would be pretty awful for everyone else (and for me!). However, it’s probably not quite right.

Our sense of self, the thing that is meant to be the rational chooser, is probably a myth (that word again). Both recent neuroscience and philosophy suggest we are fragmented and split as either our brain simply doesn’t function this way, or our mind is subject to a range of irrational tendencies that don’t really fit with the individual, rational model. We are hugely influenced by those around us, we massively discount the future in favour of the present, kid ourselves that we are better than we (by most external measures) are (do you know people who think they are below-average drivers or have a poor sense of humour?). In short, we don’t really correspond to the model of individual behaviour that we tend to assume applies to us (which is, of course, another example of how big the problem is!).

At the same time as this, we aren’t the cultural dupes that some sociologists make us out to be. People, even when doing things that appear pretty destructive, aren’t fools. We are, however, habitual creatures. Can you imagine how awful it would be if we had to think about everything we did? No wonder we go onto cruise control when we drive our cars, or eat, or drink, or when we are with friends…..and often, as a result, do things that aren’t terribly healthy as a result.

So where does this leave us? Well, we know that significant health inequalities exist (I gather life expectancies have the largest range by district in both London and Glasgow), that there are good grounds for suggesting a North-South divide exists (Danny Dorling’s work suggests it begins North of Lincoln, South of Grimsby) and that assuming people make rational, individual choices is not going to lead to good policy.

My own view is that we need to try and remember a little compassion, and to stop thinking of people who engage in a range of practices that are harming their health (be they obesity, or drinking, or smoking or whatever else) not as idiots, or as fools, but as a sign that we (as a society) are going wrong.

How is it that there are, literally walls of cheap booze available in our supermarkets, and that every time I go to the counter in some shops I’m offered massive slabs of chocolate at discount prices? Why do we celebrate drunkenness and regard it as normal in our city centres on a weekend? Why are our emergency health services over-run with people who have drunk to excess on Friday and Saturday nights? What are we doing that makes this everyday, not the exception? Why do we castigate the poor as irresponsible spongers when our society grows ever less socially mobile? Why do we tolerate social mobility declining at the same time as the rich grow richer?

We need to think again about health inequalities, and about the way we talk about them. We need, in the language of Annemarie Mol, a logic of care. This isn’t just about sympathy and empathy, although those are clearly important. It’s about saying (and meaning it) that we are ‘in this together’, and agreeing what we need to change things better for all of us. And then doing something about it.

Liberal ideas about choices and people are all about ‘me’. But we’ll never deal with health inequalities that way – we need ‘me’ to make society work, even if it doesn’t really reflect what we know about the way our brains and minds work. To deal with health inequalities we need to deal with ‘we’, not ‘me’. We need to start caring about them, and about each other. We need to challenge lazy assumptions by policymakers, and start engaging with one another about some of the behaviours that harm us and individuals, and harm others along with way. That is really caring.