Government, health, trust, knights and knaves

I went to another lecture at the RSA on Monday. This time it wasn't high-falutin' philosophy but a very real dilemma that the country faces: the cost and operation of the national health service (NHS). The speaker was Ed Miliband, the leader of the opposition Labour party and hopeful prime-minister-in-waiting, so the press were there in numbers, cameras and all.

A part of the current debate is that the current Conservative-Liberal government has decided to take financial control away from hospitals and give it to local doctors (GPs). The general idea is that will create a more effective customer-supplier relationship, forcing the hospitals to deliver what is needed rather than working on their own agenda. Yet there are huge motivational questions about the proposed arrangement, not the least that the tail starts to wag the dog and hospitals become reactive as they compete for GP support -- and then we all consequently pay the price for more short-term thinking.

The Labour party recognize something of the dilemma and seemed to be keen on ensuring greater accountability as an alternative approach. Yet this also misses the point. The underlying question seems to be one of trust.

The government wants to take power from the hospitals because it does not really trust them. And the opposition want to increase accountability because they don't trust the hospitals either. The first deep question is why? Why are hospitals not trusted? Are they not trustworthy? Why? And why do politicians distrust hospitals so? One underlying issue, I think, is the historic authority of doctors, who have long worked on the principle that they are an ultimate authority in their field and will not accept challenge from outsiders. As a result, organizing hospitals is something like organizing universities. You have a lot of bright people who are focusing on their own work and easily interpret the bigger picture as less important. Couple this with politicians who see the big picture but little of the detail, and you have a train crash in the making.

The problem with distrust is that it costs. When you put in controls, whether it is dispersing financial control or implementing close scrutiny, you also create games, such as smoke-and-mirrors and cat-and-mouse, that occupy the attention and funds of both sides. I've seen the effects first-hand in the public service I have done, including spending over half my time in endless reporting. What if we could act to increase real trust, rather than implementing expensive substitutes? What if politicians and doctors had respect for one another? How about if people could say 'we were not perfect' without fearing reprisals?

Paradoxically, Ed Miliband talked just about such a thing. He mentioned values, cohesion, collaboration and other drivers of trust. He is so near, and I hope not so far. Creating more trust is a difficult endeavour, but it is not impossible. Perchance I am currently working with a colleague on setting up a business that focuses on approaches based in Positive Psychology, such as 'Appreciative Inquiry'.

I spoke later with Matthew Taylor, the RSA chairman and former policy advisor to Tony Blair when he was prime minister. He listened patiently to my rant about addressing the underlying trust issue and noted that Ed Miliband actually did have more about this in an earlier draft, but presumably did not think the press would get it. He told me of Le Grand's book 'Knaves and Knights', which highlights how private business is seen as greedy knaves whilst public servants are perceived as heroic knights. In practice of course it's not so black and white. The systems in which they work have a significant influence on whether people act as knights or knaves. If you treat people as if they are knaves, then they will ultimately act this way. The real challenge is how to create more knights.

It was funny to hear Ed Miliband's speech reported during the day and I got a bit of an identity boost from realizing I was there, where the news was being made. Cor.

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