Cowper’s Cut: The NHS needs a chief anthropologist more than any chief inspector

I’m suspicious of good intentions, if I’m honest. (And I’m honest enough often enough to spot the difference.)

This doesn’t mean that I’m against altruism. It’s a great principle, which needs to be delivered with great care.

I just increasingly think the NHS has got a massive and largely undiscussed set of cultural problems. This is the root of probably the only original idea I’ve ever had about health policy: that the NHS needs a chief anthropologist more than it needs any chief inspector.

(And for the record, I don’t think the NHS doesn’t need any inspection or regulation. The problem is in part due to what I regard as this cultural thing; and in part because for every action in health policy, there is an equal and opposite over-reaction.)

Much of NHS regulation can best be understood as an over-reaction to the ugly Mid Staffs scandal. The Ely scandal, whose public inquiry made its chair the young Geoffrey Howe into a rising legal star, was the trigger for the arrival of inspection into NHS provision. Welsh assembly member Mark Drakeford notes that “the proposal (for inspection) was fiercely opposed by doctors, because they believed it would interfere with their clinical responsibilities”.

Ahem.

Some of the worst behaviour I’ve witnessed or heard about has been driven by individuals and system leaders being profoundly convinced that they are doing the right thing

The Ely scandal also led to the close of the long stay mental health institutions. The Wikipedia report on Ely notes that “studies of such enquiries find a similar pattern of events and responses to them. Typically, the institutions are isolated and inward looking. Staff are afraid to complain about poor practices, and if they do complain they are often not believed. The patients involved are generally people who are not easily able to complain. The reports rarely give voice to the patients”.

The lesson of these historical anecdotes?

That a proper NHS scandal can cast long shadows, (and cast them a long way.)

I think the problem that I have with “good intentions” becomes two-fold: firstly, when self-sacrifice becomes a fetish and a feature of the system, rather than a bug. The line between self-sacrifice and human sacrifice (the less PR-ed self-harm bit of altruism) can get very thin. As lines to take go, it isn’t one.

The second, and bigger problem, is about who gets to define the “good intentions” in question. People will do Some Very Bad Things Indeed in the name of ”good intentions”. Some of the worst behaviour I’ve witnessed or heard about has been driven by individuals and system leaders being profoundly convinced that they are doing the right thing.

It can be a short step from that conviction to feeling that ends justify means.

If there’s one thing I have learned can cause Very Bad Consequences, it is people who have what are believed to be morally or politically well-insulated motives. They tell themselves a story that they are doing the right thing because they have the right motives. They are driven by the above-mentioned “good intentions”.

Woe betide anybody who gets in their way.

Does this seem familiar to readers? Or problematic at all?

Myths and parables

What we’ve got with NHS culture is basically a confusion between myths and parables. That means we need to know the difference between these two things.

Myths are archetypal stories of culturally appropriate resolutions of the great and universal dilemmas. A fundamental point about myths is that they are not real.

Myths attempt to reconcile things into camps of good guys and bad guys: in myths, the former are rewarded and the latter are punished. Myths seek to resolve contradictions and paradoxes.

Life in general, and in the NHS in particular, is not quite the way things are in myths.

And are people at the NHS front line working in the platonically perfect dream of the myth, or the messy reality of the parable? And how do we manage them?

Parables are a lot more human-scale. They are often slightly inexact metaphors-cum-similes. And they are all about contradictions. Parables are efforts to make a close analogy to the real. John Crossan, in his book The Dark Interval, presents parables as the diametrical opposite of myths: “Parable brings not peace but the sword … parable casts fire upon the earth … parable is meant to change us, not reassure us. Parable is always a somewhat unnerving experience. The standard reaction to parable is, ‘I don’t know what you mean by that story, but I’m certain I don’t like it’.”

Parables accept and even embrace complexity. Myths attempt to aneaesthetise and euthanise complexity.

Where myths seek to reconcile seemingly unrelated and incongruent things, parables aim, Crossan, writes, “to create contradiction within our complacent securities”.

Parables are challenges; myths explain the status quo in order to bolster it.

Does this stuff sound familiar?

And does it sound as if it might create cultural problems?

Mmmmmmmmm.

If we are going to make a difference and act with integrity, then we are going to have to tell our own story. If we want to be effective in doing this, we must be able to retail and translate our story for others; while acknowledging that it is one story among many available choices.

Nobody controls the narrative in a digital age. That used to be possible, and now it isn’t. Command-and-control freaks may yearn to have that narrative certainty and hegemony back. They can yearn all they want: it isn’t coming back.

The writer Joan Didion memorably observed that “we tell ourselves stories in order to live”. If she is right, and I suspect she may be, then we must take great care what stories we tell ourselves, because we are sure to become our stories. And our stories are sure to become us.

What stories is the NHS telling itself in order to live?

And are people at the NHS front line working in the platonically perfect dream of the myth, or the messy reality of the parable? And how do we manage them?