Missing the point (again)

This is the text of an article in Public Servant magazine. I would like to have written something more substantial, but the word limit (which was perfectly reasonable) was limited. As it were.

Paying excessive attention to 'efficiency' and function militates against good overall care. The values that are supposed to ensure people are well-treated get subsumed.

We live in an age of fundamental suspicion. One could argue that fifty years ago the default position of most citizens was to trust unless given evidence that trust should be withheld; now the default is to suspect everyone, trust no one and deny everyone’s integrity.

Perhaps it is no surprise, then, that this is reflected in the culture developed in our public institutions. Couple this with a media that hears a politician sneeze and accuses him of deliberately trying to infect the vulnerable, and you have got a vicious circle of suspicion.

But, if that isn't enough, we then create a culture of competitiveness and 'efficiency' that uncritically assumes that the only measurement of 'the good' is financial. Hence, the NHS, for example, bounces from centralisation to localisation and back, education abandons local accountability and cedes power to the Secretary of State in Westminster (whilst thinking it is gaining greater autonomy – but see what happens if an academy struggles or the said Minister changes his fancy), and vast sums of money are spent in ideologically-driven yo-yo re-engineering.

If only there was a basic understanding of the difference between 'efficiency' and 'effectiveness', we might be in a better place.

In other words, we now have a deep cultural problem across our society – a functionalism that compromises public service. The cultural associations run deep and to question them is not easy to do – not least because they quickly assume the status of 'orthodoxy', from which heretics find themselves dismissed with ridicule.

Changing this situation cannot be easy and, by definition, solutions will necessarily be long-term and complex. It is possible that some of our systems might have to collapse before the construction of something more coherent and effective becomes possible.

For example, is it any surprise that health visitors find themselves hot-desking in an attempt to reduce rental costs for offices, but then lose the very context that allows for ready exchange of information, informal mutual encouragement or advice, joined-up consultation on particular cases or issues? The 'human' stuff always finds less value than what can appear on a balance sheet.

And, of course, this sort of thinking derives from a confusion of ends and means. If the end is to reduce costs (finance-driven), then the exercise becomes merely functional. If, however, the end is to enhance service to real people – to which end finance is a means – then different values might apply and priorities be set. This is not to deny the need for financial probity and wisdom, but it is to ask what the end is to which the finance becomes the means of getting there.

Somehow this situation requires a rejection of the sort of box-ticking mentality that leads to hospitals losing the plot. If the Francis report exposes anything, it is that paying obsessive attention to the engineering (form filling, box ticking, time accounting) militates against good overall care because the means become the end. The people get lost. The values that are supposed to ensure that people are well treated as dignified human beings get subsumed – not deliberately, but at the level of assumption in the complex dynamics of making sense out of chaos) – into something different. And when this happens bad practice becomes inevitable.

Naturally, recovering a culture of trust, integrity and clarity about what constitute ends and means is no easy task. It requires the political will to change the vocabulary of public rhetoric. It demands an open and constructive public debate about what is the end to which we aspire and for which the money we pay is intended to be a means. And this will need a re-articulation of what might untrendily be called 'anthropology': how to enable people to flourish.

 

Posted with Blogsy

 

Health check

So, what is really going on here? A review group on health matters is reported to be proposing that people should be asked about their diet, alcohol intake and other habits whenever they see a health professional – even if the reason for the conversation has nothing to do with how fat or boozy they might be. The Guardian reports as follows:

Patients should be asked about their diet, smoking and drinking habits every time they see a health professional according to radical proposals from the government’s NHS advisers to tackle soaring rates of obesity, cancer and alcohol misuse. The NHS Future Forum wants health staff to routinely talk to patients about their lifestyles, even when they are suffering an unrelated illness, and offer them advice and help to become healthier.

 
So far, so reasonable. After all, part of the social contract involved in a welfare state is that we own up to a mutual responsibility to the service. If my lifestyle choices are costing others, then I can have no objection to being asked questions. And again, after all, the questions are aimed at my better health and best interests, aren’t they? 

 
The statistics almost beggar belief:

• The number of people in the UK with diabetes has risen by almost 130,000 to 2.9 million in the last year. That is up by almost 50% in just four years (2006-7 to 2009-10). Some 90% of these 2.9 million have Type 2 diabetes, which almost always develops in people who are very overweight. 
• The Lancet medical journal has conservatively estimated that, on present trends, by 2030 obesity in the UK will have produced 5.45m cases of diabetes, 330,000 more people with coronary heart disease and stroke and 87,000 extra cases of cancer, which together will mean a loss of 2.2m quality-adjusted life years in the population, and costing the NHS another £2.2bn a year on top of the existing huge price of tackling obesity-related illness.

Yet, the Guardian report continues:

But some medical leaders last night voiced fears that such interventions might stop some patients from seeking medical help in case they were asked questions they found uncomfortable, and the Patients Association said it was “overkill”.

 

Of course the questions are ‘uncomfortable’. Isn’t that the whole point? They are supposed to be uncomfortable if they call into question the effects and consequences of our choices or habits. But 

that is no argument for not asking the questions. The guy leading for the government on this gave an example:

… A podiatrist who’s looking after the feet of a diabetic patient has an absolute responsibility to talk to the patient about their smoking, because smoking makes diabetes worse and means the patient is more likely to have a foot amputated.

 

Now, anyone who has ever been phoned by a journalist knows the sorts of games that might be being played here. However sensible the substance of the story, someone has to be found who will object. (A bishop says the sky is blue and the National Secular Society is called to object…) And it is often the case that the person being called is told a rather biased story to which the desired response can readily be given and the ‘story’ is then complete and ready for publication. I have no idea, therefore, how the ‘objections’ to the proposals above were elicited, but I do want to be wary about taking them at face value (and would be interested to know if those quoted feel that they have been quoted justly).
 

Why this interest? Well, simply that what really interested me about the story was the choice of words used by those who aren’t so keen on the proposals. Try this for starters: 

But Dr Clare Gerada, chair of the Royal College of GPs, said the policy was “muddled” and some patients might be put off by what they saw as intrusive questioning. “Young men pluck up the courage to go and see their GP, maybe about a sexually-transmitted infection, and would not want to be lectured. So we have to be careful that we don’t impose our agenda on to the patients and don’t inadvertently frighten patients who are coming in to see the doctor and who fear that they might be preached at,” said Gerada.

 
Er… ‘preached at’?’ ‘Lectured’?
 
Why these words to describe questions that need to be asked precisely because they are uncomfortable? The patient doesn’t have to answer them. As any doctor will tell you, you can double the figure any patient gives you when asked about weekly alcohol intake. But, since when has the asking of relevant health questions been synonymous with ‘lecturing’ and ‘preaching at’?

The economic price, as measured in lost productivity, welfare payments and the cost to the NHS, are already mind-boggling. Diabetes costs £10bn – almost a tenth of the entire health budget. That includes £725m spent on drugs for diabetics, and the cost of hospital beds – one in seven is occupied by someone with the condition. Yet every expert believes that, without a major change in human behaviour (which no one expects), these costs will only rise. These lifestyle diseases have been increasing at the same time as the risks of unhealthy behaviours have received unprecedented attention. Everyone knows that cigarettes are ruinous, but one in five still smoke.

… Professor Steve Field who chairs the forum admits: “Not enough people take enough responsibility for their own health, despite the amount of information that’s available.”

 
But, if this challenge to individual, personal responsibility needs to be heard loudly and clearly, so does the warning to society generally need to be heeded:

Katherine Murphy, chief executive of the Patients Association, said it agreed that patients needed more advice on living more healthily and help to do so. “But the underlying factors causing unhealthy lifestyles, for example poverty, also need to be addressed.”

 
So, happy new year to you! And my advice to myself and everyone else? Drink less alcohol, eat less, get more exercise, … and welcome ‘intrusive questioning’ about all three. It might make the difference between a healthy and a miserable 2012. 
 
 

 

Notional Health Service

Being on retreat means being behind the game when it comes to the news. So, I have picked up on the latest NHS shenanigans with a certain incredulity. Given the lesson learned from Tony Blair – that New Labour behaved during its first term in office as if it was still in opposition and didn’t move quickly or radically enough to instigate change – it is understandable that David Cameron wants to get as much done as quickly as possible.

However, he is hampered by three factors: (a) his big ideas (the Big Society, for example) have coincided with massive financial retrenchment… with the former being undermined by the latter; (b) there seems to be little dynamic coherence between the major initiatives launched; and (c) the sheer incompetence of the process for legislation.

Is the NHS fiasco the third or fourth claw-back of confidently announced initiatives? The difference here, however, is the enormity of the changes proposed and the fact that NHS reform represents the flagship policy of the new government. Clawing back the sale of forests is one thing, but announcing a ‘pause’ in the legislative process for NHS reform is of a completely different order.

The arguments can continue about NHS efficiency (provided we remember that efficiency of itself is not the raison d’etre of the NHS) and whether or not care might be delivered more effectively (which is the point of the NHS). The inevitable pros and cons of different ways of organising health care must be weighed up – and it must be recognised that any and every system will have pros and cons – but we must not confuse ends with means.

The worrying thing this time, however, is that opposition to the reform of the NHS is huge and crosses many social and professional boundaries. Some resistance will surely be down to inertia, insecurity, vested interests, fear of change and institutional bloodymindedness. That happens in any institution. But, what is interesting here is that the opposition is informed, unconvinced by the proposals and fearful of potential disarray in the system – not for the sake of the system, but for the sake of the people for whom the system is supposed to exist.

There are two dangers here for the government. First, they rehearse the Thatcherite mantra that it is not the policy that is wrong, but that some poor people out there just haven’t understood it – that once they have understood it, they will obviously have no objection. In this case the policy has been understood and is being questioned in substance by very well-informed people. Patronising opponents won’t work any more.

Secondly, the process appears to be driven by a political dynamic and not one that serves the service itself. That is to say, it might be helpful if a pilot scheme or three were introduced in order to road-test the proposed reforms. A process in which the public was able to see what the outcome might look and feel like is far more likely to win over sceptics than an ideologically driven rush for change. But, we don’t do pilot schemes any longer, do we – in education, health or anywhere else?

I have no problem with proposals for ways of improving the NHS (given the caveat above that improvements always bring with them unanticipated or unintended deficits). I have no problem trying out alternatives. I am open to be persuaded that reforms are necessary and might be helpful. But, I am not happy to see legislation passed on proposals that have not been properly thought through, not tested in the real world (as opposed to on Excel) with real people, not communicated in a way that is respectful and convincing, and possibly shaped to solve a different problem (finance rather than health).

It must have been humiliating for the Health Secretary, Andrew Lansley, to stand in the House of Commons, unsupported by Cabinet colleagues, and announce a ‘pause for listening’ in the legislative process. Yesterday David Cameron had to take personal control of the ‘presentation’ and (bizarrely) state that consultation during the next couple of months will be ‘genuine’.

It’s a mess. And it is just the latest in a line of incompetently handled initiatives in this government’s first year in office. As Blair says in his book A Journey, it is far harder being in government than in opposition. It’s also hard, having listened to the Tories accusing the last government of incompetence, now to see such obvious incompetence in office.

Wouldn’t it be great if the Prime Minister could treat us like adults, apologise for the systemic process and communication failures of his government so far (forests, education, NHS, etc.) and announce a more mature way of doing things. It’s his first year and the economic pool we are paddling in is horrible, so we might even be sympathetic. But, while he pretends that everything is under control, that all the problems are the fault of the previous administration and that all his colleagues are competent for their office, we will continue to be suspicious.

 

Beyond parody

I thought this was a parody at first…

In the USA it is not only the health care system that needs some attention. If this example of ‘expert analysis is the level of serious reporting Americans have come to expect, then the education system is seriously in need of renewal, too.

Some things are simply beyond parody.

 

NHS vs USA

The debate keeps going and the blogosphere is pregnant with people telling their stories.

Would anyone in the USA have the vision to copy to every member of their legislature and every State Governor a copy of the blog by Strawberry (which has clearly gone viral) and the comments that follow it? It tells its own story.

Or would the facts simply spoil a bit of ideological propaganda that steers the selfish, individualistic dogma of Republican America?

I hope Obama has the prophetic courage to keep going.