February’s ombudsman report had more than a sense of deja vu about it. This time, writes Fontis director Graham English, the question is not “what” we might learn from the health ombudsman’s report, but “how”.

In the rightful and sometimes righteous furore over the appalling examples of failures of care in February’s report there were very natural cries of “something must be done about this”. Again.

That’s the hardest part for me as I’m sure for many others – we’ve been here before. For all the causes are said to lie in “the target mentality”, or budget pressures, or lack of clear leadership (it caused a wry smile to hear the calls for the “return” of matron), unfortunately these are neither new problems nor indeed totally unexpected, albeit truly shocking. 

This is not to say that there aren’t many examples of excellent care and compassion in the NHS and our care services; there are. Yet it was instructive to hear John Humphrys almost shout down the RCN rep on Radio 4, when he deployed that argument just a little too blithely. There is, and should be, a limit to our collective patience with such examples of inexcusably poor care.

So why hasn’t the situation changed despite all the past best efforts? For a start it isn’t for want of good intent, or good people. Or action plans. From A first class service: quality in the new NHS through to the responses to the example at Mid-Staffs, there have been any number of formal plans developed and opportunities for new cultures to be set (I believe this is a deeply culturally ingrained pattern of behaviour).

In such circumstances it is dangerous to be too categorical, too certain about the solution for intractable problems. We’ve touched already on one problem with over-simplification, in the yearning to reinvent the past and bring back matron, a solution which has already been applied.

So too has the solution called “more and better training”. And many others have understood this as a cultural phenomenon before me. So what I suggest here are two partial solutions, each insufficient alone, but together powerful and a substantial part of a potential way forward.   

The two suggestions are founded in a single clear principle: “to change what we do, we must change what we think.”

The first suggestion is to change the relationship between people and our public services. This is intended as a true transformation, not the marginal changes currently being put through Parliament – it entails generating co-designed and co-owned solutions. It is also the work of Fontis, the social enterprise I helped found and run. It would fundamentally change the dynamic between the carer and the cared for – it is both a practical step and a strategic change.

The second suggestion is to put new emphasis on personal, self-directed and reflective learning and to adopt the principles of effective adult learning. Training is valuable but can only take us so far.  This is where I shall now focus. It is an individualistic and a collective solution, yet it can have deep, strategic implications.

So what do we know about adult learning which could be applied here, in ways it hasn’t to date?  Let’s start by looking at Malcolm Knowles’s core principles and apply those to the current circumstances.

Those principles are:

  1. the need for approaches which reflect increasing emphasis on self-directed approaches in all aspects of life, rather than passive or dependent modes of thought;
  2. the value of real experience, generating a new levels of internally held resources for learning;
  3. greater emphasis on and desire for learning which reflects the needs of the roles the individual undertakes;
  4. hence, a greater emphasis on applying that learning to immediate problems, rather than to broad subject matter;
  5. the value of contracted learning, knowing what will be learnt, why and how it will be done;
  6. the value of understanding the value the learning will bring to the individual;
  7. the need to account for individual, social and situational difference;
  8. clarity of goals and purposes for learning.

In the space available I’ll take just a few of these, but similar arguments apply throughout.

We have created a new generation of highly skilled technocrats – highly trained, and very able. Yet for all that ability which is often driven by a fearsome desire to learn, stemming from a variety of motivations, there is often a dependency on the externality of that learning – and the world sometimes seems to be divided between those who say “just leave us all in peace to get on with my job and to do what we know”, and those who say “just tell me what to do and I’ll do it to the best of my ability”. 

Increasingly we understand that if real change is to happen, it has to be “owned”, believed, made by those whom it affects most – an approach which deals with both sides of the dichotomy described here.

Or take Schön’s reflection-in-action, the means to achieving double-loop learning, the learning which challenges existing thinking and ways of acting, accepts and generates trusted challenge, the learning underlying Tom Peters’ ‘Learning Organisation’, directly picking up the principles of working from and with real experience, and applying it to real and immediate problems. 

Doesn’t that strike a chord with what we see from successive failures of earlier approaches?

These are approaches which require empathy and curiosity, an understanding of the subjective meaning, the circumstances, gained through neutral questions, a relationship between learner and their facilitator based on mutual respect and equity, the generation of safe environments, the ability to challenge (hard) and still be respected, and the avoidance of instruction or advice. These are the stuff of coaching and facilitation, of effective adult learning, of real change.

This is a different mindset to the mindset of QIPP, of squeeze and performance management. I believe both mindsets have important roles to play, informing each other, releasing the potential in each other. Both are necessary, and without the mindset of supported personal development and change we shall have a poorer service and more reports like that from the health ombudsman. The need for real change in our caring services requires we address this now.