Culture is possibly the most important, but also over-used and, at times, meaningless concept deployed by those interested in the organisation and improvement of healthcare.
We are frequently told that high performing organisations have the 'right culture'. And in healthcare, organisations with the ‘right culture’ are often seen as safer, more efficient or more responsive.
When I took up post at Healthwatch England in 2013, I had travelled across many policy domains, working in charities, in academia and in government, but I was a newcomer to health.
With the natural curiosity of the foreigner in a new land, I was intrigued by the amount of heat generated in conversations about patient and public involvement. I saw emotions run high, and predominant amongst those emotions was frustration. Frustration from patient groups who ask: why are we not being heard/taken seriously/in the right conversations at the right times? And frustration too from the managers, commissioners and practitioners who wearily confess that engagement feels like another burden, a further task on their crowded to-do lists.
The NHS is – famously – our best-loved institution. When BritainThinks run focus groups, people up and down the country tell us that the NHS is in ‘the marrow of our bones’, that it is the UK’s ‘crown jewel’ and that it represents the best of what it is to be British.
Public concern about the NHS is rising. Participants are describing difficulties getting an appointment with GPs, their hospital appointments are being pushed back, and there is worry that hard-pressed NHS staff no longer seem to have the time to care. This is backed up by national-level polling; in Ipsos MORI’s April Issues Index, 48% of respondents identified the NHS as one of the top three issues facing Britain today. This is on a par with Brexit and an eight-point increase since December 2016.
In terms of its mouth-to-trousers ratio, you'd expect the media to be long on the mouth aspect: it is, after all, the business of communication.
As for the trousers bit, the first pertinent question is who wears them and why. The majority of the UK media is in right-of-centre ownership and indeed editorship, as the MP for Tatton's recent career move shows.
At the risk of stating the obvious, the NHS (which is the bit of socialism the British people like and think effective, judging by its iconic status in repeated opinion polls of reasons people are proud to be British) is politically and philosophically not an evident fit with right-of-centre values.
The King’s Fund has said the same for the last 20 years, and the BMA for much longer. It was Labour who created the NHS Constitution, and Tories and Lib Dems who sought to circumscribe politicians’ NHS powers through the much loved 2012 Act.
What’s the attraction here? Arguments typically revolve around health care being too important to let grubby politicians near.
At the Melting Pot on 20 February my head found itself drifting to the complexity of general practice where I have worked for 25 years.
With individual patients, trying to deal with obesity is often unfruitful. It’s easy to talk about lifestyle, especially when GPs, among others, have been paid to measure and advise. But as a practitioner, all I felt I could do was impart some fairly obvious advice, offer drugs (now mostly withdrawn or ineffective), or refer for drastic surgery. Unsurprisingly, I’d be left wondering if any of this was helpful.
Surely, if there was a simple answer, there wouldn’t be such a thriving diet industry? When an obese person tips into diabetes, the health consequences are significant. However, diabetes, at least in the early years, is reversible if a healthy weight can be regained. So, given the limited tools at my disposal, was there anything I could do to make a difference?
I have seen the NHS from the waiting room and ward as a NHS graduate management trainee and clinical services manager, and the boardroom as a non-executive director.
I have worked in the Midlands (Birmingham, Solihull and Coventry), and Middle-Earth (Wellington, New Zealand). I have looked at the NHS from the inside as a manager, and from the outside as a researcher and policy analyst.
It is this connection - between research and practice, between theorists and managers - which has particularly fascinated me. How do these communities interact, if at all? What could be done to enable more fruitful connections?
The most important issue in health is, of course, to recognise that there is no most important issue in health. How could one possibly choose between the evisceration of the NHS, the abandonment of social care, grotesquely widening health inequalities, the looming nightmare of antimicrobial resistance, or the incipient planetary catastrophe of climate change?
So I’m not going to try and define any single, most important problem, because that’s a mug's game. What I would like to do instead is explore why it is that we are so often drawn back to trying to rank issues by importance, and why we find the complexity of these problems so challenging. What I’d like to propose is a set of approaches that can be used to conceptualise them in ways that may help us to achieve better outcomes.
They say the sequel is never as good as the original. My second Melting Pot Lunch, organised by social enterprise consultancy Kaleidoscope, thankfully turned that on its head.
Today’s question was posed by David Haslam (Chair of NICE), with his customary eloquence. After a recent trip to South America, he stood looking at the Inca ruins of Saksaywaman, and observed:
‘When I first saw them I remember having two distinct thoughts: How on earth could a civilization with advanced skills like this have failed to invent the wheel? How could they not have even seen such an obvious idea? And then immediately – might a future civilization look at us, and say a very similar thing? How on earth didn’t they get....?’
The question we were asked to ponder was: what will future generations say is our most obvious, glaring mistake in healthcare?
Collaboration: two definitions; either, the action of working with someone to produce something; or, traitorous cooperation with an enemy. Being of Norwegian heritage the second definition is the one that lurks worryingly at the back of my mind whenever anyone suggests we collaborate on something together. So, I was all ears and on guard for our melting pot lunch discussion on 19 August about relationships and collaboration.