Health as Context
The complexity of health is rarely appreciated: seeing in terms of supply and demand flattens complex exchanges into linear equations. The relational impact of linear interaction is hard boundaries that but up against each other, repeatedly, each time in the same way.
Managing finances from the top down results in perverse behaviours: what is valued is understood and worked towards. Analysts freely admit to massaging A&E figures to fit the target that is in vogue, which of course has no benefit at all to patients. The idea that central governments can control health by target setting is illusory.
Policymakers are looking towards DevoManc as the test bed for regionalised autonomy: the irony is the historical success of various organisations in Manchester resulted from their organic growth. The devolution agenda is more accurately seen as a top down reassertion of control.
Removing the perceived redundancies from organisations within this ecology will necessarily suffocate its development and growth. Seeing programmes as separate and distinct is an indicator that they will not work.
Much faith is placed behind the next reorganisation of health and care into Sustainability and Transformation Plans (STPs). However, none of the previous reorganisations has worked. The idea of localised commissioning is now ridiculed as a nonsensical model.
The people who find ways to make progress within this system of flawed assumptions tell consistent stories of finding patterns of working against the grain that has been prescribed. They can be seen as ‘positive deviants’. Often their patterns of working and contacts have remained the same throughout several rounds of reorganisation, all of which have purported to radically change ways of working.
Years of ethnographic research within NHS Commissioning has shone clear light on the large number of people that remain employed by the NHS with no discernible impact on patients and the public, in spite of repeated rounds of efficiency gains targeted reorganisations.
There is no quick fix, easily brandished ‘solution’ to this highly complex, intersecting set of problems, nor is it viable for government to immediately reverse its policies.
But the nature of dialogue does need to change, in ways that are at the same time subtle and radical. We describe why enforced reorganisation cannot be the singular or even dominant lever for change. Nor can the idea that inserting bureaucratic ideology into communities will help them to sort themselves out.
We still talking about patient and public involvement as a programme of work. If the involvement of users is separated from the system of healthcare, what remains? Health is an ecology: an interwoven next of relationships and patterns.
The other side of this paradox: the health of our ecology is also fundamental to our individual health. The best predictor of whether we will become obese is whether our close friends and family are. Expensive, complicated predictive analytics does not add much to this understanding. Our communities and social structures are diabetic. Wearable activity monitors become sticking plasters for pandemic rates of lifestyle induced ill health.
Russell Gundry and Aidan Ward