Tuesday, 1 December 2015

Relax With Moon

Christmas is coming, the geese are getting fat 

How stressful this time of year has become? How far our six-week shopping binge is from its roots, from that old mid-winter festival when everyone was looking forward to a celebration and a bit of community – as well as a prayer that the sun would actually come up again.

Did you know, to always make sure that was going to happen, they used to send the shepherd boys up to the highest point as the sun dropped to its lowest point at winter solstice, 21st December? And of course, there was no Roman calendar then just observation of the seasons and the sun moon and stars – so they used to add a buffer of three days for safety, so full celebration was on the 24th (Christmas Eve) to really be sure that the sun was rising.

‘Son’ rising after 3 days – could there be a spiritual clue here?

So what about now you may ask? 

Our wonderful material society that constantly encourages endless feeding but in which we never become fully satisfied. So how can we stand up to all the Tesco or John Lewis ads and Slade tracks? 

Many people, the poorest of course, often times borrow huge amounts of money and end up with serious debt with the legal or/and illegal loan sharks. A whole year paying for one day.

And before you say, ‘It’s for the children’, perhaps for us adults a little self reflection might not come amiss.

The Myth of Christmas 

You cannot deny it is a wonderful story. A new baby, stars, royal visitors, mysterious lights in the sky: wow.

I like myths. I don’t really mind whether they are true or not, if they have a great message for us all. Myths, yes, but there is of course the reality of the family and time spent with various relatives you may or may not have met during the rest of the year. Or does it only highlight a sense of loneliness for those without family, and even for those in company?

So relax with Moon. Top tips. 

1. Be strong.

2. Ignore the messages of the consumer society

3. Be courteous and respectful to those who do believe

4. Be generous of heart to yourself and others

5. Enjoy with moderation, share, no need for excessive food. Many have little. Some have none

6. Drink loads of water

7. Take time out to relax

8. Be mindful. Turn off the television and delight in the mid-winter, cosy on up with a blanket and listen to some relaxing music

9. Pamper yourself, with some time out

10. And most of all – Have a happy, relaxed Christmas.

Monday, 31 August 2015

Early Parenting Lessons for Business Leaders?

Sue McGuire considers spin-off benefits of online learning

I’ve recommended FutureLearn’s free online courses before and I continue to be astounded by their quality and thoughtfulness, and so am happy to alert you to another of them. I’ve just completed the ‘Caring for Vulnerable Children’ course which is hosted by the University of Strathclyde Centre for Excellence for Looked after Children in Scotland (CELCIS).

It’s all done online and at your own pace; and what’s great about these course forums isn’t just the materials, but the opportunity to comment, reply and discuss responses with hundreds of other students from all over the globe – great for thinking and new ideas. No doubt it will be repeated if you are interested.

The first week of the course dealt with the issues of assessing of risk, vulnerability and ‘good enough parenting,’ highlighting the tensions between a ‘more traditional’ (my words) ‘community social work’ that recognises and works to address some of the structural inequalities affecting a family’s environment and the present state of affairs of a more surveillance oriented concentration on the relationship traits and deficits of the family.

The course argues that this has arisen from the many reviews that have taken place over the years from Maria Colwell to Peter Connelly, plus a growing culture of risk aversion. I would add in our sometimes scandalous media blame-culture and myth-making.

The second week was a real eye opener for me, offering a potted history of child development theory. A fantastic presentation by Dr. Laura Steckley introduced me to Bion’s concept of Containment, and it is this that has motivated me to write today. I hope I am not completely misinterpreting this often pejoratively-used word in my attempt to explain it – but know for certain I will be teaching grandmother to suck eggs at this point!

Containment theory proposes that in the course of parenting, especially in the earliest baby phase, a process happens in which the baby’s inability to manage its own needs, for food or dryness for instance, gives rise to emotions of panic and fear.

As the parent interacts with the baby to meet those physical needs, the parent also transmits an emotional response of reassurance that problems are manageable – that they can be contained. This assists the growth in understanding of the external world to the baby and a belief in the manageability of things, which enables the fear and panic response to be contained. Done well by parents this obviously has a lifelong benefit.

The theory is not only helpful in understanding and encouraging good early parenting, but can be used to help older children, young people and even adults allay tantrums, terror and troubles in later life caused by the inability to feel things are containable.

However it was a passing remark of Dr. Steckley about another application of the theory, which made me want to blog about it. She mentioned that the concepts have been subsequently applied in all sorts of relationships and settings – including education, social work and consultancy. It's even been applied to business.

That remark got me thinking about the many anecdotes I have heard from friends and colleagues working in all sorts of businesses and sectors, but most especially in today’s Health and Social Care sector.

Here we see a high degree of anxiety and stress at the moment; target-driven, subject to increasing competition and marketplace pressures, scrutinised by external organisations with their own targets and political pressures – it seems to me that the current management and leadership style is to hector and drive.

The theory of containment suggests a lack of rational and creative thinking, poor self-belief and inability to ‘hold things together’ which result from poor containment could be the downfall not only of the people within it but of the business/organisation itself. These are the ways of thinking that have led to the Mid-Staffs hospital crisis and the alleged doctoring of statistics to cover up poor cancer treatment performance at Colchester (which subsequently was blamed on bad management and not corruption).

Maybe it’s about time our political and sector leaders learned something from the containment model’s vision of good ‘parenting’ skills?

PS: Having finished this course am now just about to start week one of another hosted by the University of Los Andes, on the great Gabriel Garcia Marquez. Look forward to some more thoughts on leadership styles from his wonderful ‘One Hundred Years of Solitude’ – will keep you posted! 

This is the link to FutureLearn’s course: https://www.futurelearn.com/courses/vulnerable-children

Monday, 29 June 2015


Sue McGuire thinks about porridge for breakfast – and vivid pink lipstick

I’ve spent a bit of time thinking about professionalism lately, and have been having some interesting conversations about it. One of the first things to say is that it’s a bit of a difficult term to define – and as to what is professional or unprofessional, well everyone has an opinion on that score, it seems.

In my own case, one of the first times I remember being moved to consider what was ‘professional’ or not was when I got rather exercised about what appeared to be a growing movement in our office for people to eat their breakfast in the office, at their computers.

I put up with it for a while but eventually, as deputy manager of that team, I had to say something in the team meeting. Basically, I wasn’t enamoured about people clocking in then going into the kitchen to make breakfast – after some of them had put their make up on in the toilets, as well.

This wasn’t taken lightly. Why was it any different to eating a sandwich at your desk at lunch time etc.? Well, it’s a fair point and I admit to bringing some of my perhaps puritanical and judgmental nature to bear here. (I think you can tell that from the make-up remark!).

In the end, we agreed that you could have your breakfast at work as long as you didn’t clock on until after it was made. All’s well that ends well, but I still shudder to see a bowl of porridge by a computer; having your breakfast in work seems to me to be evidence of a very disorganised home life, it seems to me.

I’ve seen other examples of similar behaviour, of course. I remember that at one authority I worked in, all PC games, such as solitaire, were removed from all desktops. Later on, in another authority people were often seen playing these games in their lunch times (and sometimes not only lunch times), quite openly. I thought this appalling, and wondered what people visiting our big open plan office might think. The response: it was their break times, they should do what they like.

I don’t know. I guess I’m a kind of ‘you don’t go to work to enjoy it’ person. So the following thoroughly grabbed my attention the other day and I did read it and reflected on it at length. Seven things that brand you unprofessional by Liz Ryan.

Apart from the fact that I had been discussing the experiences above very recently, I was brought up a Catholic – and there is no-one like an ex-Catholic for raking up the past for things to feel guilty about! So I had to read this and put myself through the mill.

Liz’s piece opened my eyes to a few things about this whole set of questions about what is and what isn’t appropriate in the office. It made me feel a bit bad, for example, for picking on trivial reasons for applying the term unprofessional. ‘Professional’, she says, doesn’t make you stiff or staid – and presumably, being stiff or staid doesn’t make you professional. I was very struck by some of the things she says are professional – such as ‘telling the truth’ and ‘being compassionate’. These are much bigger ‘asks’ to maintain than a lot of people give credit for and I’d be willing to bet we can all think of a time when we didn’t maintain our standards to our satisfaction on those items.

I also really like her seven ‘don’ts’ about professional vs unprofessional and if I had to go back to carrying a card around with me to tell me what values I should espouse (as one employer tried to make me do!) I’d be happy to put these on it.

• Don’t drop you commitments – do what you say you’ll do or don’t say it
• Don’t blame others for your mistakes
• Don’t attend events ‘impaired’
• Don’t assault other people’s senses
• Don’t throw your co-workers to the wolves
• Don’t cut corners
• Don’t bad-mouth your employers or their associations

I think really what they are saying is that being unprofessional consists in many small daily acts of unkindness or lack of consideration.

I can think of times when I’ve let both myself and others down on some or all of these.

It’s very good advice. So I think something is emerging here about what started out as being a controversial term, perhaps – about how being professional is about being a person others can trust, someone whose consistency and values are clear and obvious. About being someone who explains why when things aren’t as perfect as you’d like them to be and will keep trying to make them better against momentous odds. And yes, someone who keeps on trying.

The concepts ‘professional’ and being ‘unprofessional’ deserves discussion in teams and among leaders and managers. It’s a good debate and I think it’s worth knowing what people think they look like, both for good team cohesion and for good organisational motivation.

It’s also a discussion about detail and not just broad concepts. Will it sanction the freedom to eat porridge at work and wear the brightest shade of lipstick you can buy? Worth finding out, surely?

Wednesday, 27 May 2015

Sue McGuire Makes the Case for Counting Beans

So, I have been doing some Better Care Fund (BCF) work for a local authority and I’d like to share some of my thoughts around this somewhat controversial topic. 

Controversial because BCF can either be seen as a cynical move to make it look like local authorities and the NHS have been given a load more money to spend on integrating services or as an opportunity to start to generate responsibility across the health and social care system for certain big ticket outcomes; such as reducing non-elective admissions, timely hospital discharge, reducing admissions to residential homes, helping people to live independently at home… and lo and behold managing the system costs better so we can meet future demands.

Unusually for me, I am choosing to think the second option; yes, after doing this work I am going to choose optimism. I’m beginning to think it could just work. I was engaged to work with the differently-funded elements of the programme to build the business cases and evidence for:

• why their services should continue to be funded at the same levels
• what is their contribution to the BCF objectives and high level outcomes
• what cost-benefits they are generating.

I have also been tasked with developing some sensitive metrics for each scheme which could be reported to the Performance Review Group so that assessment could be made of which services were making the best contribution to the outcomes data – i.e. data which can show a link between a certain number of x-type services and, for example, a reduction in delayed transfers of care.

I have also been looking at funds like Disabled Facilities Grants and community equipment – mandatory to put into the BCF pot – and the services supporting allocation of those funds, such as OTs. I don’t really need them to build a business case for the use of adaptive technology, it’s worth noting, as perfectly good research has established this, including a fabulous PSSRU paper from 2011 

Relevance and Responsiveness 

What I do need these services to establish is that they do this well. So it comes down to a few criteria, the crucial ones, I think, being relevance and responsiveness. Do they assess the right people? Do they do it quickly enough and provide the service, whatever it is, be it a care package, item of equipment, hospital procedure, whatever in a timely way, to ensure a more costly alternative is diverted somewhere down the pathway?

To answer these questions, I’ve been having a look at a lot of potential metrics that could be of use. I’m very interested in standardised tools for measuring health and quality of life gain at the moment, especially ones which can link to determine quality of life year gain QALYs. (To my mind, these clearly include tools like EQ5D, SF36.) I’m also interested in mental health tools such as WEMWEB, in scoring used in services like intermediate care such as Barthel Index, and the Nottingham hip fracture score. I’m no expert in this area, to be fair, but I have been putting in the hours to build my expertise in this area; and as a result, I am finding it fascinating.

As a result of all this, I suggested that a lot of the services adopted a similar or the same tool and then we could measure and compare the health gains generated by, say, a mental health outreach service or an equipment service.

But a story keeps recurring to me. A number of years back when I was involved in the allocation of grant funding to voluntary organisations, I spoke to a group of young carers who were involved with a young carers’ project which networked them, did crafts and groups and took them on away days etc. I asked them, if I could spend the £200K we spend on this project on whatever they wanted, what it would be.

The outcome of the discussion was almost unanimously – and very surprisingly – that they would spend it on equipment and adaptations for their parents or siblings to make them more independent as that would relieve the caring burden on them – not, as we were doing on group meetings and networking and ‘treats’.

In an ideal world you would have both, of course. Those young people certainly deserved it. The conversation was a real eye-opener for me. There are always alternative ways of getting to the same result, after all – but it only takes asking the people involved to find out what that is. Do we really need a lot more evidence for what works?

As a result, this morning I am coming round to a new stream of thought. The BCF can work really well and it can deliver on its objectives. To do that, the BCF Performance group needs to be sitting round monthly (or even more often), not talking about numbers, as tended to happen in the past, but looking at people in the system, maybe even down to individual names and needs.

It needs to be looking at system sensitive information, such as who is waiting where, what can be done to make things happen quicker for them. Useful questions here might be, could money cross over scheme boundaries to make that quick thing happen without a business case or a lengthy trail through a governance regime? Can we get people managing the services to sit down and look not at what happened but at what is going to happen next?

In other words, we need to start looking at the numbers that predict the future, not those which tell the past – and, see if someone else is already doing this first, by the way.

We still have to decide what information should be brought to the group. But my guess is it won’t be as complex as the information I originally thought we might need. All this might even be described by some people as bean counting… but you know what, if beans have already been proved to be highly nutritious if you eat enough and likely to give you wind if you eat too many – why wouldn’t you make sure you are counting them accurately?

Monday, 20 April 2015

Sideways Innovation

Robert Templeton of Well Street, Better Care and Health takes a sideways look at innovation

Innovation is a term widely used by government and industry, as well as in health and social care – and undoubtedly, in the run up to the General Election, all the political parties will be discussing innovative ideas and policies. Perhaps they’ll even use the reliable shorthand for the whole process, blue sky thinking, to identify the way they’ve come up with such ‘breakthroughs’.

Alas, in the real world, innovation is a lot more common that that metaphor implies. The problem; delivering its benefits is a lot more of an issue. It’s implementation of the good idea that’s the obstacle, not never having one.

But why is it so difficult to get innovative ideas to work in practice? There are perhaps three ways I’ve found to explain why ideas that look great on paper fail when implemented locally: Top down, Context and Suitability.

Top-Down Approaches 

One of the biggest roadblocks for innovation in health and social care is that the services such teams provide are for the most part funded at the national level. As a result, new ideas often first get traction centrally, which drags along an expectation that the front line will implement them. This creates a policy-to-practice gap, in which good ideas too often fall - largely because local health and social care organisations are unable to accommodate the change without significant risk.

Furthermore, without buy-in from frontline staff and service users, there is very often insufficient positive incentive to change. That’s a big reason why we see time and again new policy ideas are often short lived, too susceptible to changes in the political landscape. This ’top-down’ approach frequently leads to ‘badge engineering,’ in which services fundamentally remain the same – but are rebadged by latecomers to fit the latest policy Zeitgeist.

Is there a way out of this one? I think that taking a collaborative approach and expanding the number of people that contribute to innovation helps a lot. Innovation works best when everyone is involved with creating and implementing ideas that lead to success. A good example of this is the Think Local Act Personal (TLAP) initiative - a national partnership of more than 50 organisations committed to transforming health and care through personalisation and community-based support. The partnership spans central and local government, the NHS, the provider sector, people with care and support needs, carers and family members – and is a great case study of just what I am talking about, innovation that works.


To sell innovative ideas, it is vital to have examples of how they work in practice; for example, how a new way of working has positively changed someone’s life, or how this new approach saves money. There’s a problem, here, though; what works brilliantly in one context might not in another – and while case studies and examples definitely have a place, there is a risk in oversimplifying the narrative and ignoring the context in which the services are delivered. False impressions may get created.

This is a crushingly familiar snag with pilot schemes, which work in the context of the pilot area(s) but seem to fail when implemented nationally. Indeed, context is king when considering integration of health and social care services. As we all know, since the mid-1970s, greater health and social care integration has been the aspiration of successive UK governments. Despite this, progress has been glacial. Exceptions do exist (Torbay, North East Lincolnshire) and these examples get trotted out again and again as clear signposts to show how integration works. However, neither offer a ‘one size fits all solution’ to integration. Both areas are small and have a unique set of circumstances that led to the establishment of integrated services. This is well discussed in an evaluation of Torbay by the Kings Fund (2011), which makes the telling point that there is no ‘textbook’ to guide the process of health and social care integration because local context - especially the interplay of people, relationships and processes - are key variables.


Innovation often flourishes when money is available to groups of individuals who are organised and determined to make a difference. Short-term money for proof of concept is a good thing, but the obstacle here is deciding how such pioneering individuals and projects get supported and sustained in the long term.

An example of this is the independent social work practices for adults. In November 2010, the then-new Coalition Government announced £1m to pilot adult social work practice outside of local authorities. The outcome was six successful Social Work Practice pilots and ten Social Work Practice Pioneer Projects, all centred on people who use the services. Many involved in these projects took great personal risks by coming out of local authority employment to work for a social enterprise and there’s some real breakthrough here.

But it’s really only been in a very small scale. And the challenge for such social work practices is the same for all small innovative organisations… they may be able to prove concept - but are they sustainable in a competitive environment? Public sector procurement processes are often the stumbling block, of course. And although they can be circumvented for the purposes of a pilot, in the longer term procurement as it stands in the sector does still tend to favour larger organisations which can provide a variety of services, have economies of scale and business development functions, all of which easily outcompete smaller groups of dedicated individuals. Again a ‘one-size fits all’ approach to commissioning stifles innovation, forcing as it does an over-emphasis on winning new business above delivering great services.

Falling from a blue sky 

My point is that innovation rarely falls from a ‘blue sky.’ The best, most sustainable innovations, often come from the hearts and minds of those who work in or receive services. The trap in searching for the next centrally led ‘big innovation’ is that we miss good ideas already under our noses, I fear.

Is there an answer? Perhaps what is needed from any newly elected government is not new ideas but a strategy constructed in such a way as to foster and nurture grass roots innovation to flourish at the frontline?

That would be a Big Idea I’d vote for, don’t know about you.

Monday, 13 April 2015

I Want To Be A Systems Thinker… I Really Do!

Sue McGuire reviews Systems Learning, a free online http://www.systemslearning.org/systems-learning six video course that claims to be a ‘gentle, yet detailed’ introduction to making you be more effective. Does it work? 

I want to be a Systems Thinker, I really do. It’s the almost evangelical style of the Schumacher Institute’s tutorial package of six videos which makes me want this – and to share the love, too; less than halfway through, I find myself gripped by seemingly uncontrollable urges to stand up in unsuitable public spaces and announce to one and all how, ‘I’m saved’.

Joking aside, there is a definite ‘spiritual’ aspect to all this that can’t be denied; the main presenter/teacher on the course, Martin Sandbrook, even says (in video 4, fact-fans) that some of the objections to the philosophy he is espousing centre on how it can look how, ultimately, ‘You’re telling me I have to believe in God.’

There are many aspects of all this that I do find attractive. But the online approach to finding out about Systems Thinking sometimes doesn’t really help; the unbroken ‘talking head’ approach, spread out over these lengthy (18-19 minute) videos plus one long paper, consolidating a LOT of ideas, was not the least of the aspects I found challenging.

But it’s really not just the pedagogical style. Systems Thinking is a pretty revolutionary thing, asking us to rid ourselves of all thinking that owes its origins to Copernicus and Descartes – i.e., ‘mechanistic’ thinking… though every negative word the speaker can seemingly think of is here in this brief history of mechanistic thinking – I have so far counted reductionist, dualist, pervasive, controlled by experts, scientific, using the metaphors of machinery, material, and hard, judgemental stuff. And I’m not finished yet, remember!

You may not be too surprised to learn that by very sharp contrast, very positive terms abound when talking about Systems Thinking: democratic, holistic, respectful of nature, flexible, organic, open, interdependent, emergent, organic - using a lot of biological metaphors, e.g. fluid, descriptive, collaborative, reflective and so on.

I’m definitely going to want to be part of this. So why can I just not quite get there? I’ve been thinking about how to nail that down and I suppose it’s because I’m deeply sceptical about anything that has a slightly mystical sound to it. Which is what this video course has no shame at all in saying it’s proposing – promoting the approach as a ‘[new] way of seeing the world,’ ‘a better way of acting in the world’ and so forth.

Which is a shame, as underneath all this are some very simple and, I think convincing, useful ideas that don’t need all the baggage. Really, Systems Thinking is just a way of reminding us that self-awareness and awareness are just words for the filters we use daily to screen out the things not favourable to our world view and which we use to get in, for reinforcement, all those things which are.

There’s a quicker way to get there, I think, as watching the last one I finished, I was reminded of a story cult American writer David Foster Wallace told in his marvellous commencement speech at Kenyon College in 2005. Please read it if you never have…. As it might save you a couple of hours of trawling through at least a couple of these introductory talks: Two young fish are swimming along and they meet an older fish swimming the other way, who nods at them and says "Morning, boys. How's the water?" The two young fish swim on for a bit, then eventually one of them looks over at the other and goes "What the hell is ‘water’?" 

In other words, we all have different world views and we can gain a lot from trying to see how the other person is thinking. OK, that’s the basic overall idea, what else do you really need to know? The course suggests a number of techniques to develop your awareness, which I think can be perfectly well summed up by, asking more what other people think as a quick way to push your world view a little less. I did like the ‘Frame, Illustrate, Enquire’ technique expressed here, indeed have met a few people who could benefit from it, not excluding myself, incidentally, by any means.

I’m also convinced that we are too one dimensional in our current ways of analysing and trying to solve problems. Sandbrook tells us that in Systems Thinking you do not try to ‘solve’ a problem, but envisage a solution and work towards it. I see that as a useful perspective. In my and I am sure your experience, organisations are weighed down by problem solving and lose vision and motivation. We use rationalism as our only tool to the neglect of emotion and intuition. Vast amounts of creativity can get lost in a system of organisational development and improvement that only allows what is planned, what has a business case, fits with the programme and contributes to ‘step change’. I think Systems Thinking is as good a prompt as any to make us look at different ways of doing things.

Social Care 

Let’s apply all this to a real problem and see if it works. For as long as I’ve been working – certainly for as long as I’ve been aware of people having social care needs - the mantra of integrating the delivery of social care support with support for health care has been on the agenda. Yet still we hear stories of people routinely pushed around mutually exclusive systems, ignorant of each other’s policies and practices, working alongside but not with each other. A bit of Systems Thinking, one that puts the people and their needs at the heart of the solution could be great to anchor the attention of the deliverers of the service.

At the same time, paying attention to how systems interact instead of how they are structured internally, or even to how to push them together into a new structure, could also be a boon from this way of looking at the world. Why? Because systems interact through people. Give people objectives instead of targets and permissions, instead of rules and boundaries, will be automatically more flexible and optional.

What else did I like from my exposure to Systems Thinking? I did really like the understanding of organisations demonstrated in the course as complex responsive processes ‘mediated by conversation’, which I think are more free flowing and less rigidly bound concepts than we are used to imagining.

Why? Well, organisations typically describe themselves in terms of hierarchies and structures… but anyone working within them knows that they don’t truly function like that, but are instead actually a series of allegiances and alliances, constantly renegotiated, with people crossing their grade and task boundaries on a daily basis. Progression and change happening despite restructure and statements of corporate values, not because of them. For instance, I will never forget working in an organisation where the cleaning staff, who were in fact critical to its overall effective functioning, thought that the ‘boss’ was the Premises Manager. They had never even heard the name of the Chief Executive and that person was in of no interest to them …..whatsoever. 

Another nice find from my bit of extra-curricular learning was the claim that long-term planning is largely a waste of time. Well, yes. I have always been sceptical about project planning approaches. Systems Thinking says a better way is to talk more about looking to the next base; it wants to build into organisations ways of dealing with things that crop up, rather than ways to explain and excuse them as though they are signs of failure, as they were not in the plan. How often have we been in that place, guys - where some good thing seems to have been delivered in the end in spite of the costly and interminable project machinery, rather than because of it?

So how to sum up? Like I said, I want to be a systems thinker…I really do. In fact, I think I am. I’m just not sure what I can do with it yet - except see the limitations of mechanistic thinking. So I am in a sort of half-way house.

Which is all well and good, but this course tells me I have to be saved from myself. I can’t just be a mechanistic thinker who tries to use some of the systems thinking tools from time to time - that’s the primrose path to Hell, it warns, you can’t sit on the fence here and try and do both styles of thinking, you have to commit to one thing or another.

Well, that’s a bit off-putting for me, though of course that kind of strict either-or stance might be a style that appeals to others. But what I can say is that this short look into Systems Thinking has definitely left me wanting to find out more.

Monday, 9 March 2015

We Need To Start Measuring Social Care Outcomes As Closely As We Do Health Ones

Sue McGuire learns about metrics

How do we know if what we are doing is working? Or judge how effective it is?

One of the differences I noticed in the different cultures of the Health and Social Service worlds I have worked in (if you can consider them separately), is that in Health they seem to be much more rigorous about knowing and establishing the evidence base for what they do. (I know measuring has changed a lot since I worked in a purely Social Services setting so I’m ready to be shot down here.)

I wonder if that’s because, in Health, the range of treatments and interventions is so wide that the need to establish the most effective ones is vital. Or could it be that because the risk of doing harm is great, in addition to the possibility of patient claims against the system, makes its practitioners more rigorous?

Whatever the cause might be, there seems to be a more established research culture supporting clinicians, commissioners and patients themselves to make choices about what they use and where money gets spent.

Massive Open Online Courses
Following my interest in these questions, I started a FutureLearn course recently called ‘Measuring and Valuing Health,’ the third FL course I have done to date: if you’re not familiar with it, FutureLearn is one of the providers involved in opening up FREE learning on line in the MOOC environment (Massive Open On Line Course). The other courses I have done have followed my literary interests, specifically in Shakespeare, delivered by world class lecturers such as Jonathan Bate of the University of Warwick, and Michael Dobson, Director of the Shakespeare Institute at the University of Birmingham. FutureLearn brings together 1000s of participants throughout the world, a process that generates lots of discussion, comment, information sharing and networking. In short, if you’ve not tried this resource yet, you are missing a treat (and the range of subjects on offer is increasing all the time, too).

I am involved with a voluntary organisation which aims to improve the life and health of vulnerable families and we run something called a ‘Families Fit for Life’ course. (The ‘Fit for Life’ course is about improving skills, knowledge and behaviours around many areas of a family’s life – health, diet, activity, parenting, finance, social engagement.) I am learning now about the techniques behind developing measuring tools, literature research, and patient and clinician engagement, focus groups, hoping to do some technology transfer and apply some of these tools to track our group’s impact.

To get back to measuring, I was part way through week one of the course, learning about how to develop a Patient Reported Outcome Measure (PROM), when the old debate about what we call people sprang to mind - Patients, Service Users, People? We couldn’t use a PROM; the people on our courses are not patients. But it struck me we could rename it a BROM – a Beneficiary Reported Outcome Measure. Well produced BROMs could be more widely used across of spectrum of social service interventions, family support, home care, even for comparing the effectiveness of assessment teams.

So I think we can agree there is a lot of ‘science’ going into the Health side of measurement. But like I said, I think we are very far behind in Social Care. For example, for many years I was involved in delivery of the grants to voluntary organisations programme of a large council. Almost every year I did this, the budget was cut, and decisions had to be made about which services we could not support any longer.

I struggled to bring some objectivity to this work, as I disliked comparing apples with pears, and I tried to develop a way of outcome reporting. I don’t think I really achieved that much, despite all my efforts; I think the struggle on that still has to be won and for services delivering more ‘social functioning improvement’ than health improvement, I think it is vital we strive to get the same rigour and academic support into this as health has.

I rather hope someone is going to tell me it’s all happening already! Which is fine – but if you’ve found out nothing else from this blog, I’ve promoted Futurelearn which I can’t speak highly enough about. Go and check it out! https://www.futurelearn.com/

Monday, 16 February 2015

Unscrambling Eggs in a Panarchy

Mike Wright rises to a blogger challenge

First things first... I feel it needs mentioning that this blog topic has neither been conceived in, nor born from the fertile womb of, my own mind; it is not my brainchild. The idea was in fact left in my virtual care via a figurative ‘basket on the doorstep’ (an e-mail), with an accompanying note suggesting I raise it out here in the public space. That being said, I have attempted to invoke the spirit of those ‘Three Men And A Baby’ of Hollywood comic legend (played by, as I recall, Ted Danson, Tom Selleck, and… that other guy), to love and nurture this idea as if it were my own. Still, I feel I must at this point send out an apology to the (real) biological ‘parent’ of the notion, an apology in advance if the idea doesn’t quite turn out how you intended it; I did my best.

Let’s crack on then. First, the title. If you’re anything like me, you probably read the blog title and thought, “Eh!?” And after that, you probably thought, “Mmmmm… scrambled eggs!”

But if you’re not like me, and you’re more like, say, an expert in etymology, or a human encyclopaedia, you may have instead said to yourself, “Ah yes; ‘System’, from the Greek systema, meaning organised whole, a whole compounded of parts or a set of correlated principles, facts, ideas, etc.”

You may have also then mused over the fact that Panarchy is a conceptual term first coined by Belgian philosopher, economist, and botanist Paul Emile de Puydt in 1860, referring to a specific form of governance (-archy) that would encompass (pan-) all others...

And then again, if you’re like me, you may have responded by saying, “Sure, but did somebody mention scrambled eggs, though?” If we treat ‘scrambled eggs’ as a metaphor in this case (sigh – I want eggs now!), we may wish to tackle this proposition: Can processes or systems be undone or reversed once they have been put in place? And if so, why would we wish to do this? 

If we interpret the above definition of Panarchy in its widest sense, we could say that the Universe or Existence itself is one (or perhaps One). We could perhaps identify the component systems and processes that function to make the Universe ‘work’,’ as Natural Rules or Laws. (An example of this would surely be Gravity.) If we were then to ask our question as to whether we could undo this system or law, I would expect the answer to be the same as that delivered from a stressed-out waitress during a busy breakfast service in response to a customer demand to have an order of eggs unscrambled in favour of having them poached… In short, “No chance. Scrambled or nothing!” And hey, let’s face it, if it’s a choice between Existence and its governing principles, or Absolute Nothingness… I would expect most people to settle for their eggs scrambled!

It seems wise to accept immutable systems which facilitate our existence as they are, then. But what about those systems that we have designed and implemented ourselves? In the realm of Science and Technology, it may be said that things are changing by the minute. It would, therefore, seem unlikely that any system we implement will not at some point become outdated or obsolete, due to an advancement in our understanding of the world and its ever fluctuating conditions. For example, advancements in the manner we are able to send and receive messages have left many carrier pigeons unemployed and bereft of purpose; forced into an itinerant lifestyle, wandering between train stations and town squares, as you may have seen for yourself.

Both the computer and the Internet have changed the way in which we process, store and disseminate information, as well as providing faster means of communication and commerce. Advancements in Medical Science have meantime fundamentally changed the methods and processes by which we receive treatment and care. Developments have also impacted our Legal Systems in relation to the question of when in our development we can be considered to be a Human Being.

It seems, then, there has been no end to the process of scrambling and then unscrambling of some sort of eggs (or at least throwing them in the bin and starting again) when it comes to the systems we use to govern ourselves individually and as a society. It may even be necessary to do this. Lance Gunderson and C.S.Holling, in their great little book Panarchy: Understanding Transformations in Systems of Humans and Nature for instance explain Panarchy, in the sense of a theory, as ‘the structure in which systems, including those of nature (e.g., forests) and of humans (e.g., capitalism), as well as combined human-natural systems (e.g., institutions that govern natural resource use such as the Forest Service), are interlinked in continual adaptive cycles of growth, accumulation, restructuring, and renewal… (with an) essential focus to rationalize the interplay between change and persistence, between the predictable and unpredictable.’

This interplay, between ‘change and persistence’, seems to be the key dynamic in our decision to implement or adopt a new system in place of the old, or where there was not one before. After all, a system is only good for as long as it is useful.

But there is also a case for perhaps avoiding adopting a knee-jerk reaction to change with the introduction of a new short-term strategy. David Suzuki has expressed concerns that, ‘Rapid population growth and technological innovation, combined with our lack of understanding about how the natural systems of which we are a part work, have created a mess… If we pollute the air, water and soil that keep us alive and well, and destroy the biodiversity that allows natural systems to function, no amount of money will save us.

I think this adds a new dimension to the topic of systems - and what we view as a “good” or “useful” one. The adoption of a system designed to make things better or faster in one aspect of our lives could have a detrimental impact to another sphere of our existence (may I turn your attention once again to those poor pigeons!). The use of fossil fuels and the impact on the environment may be one example of this; it could be argued that the recent global financial crisis is another. Therefore, it may be wise to consider, when we are thinking of creating any new system, as to how the manipulation of the component parts affects the organised whole and whether this would be a beneficial change.

In terms of the issue of ‘unscrambling eggs in a Panarchy’, therefore, it may be prudent every once in a while to consider whether instead of scrambling some eggs, an omelette may be the wiser choice? 

And I know what you are thinking now. Mmmmm. Some omelette!

Wednesday, 11 February 2015

On Both Sides Now

Sue McGuire takes a look at ‘the grass on the other side’

The other side of the fence is a place where you can learn a lot… even if you were the sort of person who didn’t know there even was a fence - or who thought they’d been pretty good at looking over it but who often found on the actual other side of it that it’s not just ‘there,’ it’s a lot bigger and denser than you thought it was!

I know this for a fact in my own case – as after about eighteen months of retirement from 23 years in Health and Social Care services I’ve been involved in supporting relations through three continuing health care assessments, none of which looked or felt anything like I thought they were supposed to look or feel when I worked; and believe me, I should have known what they were like.

What I am saying is that I thought I knew it all… but there is always more to learn, as there always is when you think you know it all. I’m willing to give the benefit of the doubt and believe that most local authorities, CCGs or Health Trusts aren’t deliberately trying to hide much. But I do think they are awful at making information as accessible as it really should be to the public. Try entering any local authority website and just finding out who the main people responsible for Safeguarding are, for instance - and you are likely to find yourself having to wend your way through several pages to get to a place where you can download some minutes of a committee or an annual report to find some actual names.

For contact details it’s even harder; the Wooden Spoon award has to go to Birmingham City Council, which you might almost believe had made a deliberate decision not to reveal any management names below the Chief Executive – unless it’s the courageous people responsible for the library service. Grr Come on people; if you want to be paid to be responsible for something as important as Safeguarding, put your name on it! Gold award would go to Coventry who bravely publishes an easily accessible and fabulous list of all its senior managers with their job titles and salaries, which makes it a snap to spot immediately who has safeguarding in their title.

When I was a busy middle manager, I remember the air turning blue when a Freedom of Information (FOI) request came through and had to be added to my seeming never ending list of ‘Things to Do’. To be fair, many such requests did not feel like they were citizens trying to find out what they needed to know to negotiate a tricky system; many were from businesses really wanting to know what systems and products we used and thus who they should rugby-tackle to try to get a foothold for their own brands (or they were from researchers for MPs or political parties wanting to ask awkward questions to score points).

The thing is, now I have found a use for ‘Freedom of Information’ information and bless their cotton socks, our fellow citizens who have been beavering away at getting information suddenly seem very useful. Specifically, I have been trying to gather a list of safeguarding lead names for the West Midlands but the varying quality of local authority, heath trust and CCG websites means that while some have excellent information almost immediately discoverable by very simple searches, others are like searching for the proverbial needle in the vast haystack. Luckily, great website called 'Whatdotheyknow' as come in very handy for my purposes; if I want to know it, you can bet someone else wanted to know it before me. WhatDoTheyKnow is run and maintained by UK Citizens Online Democracy, a group that wants to help enable people to frame their FOI requests in a brief note and then they send the request to the relevant public authorities.

And it’s a job it is doing very well, let me tell you; plus, any response received is automatically published on the website for all to find and read. So I recommend you have a go yourself - go onto the Whatdotheyknow website and type in a search for Safeguarding. You will immediately see how many requests begin with a desire to know who the responsible person for Safeguarding is. The website makes the requests and the answers as accessible as they really ought to be.

A lack of consistency between councils in respect of naming senior managers is not really excusable and likely to be just another thing that feeds anxiety and distrust. This I can see, now I am on ‘the other side of the fence;’ maybe if it was all easily accessible some busy middle manager might not have one more thing to add to their list…?

Monday, 2 February 2015

A Quiet Place Retreat

Penny Moon describes the process of developing a bespoke personal reflective experience 

“Who we are looking for is who is looking.” - St. Francis of Assisi 

A little light bulb moment dawned for me recently that led me to develop a new programme - a personal retreat with Mindfulness and Reflective Practice as key. I knew as soon as I had the idea that it would have to be on a one to one basis and would have to be able to give people some time to practice being as well as offering them some space to:

• Create space in their lives
• Rest in a warm, safe environment
• Get nurtured body and soul
• Clear their minds
• Consider their options
• and get to ‘re-member’ their true Selves.

It also would have to be more than a ‘pamper’ day or marching over hill and dale - which are relevant, but not what my light bulb told me was needed: something different, fed from ancient practices where retreat is considered essential for the development of the soul. I also knew I wanted to give a taste of this wonderful experience in a secular way.

I was very pleased with my vision – then realised that is exactly what A Quiet Place does.....! Silly me. Very much aware that this kind of thinking is not everyone’s cup of tea, I also wanted it to be adaptable across the board for corporate executives as well as those simply needing a break. Conscious that some people may feel a little anticipatory concern of imagined inner religious undertones or personal secrets to be let out with such retreats, so I needed to be able to allay any fears and create a set of menu options to build a great bespoke day.

 Developing this experience was an interesting opportunity for me to wander memory paths of my own reflective practice through a variety of gateways that I have explored over the years. I am personally interested in the spiritual path and have had the great good fortune to meet a variety of extraordinary teachers along the way, incidentally; I don’t mean the popular ones on the Internet, either but from times pre the modern global ‘self-development industry.’

1. The process, then, meant finding an appropriate place, having a pre-meeting to decide an order of the day with some sort of feedback session after about 3 weeks.

2. The content I had fun developing; so many possibilities! I had an image of a beautiful winding river, gentle today but with some adventures to tell and a few places to rest, have delicious picnics as well as explore with the companion… i.e. one’s self.

Questions this process raised for me:

• When do we ever spend seven hours on our own with another human being nowadays, except for family?
• Might it all be too intense?
• What can we do that would fulfill the bee… ness I had imagined as well as being of practical use to apply in the real world?

Might it be seen as self-indulgent - and whilst that may be OK not sure if people would be given time off work for this! To help me answer these questions, I prepared a timetable that would start with a holistic well-being audit (a series of questions I have devised to look at different issues which range from physical, emotional and intellectual to spiritual and creativity). This informal conversation produces a complementary agreed prescription with Top Tips, as well as providing clues as to what direction the rest of the day might take. Additionally, it informs the deep relaxation and guided visualisation I saw as a key component of the day.

To my delight and pleasure it worked well! I have played with the idea over 6 separate days - each person unique. The venue has been the extraordinary  in the conservatory (see this great pic of the wonderfully misty view from it first thing).

An ex-chef friend of mine made wonderful food for lunch and we wandered a little in the grounds.

The flow of the day worked well and finishing off for coffee and cake at the in Parkgate to watch the sunset over the Welsh Hills was just right. What else could we ask for… and of course we worked very, very, very hard!