Today, one photo, a single email or a simple hashtag can launch a worldwide movement.
Alicia Garza posted a Facebook post that ended in ‘black lives matter’, Patrisse Cullors created the hashtag #BlackLivesMatter and Opal Tometi took the phrase Black Lives Matter and helped turn a hashtag into a transnational networked movement. This was their call to action. Three women, who wanted to address the issue of racism, who reimagined a world that is a better place and created a movement that challenges systemic racism in every context.
When asked what it takes to do this they describe; mobilising a network of people demanding change, inspiring everybody to fight for everybody, helping people flourish, helping them share and shine.
When they talk about leadership they believe that leaders are not super heroes but real people who need to trust their teams, recognise that different people contribute different strengths and thank them for what they do. The leaders also need to be supported because ‘being a leader is hard when you have to make difficult choices’. But they talk of the fear people have of being a leader and call for people to be ‘less brutal’ and ‘you can have disagreements without being disagreeable’.
One key tactic they use is that of ‘reimagining’; using hope and moving away from negativity to a more positive world view, for example seeing black people thriving and not dying, showing the world as it could be, not just the world as it is.
This ongoing story beautifully describes what social movements are all about. They are agile and dynamic, emergent phenomena that arise outside formal institutions and established power structures. They cannot be imposed from the top down. They grow from the grassroots. Movements make society and institutions deeply uncomfortable as they challenge the prevailing attitudes, values and norms.
So it feels a bit odd when you read how institutions themselves want to ‘build’ or ‘create’ a social movement. For example building on the agenda set out in the Five Year Forward View, NHS England has launched in 2016 a three year programme to support social movements in health and care[i] ; ‘…to kick-start a social movement toward workplace health and wellbeing …create a programme to `hard-wire’ social action into a transformed health and care system’
NHS England and partners aim to develop, test and spread ‘effective ways of mobilising people in social movements that improve health and care outcomes and show a positive return on investment’.
How can a formal institution create something as intangible and evolving as a movement? Can a shared purpose really be created from this powerful base?
Strengths of social movements include:
Helping people work together and think together collectively to create a shared purpose, shared goals and values
Learning how to mobilise people to act
Developing distributed leadership which avoids the fragility and narrowness of relying on a single person who holds all authority
Evolving decentralised structures and decision making
Using stories to create an emotional link to the shared purpose and values
These start and help movements grow and flourish but there is one crucial element if there is any chance of sustainability - the right kind of organising. Without organising there is chaos, poor decision making and a lack of follow through; too much of it and you get a military like organised structure that centralises all planning in the hands of a few chiefs. Scale up quickly without any scaffolding supporting them means the movement is doomed to fail.
So when people say things like ‘we must harness the power of social movements in order to rapidly improve health outcomes’ – realise that they cannot be forced or manipulated by central bodies.
The only way movements can be relevant for the NHS is to learn from them and use their strengths to help shape a different approach to change; for example to move away from top down instruction to helping change grow from the grassroots up. Even better, create the conditions where the grassroots demand the change.
Dr Suzette Woodward, National Campaign Director, Sign up to Safety
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.
We are also told about the 'wrong' culture, a 'blame' culture, a culture of ‘doing the systems business’ or protecting the interests of a profession ahead of safeguarding the interests of patients. These types of culture work against safety and improvement. As such, those concerned with improving healthcare regularly talk of the need for 'culture change'. In fact, nearly every major scandal and inquiry has called for some form of culture change.
But what is this thing called culture?
In some sense, we all know it is there, but it is often difficult to pin down. You can see aspects of culture in the way we design and decorate our environment, in the clothes we wear, the food we eat, the music we listen to, and the words we use.
In another sense, culture is the 'social glue' that holds us together. We share aspects of culture - we believe similar things, we use a common language, we know how to fit in. And then we go on holiday, for example, and we see difference in the cultures of other people, which brings our own cultures into stark relief.
The scholar Edgar Schein famously described cultures along three dimensions. The 'artefacts' we can see, the 'values' we espouse, and the deeper assumptions and 'meanings' we share. Whilst artefacts are more visible, values and meanings are more difficult to see or talk about. They often need to be inferred from what people do together.
Another important point, is that we are not born with a culture, they are not inscribed into us or fixed. Rather, we learn our culture through socialisation, so that we do not even know where and how we came to believe or value certain things. This process of learning takes place slowly over many years of interacting with others. And it never stops. Through new experiences we form and share new meanings and values, these are learnt by others and transmitted to the next generation, who in turn will gradually learn and change their culture.
It is this gradual process of learning a culture that makes efforts to change culture difficult. In effect, it means un-learning things we might not even recognise, and learning new ways of ‘being’. The idea of ‘being’ is essential. Cultures are not things or resources to be manipulated, rather than are who ‘we are’ and what ‘we do’.
For those interested in organisational change, cultures are often regarded as a piece of the puzzle: a resource or variable to be managed. But maybe we should see that 'culture is the puzzle'. As I say, culture change happens all the time, but managing culture change is difficult, and use of behavioural incentives, prompts or punishments to change cultures often fosters learning and change that is radically different from intended.
So, whilst cultures are an essential feature of all social groups and communities, we tend to find a pre-occupation with managing the most obvious aspects of culture, often through very crude incentives and punishments. And the deeper and tacit aspects of culture - the bits we have learnt but don't really know we have learnt - often remain elusive.
I am not suggesting we disregard culture, far from it, but we need to take culture far more seriously and move beyond simple classifications of ‘good’ or ‘bad’ or ‘strong’ or ‘weak’ culture, and recognise that cultures are the things we learn, we share, and we live.
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.
And here is the paradox: the stated commitment to public and patient involvement is much higher in health than it is in most other policy arenas. Indeed, it is enshrined in legislation. By contrast, if the Chancellor changes rates of income support or the indexation rules applied to pensions, he is under no obligation to consult. Likewise, a change in national curriculum or the introduction of a different package of support for offenders pass into national policy with little expectation of public or user engagement.
So how can we take the conversation about public involvement to a new place, start to reduce the heat and begin shedding light on this issue? I think these three things might help:
1. Start with “Why?”
The discussion about patient and public involvement too often focuses on questions of how. How can we secure representation, engage beyond the usual suspects, be credible? Don’t get me wrong, these are all good questions. But questions of “How?” should only be posed once an organisation has answered the question “Why?”. Starting with why means an organisation has to be honest about its motivations, clear about its end goal and specific about what is up for grabs in the conversation and what is not.
Why questions are strategic in nature and require the involvement of senior decision makers. This means that asking why not only secures clarity, it can help write involvement more deeply into an organisation’s plans, affecting its priorities and decisions, rather than being a last minute operational add-on.
2. Ask not what will involvement take, but what will it add
Let’s be honest, engaging with the public and patients is often seen as an organisational burden: something that might disrupt, distract and, most feared of all, slow things down. To counter this, we need to move beyond demonstrating a moral imperative and start showing that involvement and engagement helps achieve organisational end goals more quickly and efficiently. Tough decisions are less likely to be unpicked when people see first-hand the difficult trade-offs involved. Services that users have been able to design and personalise are not only more effective but can be cheaper too. Careful consent is critical to sharing existing health data, but unlocking people as data generators would revolutionise our evidence base on health.
3. Let’s talk about power
Finally, in a new conversation we need to say things that previously went unsaid. Creating a dialogue with your users, or with the public more generally, can feel frightening to people who have been promoted and rewarded for being experts. It can feel like ceding power. The interactions patients have with clinicians, managers and paid staff frequently leave them feeling powerless.
Acknowledging these feelings and the power imbalances in these conversations – perceived as well as real – is fundamental to creating open and honest dialogue. In the longer term, it might also help create a new understanding of where power sits, challenging the very division between those “in the system” and those who “use the system” and recognising the permeability between those two categories as well as acknowledging their interdependence.
A new conversation, framed in a new way, will help reduce heat and start shedding some light on this important issue. I hope these thoughts help unlock that conversation,
Good luck – and don’t forget to send me a postcard telling how you get on.
Katherine Rake is Founder and Chief Executive of totalpolicy.co.uk, and was previously Chief Executive of Healthwatch England
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.
It might seem logical, therefore, to assume that public attitudes towards the NHS will shape how people vote on 8th June. Indeed, the public themselves say that it will: 31% of those surveyed for Ipsos MORI’s most recent Political Monitor say that the parties’ policies towards the NHS will be ‘very important’ in helping them to decide how to vote. And yet…
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.
It’s a cause which unites across the political divide. “We need to take politics out of the NHS and set up a Royal Commission” boomed the Daily Telegraph last month. The King’s Fund has said the same for the last twenty years, and the BMA for much longer. It was Labour who created the NHS Constitution, and Tories and Lib Dems which 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 20th 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, amongst 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?
Harry Rutter London School of Hygiene & Tropical Medicine
Topic for Melting Pot Lunch #10
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 mugs 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?