Let's stop believing in magic : whose culture do we need to change?

So changing the culture of the NHS is what we need. The declaration is being made with great certainty and in ringing tones. Let’s think about it though, about culture and the NHS.

As every Briton knows the NHS is one of the largest organisations in the world - politicians and pundits tell us this frequently. What they rarely go on to point out is that its culture (its shared beliefs, its ways of responding based on those beliefs) must therefore be synonymous with that of the UK. How could it be otherwise? How could 1/50th of the UK population not be representative of the whole? Opinion pollsters make do with a sample of 1000, in the NHS we have over a million.

So if it is a change in the culture we need it is ‘ours’, not ‘theirs’, and it is us and our habitual ways of behaving, our implicit assumptions and beliefs, and our ways of seeing the world that will have to change. Not a comfortably distant them and theirs.

What is it about our behaviours and the assumptions that lie behind them that is shaping care in the NHS? Some of the following (not in any particular order of priority) have been game changers over the last 25 years.

We think money is the foundation of everything.

Whether it is economic growth, sticking within budget, or wanting to win the lottery, we make money very central to our lives. And we forget that money doesn’t exist. We forget that money is a way of making a complex system of production and consumption work. It allows us to earn now and spend later (or vice versa). It allows us to exchange goods easily and readily, but it has no value to us in itself.

If whenever we talk of money, budgets, economic growth and all the other money talk, we replaced that with whatever it is that money is the proxy for we would behave very differently.

Instead of pursuing economic growth we might talk about a flourishing society with dignified relations between the individuals and groups that make it up and with everyone realising their potential.

Instead of discussions within NHS organisations about budgets we could talk about how to reconcile the interests of different patient groups, about how to use our resources wisely and well. This after all what lies behind budget problems. Financial statements are only ever a snapshot of activity turned into numbers with a £ sign in front. Let us stay focused on the activity itself.

When we do this we see all sorts of alternatives open to us, many ways of achieving what it is we care about, most of which remain invisible if we focus on something we don’t care about at all – figures on a sheet about economic growth or money.

We believe we can ‘know’ definitively whether an organisation or a person is performing well or badly by looking at data.

Can we? There are some things we can know, some things that either are or aren’t. Its Thursday not Friday. The temperature outside is 15 degrees not 23. There are other things we can make judgements about. This avocado is nearly ripe enough to eat. That nurse is finding it difficult to cope with the pressures of her home life at the moment. For the first we can rely on data and reason, for the second we use all sorts of other senses, and on our experience of other instances built over time into our wisdom.

Data can help inform our wisdom but it can never replace it and we need to stop pretending (hoping, believing, relying) that it can.

In a similar fashion we believe there are ‘answers’ to questions and ‘solutions’ to problems.

And indeed there are questions to which we can find answers and problems that can be solved. But not the ones we most care about.

So instead of trying to prescribe every action through protocols and guidance, finding fault, if anything goes wrong, with those who have chosen to adapt or replace them in particular circumstances, we need to applaud those who are struggling to move forward in situations that are complex and unpredictable. We need to support their ability to ‘muddle through elegantly’ as the complexity folk describe is necessary. Aristotle called it phronesis or practical wisdom and it is as necessary today as it was in Ancient Greece. We need to support and understand those who face dilemmas on behalf of us and of society, be they clinicians, politicians, front line workers in fields like law and order, education, social services, managers of complex organisations, parents struggling on the breadline with chaotic family lives ....

We need to help people make better judgements and we can only do this if we recognise that all of us are a complex mixture of contrasts: altruism v self interest; striving to make things better v complacency and self righteousness. That recognition allows us to consider how we can support behaviours that are constructive and challenge those that are not – and to do so effectively through face to face conversations. Data can inform these conversations but never replace them. And these kind of conversations are what we used to call supervision or management. They have gone. Squeezed out by our belief in data and in managing performance rather than people.

And along the way we have to stop believing that replacing expensive people with cheaper ones allows us to be more efficient. It doesn’t, it makes us more rigid and inflexible – which ends up costing more. Instead of choosing to employ more, cheaper people we need to be encouraging expensive people to behave with all the skill, wisdom and judgement that will justify their cost. Conversations again.

We believe technology can replace people and that innovation will increase efficiency and productivity.

Technology rarely replaces people. Sometimes it moves them (from being ticket collectors on railways to working in factories making the ticket barriers). Often it shifts the cost from providers to customers in a way that is described as efficiency rather than theft (we now have to get to a station early enough to buy a ticket where before we could buy a ticket on the train). Sometimes it is a real boon (washing machines, toilets), and often it can help people work better – more quickly or more wisely. Equally often the benefits go to employers just as much as – or at the expense of - customers or workers (combine harvesters to smart phones).

In other words innovation will sometimes be valuable, and sometimes protecting what we have will be much more important. In the latter we must remember to include things like conversations and care, things that cannot be undertaken by technology: compassionate conversations between carers and patients, compassionate conversations between carers and those caring for them (their organisational seniors).

We are increasingly anxious about our health

At the end of the 19th century 2/3 of deaths were from infectious diseases. Death was often unpredictable, rapid, arbitrary in its target - and fear of illness was justifiable.

Now, in the UK, average life expectancy is amazing, our lack of physical disability is unknown in history, and yet those of us who are affluent and educated appear to worry constantly about our health. Of course these fears are fuelled by our media as part of a wider media/military/industrial complex, and in countries where health care is a consumer good offered within a thriving market this is not a problem, it just pushes the energy of the economy towards health care and away from other forms of passing our time. Health care becomes essentially no different from markets for cosmetics, leisure and food and hence consumer fears are valuable contributors to economic growth. Not to a flourishing society but that is what happens when you privilege the first over the second.

But where we are interested in meeting genuine needs rather than industry fuelled anxieties this does cause a problem. Our resources are limited, we have made choices-democratically- that a large percentage of our national income will be spent on health, but not more than that. So it would be well for us all to remind ourselves that one very good way of defining health is as the foundation for achievement. It is not an achievement in itself. If instead we paid more attention to what it is we are doing with our lives, to how we are contributing to the wellbeing of society, to how we are savouring and appreciating each of our own moments, we might have a more robust approach to the scare stories of the health industry reported in the media.

We could stop to recognise that we are amazing products of evolution and environment, and that we are part of a constantly changing equilibrium, and our health is a manifestation (or a description) of how well we are coping with that constant change. We could also remember the sufi observation that in any life there will be 10,000 joys and 10,000 sorrows and stop trying (childlike) to have only the joys. If we could appreciate the depth of that we could have a transformative dialogue about the health of society and its members.

We believe that there are magic wands, ‘big ideas’ that will sort out our problems.

The latest is ‘changing the culture of the NHS’ along with ‘innovation’, and ‘leadership’ , and none of these will magic our problems away any better than their predecessors: general management, purchaser provider split, big IT, ‘better procurement’ etc.

We could instead stop believing in magic and re-orientate ourselves so that we accept that lots of things in our world are uncertain, changing and unpredictable, and that trying to control them is a doomed enterprise. That muddling through elegantly will feel OK if we just let go of our demand for certainty and stability.

Along the way we will have to change the role of our media and that will mean accepting too that we are all a complex mix of helpful and unhelpful motivations, and that blaming is almost invariably less helpful than seeking to understand, and that everybody benefits from being supported and challenged if they are to be the best they can be.

If we do that, accept reality rather than looking for magic, we will transform not only the NHS but the food industry, financial services, the government, ..... and the UK.

But it does need us to wake up and stop believing in magic.

Download Let's stop believing in magic : whose culture do we need to change? as a pdf

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