Published: 17 April 2020
Author: Professor Donna Hall, CBE Chair NLGN, Bolton NHS Foundation Trust and former Chief Executive Wigan Council
Everything that we knew before the pandemic has undergone a seismic shift. We have witnessed a remarkable change in risk appetite and also in mindset. So what has fundamentally changed?
It’s all about human relationships. The relationships between people and the state and between the various parts of the state working together in a place. We are no longer as fearful of how we will be judged as an individual heavily monitored organisation but how we will fare together as a system serving the needs of our residents together.
Culture change on this scale only happens either when there is a change of leadership or a crisis.
Maybe we need to capture this learning from crisis and reframe the way we design health and care services forever. We also need some totally different and radical ideas, a new social science, a new social contract some fresh, creative and inspiring thought leadership to help us reframe and redefine the future purpose of public services. Whether austerity is or isn’t over as a result of the pandemic unless we break away from our rigid, transactional, paternalistic models mostly designed in the same way as when they were first created in the 1940s, rising demand for services will finish us off anyway. Maybe a focus on a completely different way of thinking about human behaviour and our relationships with communities, staff and each other will help us get to the heart of the increasingly complex and challenging issues we all face.
We have had over ten years of sustained austerity twinned with significant rising demand for all public services; to which transformation teams, accountants, digital whizz kids and policy professionals have struggled to find a holistic, deliverable, sustained solution.
Do we need to reach for a “new” but actually ancient “ology” to help guide us through this complexity and get back to basics and what really matters to the people we serve?
Anthropology as the study of how contemporary human beings behave in social groups offers us some really invaluable insight into solving some of our intractable often disguised societal problems.
As a science, anthropology provides a deeper and more meaningful analysis of why people do things and how we can make things better in communities by building a different, more meaningful relationship with each other on a human to human level. It makes perfect sense to build this different way of relating to people in places just the way we work together every day rather than a project, a programme, a pilot or another mandatory training course.
We can’t even begin to understand why people do things unless we start to listen to them in a totally different way. The starting point of being an effective anthropologist is quiet observation and deep listening. Developing a very practical toolkit for all front line professionals to support them to listen more effectively, to have deeper more profound and relevant conversations without judgement and categorisation is so simple but has a remarkable impact if done well. It really helps to reverse the feeling that people are being “processed” in the system as an anonymous unit of need and encourages as an asset-based approach, building on what matters to someone not what is the matter with them. The relationship quickly shifts from one of transaction to a two-way conversation, from paid professional fixing the passive recipient of services to heading towards the best possible outcome for the person, the family, the community together.
We spend as public servants around 80 per cent of our contact time with residents assessing them, referring them on to other bits of public services and only 20 per cent on building a two-way relationship. Given that all the evidence shows us that it’s a relational practice that is the most successful we insist on clinging to old familiar models because the new world can be a bit scary and some people still want to cling to their clipboards for protection.
The role of system leaders as anthropologists is an interesting and crucial one. Giving permission to everyone in the place to innovate and to practically apply the simple principles of anthropology to their everyday jobs in communities is a vital part of the role of senior system leaders, chief executives and politicians. Making it totally acceptable and celebrated for frontline teams to try new things by working creatively with groups of residents in neighbourhoods, some of which may not work but we have to try as part of the learning journey.
Hardwiring a sincere humility and deeper listening into the public service system in your locality is a relentless task for the Chief Anthropologist or Chief Executive. Pre-pandemic there were still some local leaders who thought they knew best and as the Chief Executive of The NHS Trust, the CCG Accountable Officer or the head of children’s services communities need to be fixed, we know best and they can’t be trusted.
Archaic blame cultures exist and people still cover their backs by sending nasty emails copying in people’s line managers in a passive-aggressive way. For goodness sake please stop. Go for a coffee. Talk about it face to face. Listen. Listen harder. Be a true anthropologist leader in search of the essence of what makes humans human.
We see this play out as the remnants of the old state and market paradigms cling on to try to re-assert their diminishing relevance to modern society and how people really live their lives these days. Moving away from prescribed top-down state solutions; away from market-driven outsourced and competitive organisations. This is really essential preparation for the newly emerging community paradigm - the fourth and essential stage of public services where power and control is in the hands of the people.
Drawing on the Nobel prize-winning ideas of Elinor Ostrom, combining anthropology, economics and politics help us articulate the thinking behind our Community Paradigm philosophy and we are keen to work with others to further refine our thinking and more importantly its practical application for communities.
Over an eight-year period we deployed this community paradigm thinking to create the award-winning Wigan Deal: a radical approach to health and wider public service reform which delivered incredible outcomes including a seven-year increase in healthy life expectancy whilst reducing cost. The Wigan Deal has been highlighted by The Kings Fund and others as a unique experiment in redesigning public services around people, not conditions or silo services. Despite being the third-worst cut council in the UK by central government grant cuts, the council and its partners created a new social contract with its 323,000 residents. Council tax would be frozen for eight years, people would be seen as human beings rather than units of individual need, and everyone would support their local community, recycle more, take care of their health etc. Alongside this, a Community Investment Fund was established to provide support for over 500 grassroots community prevention projects. The end result was £160 million was reduced from operating budgets and outcomes across all services improved.
The NHS & wider health and care has things it can learn from The Wigan Deal and there is considerable interest in a new social contract across the UK post-pandemic. For example, we are applying some of the learning in Bolton in the Foundation Trust as we deliver our joint plan with local people (not patients!) For a Better Bolton along with the CCG and Bolton Council.
It can be done if we are bold enough to create a radical new paradigm and don’t revert to normal as normal wasn’t working.