The West Front of Wells Cathedral in. Somerset is an eloquent surviving sculptural representation of this. The three square towers were not built until a later and ...
The Architecture of Healing and Health Collaboration and Competition in the English NHS Nick Leggett1
The 2013 Dispensation This early (2013) government infographic of the new English National Health Service (NHSE) brings to mind the phrase, ‘Lonely Planets.’ The names of the individual NHS planets depicted here may be hard to read, but in the whole cosmogram there is a sense of disconnection, if not of vacuum. Now, in the autumn of 2016, some of the orbiting
2 planets in the infographic have changed name and/or function, but NHSE has remained a vastly complex constellation, replete with contrary and antithetical gravitational forces. The 2013/14 reforms built on prior developments since the start of the new millennium to create an elaborate, Byzantine, hybridised quasi-market. The experiment displayed breathtaking ambition. It aspired to contain spiralling costs, whilst delivering excellent, joined-up health and social care. Here is an alternative representation of NHSE, produced by the King’s Fund at about the same time:
As with the first pictogram, you will find it hard to read all the labels, but this does not matter for the purposes of this analysis, which concerns itself with the kinds of message each representation seems to have been intended to convey. The Department of Health cosmogram can be described by a Sanskrit word, maṇḍala, which has entered our language as ‘mandala.’ The notion of a mandala was probably made most famous by the psychoanalyst, Carl Jung, but here it will be kept as the transliterated, diacritically-marked, Sanskrit term, because it is being deployed in a way closer to ancient Eastern ontology than to Western psychology.2 Ancient Indic maṇḍalas always have a ‘Central’ (or ‘Organising’) ‘Principle,’ which unifies, energises, and makes coherence out of the concept or entity they express. This Central Principle, logically enough, is most often depicted at the centre, in diagrams, paintings, or drawings of maṇḍalas. The Department of Health placed “People and Communities” at the centre of their 2013 cosmos. They perhaps wanted to reflect their contemporaneous slogan, ‘Putting the Patient First.’
3 The King’s Fund representation is not in any obvious, recognisable sense a maṇḍala. It might better be described as a hierarchy, which employs a plumbing metaphor. At the top of this hierarchy, (the place of power in any hierarchical depiction), we find ‘Borrowing’ and ‘Tax.’ The income from this revenue wellhead streams down, via the English government and the NHS, through rickety pipes. Additional quasi-governmental entities, such as ‘NICE,’ ‘NIHR,’ and ‘HEE,’ are not even plumbed in. ‘People and Patients’ are stationed at the bottom of this King’s Fund hierarchy; trickledown and powerlessness would seem to be implied. Even though the ‘people’ presumably have provided the tax revenue at the top of the pictogram, they appear only beneath. Where the Department of Health cosmographic maṇḍala looks celestial, the King’s Fund hierarchy expresses a more chaotic and pessimistic view of the new reform. At its most simple and unelaborated, all that is required for an ancient Indic maṇḍala, besides its Central Principle, is a ‘Boundary.’ Most people tend to imagine these maṇḍalas as colourful, circular representations, like this one:
But, in ancient Indic thought, any animate or inanimate entity could also be imagined as a maṇḍala. So, the human body can be described as a maṇḍala. The Central Principle of the human body may be understood as the heart. The heart directly affects, controls and
4 modulates the rest of the physiological maṇḍala, the living body, and it does so through blood vessels. Or, the Central Principle might be viewed as the mind or brain. The Department of Health depiction puts the public, communities, and, by implication, patients, at the ‘heart’ of its new dispensation. But, in that diagram, by what linkage did commands and other energy flow from ‘the public and communities’ to all the ‘lonely planets’ in the NHS cosmos? And was the public, positioned at the heart of that maṇḍala, active and controlling, or passive and controlled? Were citizens really the Central Principle? Or was this political spin? What was the Central Principle of the UK Coalition government in 2013? The Conservative Party and the Liberal Democrat Party, the Coalition partners, can also, each separately, be imagined as maṇḍalas, but they exhibit rather different Central Principles. To find a shared Central Principle for the Coalition, a Venn Diagram might assist:
Conservative→
←Lib Dem
One overlap between the two parties was an idea which had also been evident in the predecessor Labour (‘New Labour’) governments – that citizens should be encouraged to be active, responsive, and responsible partners in a democratic community. ‘Rights should be balanced by Responsibilities,’ the rhetoric ran (and still runs). If we move back to imagining a single circle to express the Coalition maṇḍala, its Central Principle could thus be said to have been ‘Democratic Participation’ or ‘Responsible Citizenship.’ In some - but certainly not all - ways, this Central Principle reflected the theories of ‘New Public Management’ (NPM). Developed in the second half of the last century, NPM aimed to bring good business practice to public administration: NPM... focuses on citizens as sophisticated clients in complex environments. Relying heavily on private sector management, citizens ...are perceived ...as clients with multiple alternatives for consuming high-level services. Public authorities must treat the public well, not only because of their presumed administrative responsibility for quality... but also because of their obligation to democratic rules, accountability demands, and transparency criteria, and sometimes even because of their fear of losing clients in an increasingly competitive businesslike arena. Hence, NPM opposes the more classical approach to governance and public administration, that used to see citizens as simple constituents or voters. 3
5 The public are only at the centre of this NPM model, in the sense that they are consumers who want an effective, high quality service. In maṇḍala terms, the Central Principle is not the public consumer, but rather cost-efficiency or even cost-reduction. The result of NPM, as Vigoda and Golombiewski proposed in 2001, could be a degree of public passivity: NPM has taken the lead in the study... of public systems, highlighting the main direction of flow of responsibilities: the commitment and obligation of public institutions to citizens as passive clients. ...The idealized relationship between citizens and governments has been described more in terms of a unidirectional treaty rather than the bidirectional relationship, consistent with representative democracy. Administrators are encouraged to assume greater responsibility toward citizens, whereas citizens’ participation and involvement in the administrative process is perceived by politicians and by public servants as problematic. 4
Vigoda and Golombiewski recommended some modest measures to enable more active public involvement. The underlying philosophical idea in NPM, even if it is reformed along these lines, seems most strongly to reflect a limited understanding of the philosophy of American Pragmatism, particularly the ideas of Charles Peirce (1839-1914) and John Dewey (1859-1952). Although Dewey started out with a strong affiliation to G W F Hegel (1770-1831), his mature philosophy envisioned society more as a harmony than as a Hegelian dialectic: A society is a number of people held together because they are working along common lines, in a common spirit, with reference to common aims. The common needs and aims demand a growing interchange of thought and growing unity of sympathetic feeling.5
Dewey, like Vigoda and Golombiewski, was concerned with the passivity of citizens in the face of modern technology, but he moved increasingly towards the ideas of Charles Peirce, about active communal debate and engagement in social reform. Citizens in the King’s Fund hierarchy appear anything but active and engaged. They cluster together beneath the plumbing. They are colourfully dressed, whereas the government figures on high wear black and white formal attire. Three flags are attached to citizens: “People,”; “You”; and “Me.” We, (“you” and “me”) are bidden to identify with this “people” (proletariat?) at the bottom. Is this a graphic of Top Dogs and Underdogs? The politicians at the top are apparently not ‘people,’ and certainly not ‘you’ or ‘I’? They are colourless, monochrome, stiff and starchy, by deliberate contrast with the colourful proles. Where the Department of Health’s NPM-oriented, centrist, architectural cosmogram brings Dewey and Peirce to mind, the King’s Fund hierarchy summons up Karl Marx (1818-1883) and his successors, or Michel Foucault (1926-1984).
6 The sense of public powerlessness is exacerbated by the use of a hierarchy. Citizens elect the government, but this is not shown. There is a characteristically Marxist sense of bosses and workers, oppressors and oppressed. Michel Foucault springs to mind, because of his philosophical ‘archaeology’ of the power relation in the institutions of society, here particularly its medical institutions. In La
Naissance de la Clinique, he traced the nineteenth century language and ethos of healthcare back to the pre-revolutionary French Church. French clinicians came to be viewed, and to act, much as priests had, before the Revolution.6 In the earliest Middle Ages, the Neo-Platonist, Pseudo-Dionysius (floreat late fifth to early sixth centuries CE), had lauded hierarchies, with God at the top, with angels on the next row, with saints on the next, with archbishops, bishops, rulers, and aristocracy a row below, and with lay people on succeeding levels. The West Front of Wells Cathedral in Somerset is an eloquent surviving sculptural representation of this. The three square towers were not built until a later and more Aristotelian part of the High Middle Ages. The original intention, drawn from the Neo-Platonism of the Twelfth Century Renaissance, can only be understood if the viewer imagines away the square towers. Then there is a clear hierarchy of statues through the Holy Trinity and up to God.
7 The King’s Fund pictogram abolished God, but expressed what others might have believed to be government for the people, and by the people, as a hierarchical dialectic of haves and have-nots, separated by impenetrable and imponderable bureaucratic plumbing. Both the King’s Fund hierarchy and the Department of Health maṇḍala were rhetorical. They proceeded from philosophical positions which, at least in some senses, are polemically opposed, one to the other. There was also a difference in tone or flavour. The Department of Health maṇḍala aimed to imply proactivity, where the King’s Fund hierarchy was satirically reactive to the reform. Satire, publicly anyway, is always unidirectional, from the people toward the rulers. Satire aims to subvert, by humour. It is most often a weapon of the oppressed, or those in the media who purport to advocate on their behalf. Each representation, then, has clear flaws. The Department of Health ‘puts the patient first,’ but actually NPM and cost-effectiveness appear to have been more central to its real concerns. The King’s Fund response, whilst compassionate, created an ‘us and them’ dialectic, and depicted democratic citizens as helpless. The maṇḍala of the human body has skin as its Boundary. The maṇḍala of a pebble has its outer surfaces as its Boundary. This Boundary is the place where a maṇḍala interacts with other maṇḍalas: where the body or pebble interact with an external environment. In the Department of Health cosmogram, the Boundary is occupied by the “Department of Health” and “Other Government Departments.” The designer of this representation was probably unaware of ancient Indic Maṇḍala Principle. But some purpose seems to have been present, in making the Department of Health peripheral in the pictogram, whilst the public and communities were made central. Did this reflect a desire, consistently displayed by UK governments in recent decades, to place state services at arms’ length from politicians? The NHS is a much-vaunted government flagship when it is going well, but it becomes a ‘toxic brand,’ whenever performance indicators dip, or periodic scandals erupt. Maṇḍalas are in one way very different from hierarchies. Yet, ancient Indic societies were manifestly hierarchical. And, in a hierarchical pyramid made of, say, soft modelling clay, if one pressed downward with force from above, the pyramid would squash flat into something like a maṇḍala: what had been the top of the hierarchy/pyramid would be at the centre of that flat maṇḍala. If one drew out the English NHS within a pyramidal government hierarchy, parliament or the monarch might be at the top, followed, on successive levels, by the Department of Health, NHS England, and all the other agencies in the NHS. The people and their elected representatives would thus indeed be at the top, but the Department of Health would not be at the bottom of that pyramid. If the pyramid were squashed flat, the people might end up as central, but the Department of Health would not be peripheral. Whether in hierarchies or maṇḍalas, it is very strange to place the Department of Health at the bottom, or on the outside. It almost feels as if the Department of Health, and thus
8 the government, did not want to take full responsibility for NHS England. Perish the thought! Hierarchies in general reflect a seeming truth, which is uncomfortable to some libertarian or anarchical modern thinking – that, in organisations and societies, some degree of vertical structuration is required, in order for matters to be dealt with in a timely way. How far hierarchy is needed, depends on the nature and urgency of the task. In the emergency department at an acute hospital, as a team gathers around a critically ill patient, somebody needs to be in charge. In wartime or civil emergency, action needs to be rapid and this will require a command structure, which will be hierarchical. Even a family, in some aspects, has to be a hierarchy. Whole typologies of leadership have been developed to address this. With more complex tasks (so-called ‘wicked problems’), where there is no ‘off the peg’ solution, it is argued that hierarchical command structures are less effective or relevant.7 Where does the English NHS fit, in this continuum of leadership style? Arguably, there are urgent command issues in NHSE which require hierarchy, as well as more ‘insoluble’ problems where collaboration and networking is more helpful. Is a constellation of orbiting planets fit for every kind of purpose which NHSE has? Can the Secretary of State for Health achieve the complete range of the government’s strategic intentions, via the architecture created a few years ago? Does the Chief Executive of NHS England hold sufficient levers of power to ensure that the will of the Board of NHS England can be translated expeditiously into action on the ground, where expeditious and decisive action is necessary? Was the NHS England ‘Five Year Plan’ ever fully viable, given its vehicle, the new structure and architecture of the NHS? Would the Chief Executive of any very large commercial business ever design the NHSE style of organisational architecture – or has it just grown up over time in a rather characteristically English way, as a set of compromises, and a set of checks and balances? Can such an elaborate and peculiar set of organisational arrangements be efficient and effective? Is NHSE an organisation designed to make things happen in a timely way, or is it a bureaucracy whose greatest use to governments is its capacity to dissipate and distribute blame toward any number of semi-detached and devolved sub-entities, sub-maṇḍalas, orbiting in an interstellar and intergalactic vacuum called NHS England? A classical maṇḍala has further Aspects: its ‘Structural Body,’ and the ‘Bonds of Connection’ within the Structural Body. Returning to the analogy of human physiology, in a human body there are mechanisms by which the Central, energising Principle connects with all its ‘components.’ Flows of energy move along the Bonds of Connection. The skin receives messages from its environment, which are translated to the brain and heart; the brain and heart communicate with and, in some sense, enable or underpin the functioning of the skin. And then, there are arteries, blood vessels and nerves – and this illustrates a further Aspect of Maṇḍala Principle, the Aspect termed ‘Energy Exchange,’ which occurs within and between maṇḍalas.
9 Maṇḍalas contain sub-maṇḍalas and operate within supra-maṇḍalas. There is a maṇḍala of the body, but the body contains organs and systems, each of which themselves can be understood as a maṇḍala, with its own Central or organising Principle, its own Bonds of Connection, and its own Energy Exchange – the kidneys, the liver, the nervous system, the circulatory system and so on. We can takes this right down to cellular level, molecular level, atomic level, and sub-atomic level, though not all Aspects of Maṇḍala Principle are present in less elaborate and more simple forms. So the English National Health Service maṇḍala does indeed contain all the entities listed on both the King’s Fund and the 2013 Department of Health pictograms – these sub-maṇḍalas include NHS England, Public Health England (PHE), the National Institute for Health and Care Excellence (NIHCE), the National Institute for Health Research (NIHR), Health Education England (HEE), NHS Citizen, NHS Improve, the Care Quality Commission (CQC), the Academic Health Science Networks (AHSNs), Healthwatch England, the clinical commissioning groups (CCGs), the hospitals, the ambulance services, and so on. Each of these sub-maṇḍalas of the English NHS contains a set of further organisational sub-maṇḍalas. This is rather like Russian Dolls, taken to infinity; and there are also links from Maṇḍala Principle to modern cybernetics, or systems theories. The Department of Health 2013 Structural Body, represented by a cosmogram, drew no Bonds of Connection between its orbiting sub-maṇḍalas. Many professionals in the new NHSE found themselves uncertain, for a considerable time, about the Bonds of Connection in their Structural Body. How should they relate to former colleagues and friends, who had now migrated to distant planets? The AHSNs, to take just one example, took a considerable time even to receive their licenses, and when the licenses were in place, the AHSNs ended up operating in a set of idiosyncratic and almost incommensurable ways. Given that AHSNs were originally conceived as a key catalytic tool to prompt rapid innovation at scale, the initial and huge cut in the budgets originally planned for them, and the lack of specificity in their licenses, arguably exemplified a degree of hasty and muddled thinking in government, at a critical early stage in the implementation of new legislation. Herman Hesse wrote a book called Strange News from
Another Star. There was much ‘strange news’ and tangled communication in the new NHSE constellation. Energy Exchange becomes difficult or impossible, where Bonds of Connection have not been established within a Structural Body. The strategic health authorities (SHAs) in the pre-2013 NHS system had been the subject of internal animus: they were sometimes regarded as bullies. But now, in 2013/14, the new NHS lonely planets found themselves curiously disconnected, one from another, rather free-floating and rudderless. The legislative framework had had a troubled passage through parliament. In the process, Andrew Lansley, its original architect, had been jettisoned. Complex compromises had been hammered out in committee rooms, between the Coalition partners. The final result was some distance from the original Green (consultation) Paper. In practice, to those who had to implement it on the ground, it
10 sometimes felt like a structure sketched on the back of an envelope. There were more questions than answers. Yet this structure was tasked with delivering epic efficiency savings within a tight timescale, whilst at the same time ‘putting the patient first’ - which most often translated as ‘keeping the public on board.’ If you had wanted to get a great deal of work done well, in a hurry, do you think this new architecture would have been fit for purpose? At the nub of the areas of difference between the Department of Health and King’s Fund pictograms, lay a philosophical divide, a political divide, and a pragmatic divide. Free enterprise or state provision? Competition or collaboration? Individualism or statism? ‘Fiscal responsibility’ or ‘mission creep’? Was the NHS a socialistic mechanism to remedy disadvantage, deficit and ill health, or was it an engine to promote choice, independence, responsibility and resilience? The last paragraph could be argued to have exaggerated the polarities, but readers will recognise characteristics of a continuing healthcare debate, reflected by the opposed 2013 pictograms. What kind of tasks does NHS England face – command tasks or consensus tasks? Is the architecture of NHS England fit for these purposes? Most fundamentally, are we competitive or collaborative beings?
11
Competition and Collaboration: Anthropology and Biology
12 Are we human beings ‘naturally’ competitive, collaborative, or both? Agustin Fuentes’ took two first degrees at the University of California, Berkeley - in zoology and anthropology; his PhD at Berkeley was in anthropology; and he is now Professor of Anthropology at the University of Notre Dame. Fuentes is the author of several major books and numerous articles. The 2009 work, from which the table on the preceding page was derived, reviews the evolution of human behaviour. Early in it, Fuentes assessed the contributions to his chosen field of Charles Darwin (1809-1882), Alfred Russell Wallace (1823-1913) and Herbert Spencer (1820-1903), whose views, taken together, have had a lasting effect on the popular and even academic imagination: ...Darwin... went so far as to partially suggest that human groups competing with one another can produce higher levels of cognitive function and thus greater social complexity in the more “fit” group...8 Wallace proposed that intergroup, or inter “tribe” competition acted to enhance the moral and mental qualities of the more “fit” groups, which over time resulted in the modern behavioral forms.9 Spencer saw the individual expression of altruism as having a selfish motivation. As humans relate to the misery of others (sympathetic response) we act to alleviate others’ suffering in order to avoid our own. Spencer also eventually allowed for a form of altruism that can arise through a series of reciprocally beneficial acts... However, Spencer did also agree with both Darwin and Wallace that community or family altruism could arise as behavior within the close group or family and could be widely beneficial. In a sense, Spencer argued that this final type of altruism could arise, much in the way envisaged by Darwin and Wallace, via competition between groups...10
Toward the end of considering most of the current evidence for the evolution of behaviour, Fuentes wrote: Nearly all [studies] see some form of cooperation as central to human behavioral evolution... There is little or no debate that within-group cooperation has been an important component in human evolution.11 Competition with other human groups, which as an environmental factor shows up in just under a third of the hypotheses, is in line with the common assumptions about competition between groups in our species... Again, however, the actual data are quite limited and this prevalence may reflect societal and paradigmatic assumptions.12 I think it is likely that human ancestors and humans throughout time participate(d) in defense... of core areas within their ranges, when needed. However, was there sufficient resources-stress in the typical early human environment to lead to significant competition and therefore conflict between groups as a normative state? Is it also possible that one way in
13 which humans, unlike most other organisms, dealt with ecological challenges was to cooperate between certain groups? ... My position is that it is the human potential for both conflict and cooperation in complex and innovative ways (relative to other organisms) that has played a major role in human behavioural evolution, not just that conflict (competition) is the main driver of behavioral systems.13
When Fuentes states that “the actual data” [for competition] “are quite limited and this prevalence” [of competition studies] “may reflect social and paradigmatic assumptions,” he is referring back to the majority modern view of natural selection, derived from Darwin, Wallace and Spencer among others. This set of ideologies went wider than anthropology and biology. The consensus view about why Wells Cathedral was created when it was, in the twelfth and thirteenth centuries, and why it was designed with certain unique features such as its West Front, is that it was generated by intense rivalry and competition with ecclesiastical institutions at nearby Glastonbury and Bath. This theory had its origin in the late nineteenth and early twentieth century, when nationalism and great power rivalry were in overdrive across Europe – leading eventually to two world wars. There is quite as much evidence for collaboration between Bath, Wells and Glastonbury as there is evidence for competition, but strong conservative historiographic forces continue to prefer competition arguments to collaboration arguments. Walter Goldschmidt (1913-2010) was the long-time Professor of Anthropology at the University of California Los Angeles. His final book, The Bridge to Humanity – How
Affect Hunger Trumps the Selfish Gene, published in 2006, also surveyed these issues of competition and collaboration, throughout evolutionary history. Starting with biology and zoology, he commented: Consistent mutual interaction among conspecifics – social life – runs throughout the animal world. Students of evolution like to emphasize the competitive aspect of animal behavior – the survival of the fittest – and play down the role of affinity in the daily lives of living things. Competition is important but mutuality is equally so. Mushrooms are formed by millions of separate individually viable spores, single-cell bits of life, each of which is capable of reproduction but all “collaborating” to form towers that give a greater chance for the reproductive success of their common genome....Disengaged from reproduction, each rankand-file ant, termite, or bee has no competitive urge via-à-vis one another – only against rival hives. Mammalian society is built on parenting. Central to this parenting are the affective ties between their parents and their offspring.14
Toward the end of his book, he wrote: The duality between the fierce and the sweet is essential to our species; it is the cross we must bear for the privilege of being human. It is the work of culture to maintain the balance between them.15
14 Human society depends on individual human beings being motivated to act on their own and in their own interest, but at the same time its effectiveness depends on their commitment to the social order to which they belong ...This is the inescapable duality of the human world: the physical world of animal motives and self interest and the symbolic world of cultural values and other-interest.16
The evidence from Fuentes, Goldschmidt and other recent anthropological and biological studies would appear to apply a corrective to nineteenth and early twentieth century studies, in which natural selection and competition were seen as by far the most powerful drivers in evolutionary psychology. Collaboration and cooperation now appear to have been significant, as well. This fits typologies of organisational issue and leadership style. Context is all important. Certain challenges and situations require competition; others necessitate collaboration.
15
Competition and Collaboration: Cross-Cultural Comparators
Competition and collaboration have become something of an ‘either-or’ in western societies, with politicians and media competitively favouring one or the other. When Scott Lash, Professor of Sociology and Cultural Studies at Goldsmiths, University of London, wrote, “Western democracy, with its moralism and utilitarianism, has its shortcomings,”17 he implied more than political thought. He was considering what might be termed ‘metaphilosophy,’ the underlying structures of the ways we think and reason. Professor Lash had a particular interest in the work of the French philosopher, Hellenist and sinologist, Professor François Jullien, one of the world’s most translated contemporary thinkers. Jullien’s knowledge of both ancient Greek and Chinese cultures makes him uniquely well-placed to compare their two philosophical traditions. At a time when China has become massively influential in the world economy, Jullien’s work has particular resonance. Jullien has commented: One intuition at the core of Chinese thought is the concept that everything that actualizes itself through opposition always latently contains its opposite, so that opposites, by remaining linked, alternate between themselves...
18
Applied to competition and collaboration this would suggest that collaboration latently contains competition, and vice versa. Each would be the dark side of the other’s moon. “The objective of the Confucian remark,” said Jullien, “is not truth, which is why it cannot be developed dialectically...”
19
This is unfamiliar territory for the Anglo-American
logical tradition. Jullien wrote: ...Confucius tries to maintain a delicate equilibrium between surplus and deficit, which is entirely determined by the situation: regulation is based not on a preestablished principle that transcends the course of events but on a purely indicative relationship whose coherence is immanent (that of the Chinese word li, as opposed to logos as reason).20
And again: ...Confucius does not pose the problem of definition because he is not seeking to extract a stable – and therefore ideal – entity, separable from becoming: he does not inquire into the essence of things because he conceives of the real not in terms of being (as opposed to becoming) but as a process (whose nature is to be regulated).21
So Jullien proposed that Chinese thought is “indicative” rather than definitive or decisive; it nods towards (indicates) rather than pins down; it inflects; and it expresses itself through metaphor and allusion.22 Scott Lash commented:
16
Chinese thought... devalues predication on all sides. It... does not start from the ontological question of ‘What is this?’ There is no obsessive will to truth. There is no word for substance in Chinese. Substance in the sense of ‘standing under’... is fundamentally about cause. There is no idea of this sort of cause at the heart of things in Chinese... Instead, a thing, a dongxi ( 東西 ), which is ‘east-west,’ is already a relation, a polarity... The dongxi is neither-nor. It is a polarity. It is relational. It is outside, at the same time as possibly in between...23
There is a saying in Japanese Zen Buddhism, “A step to the east is a step to the west,” which feels counterintuitive, if not irrational, in Anglo-American logic - based as it is on Aristotle’s Principle of Non-Contradiction. It is a bit like saying: “To compete is to collaborate; and; to collaborate is to compete.” It feels like nonsense, but whilst in one sense it is nonsense, in another it may reflect a dialectical interconnection between the two words and their linked concepts.
17
Competition and Collaboration: Commerce and Industry
Etymologically, ‘collaboration’ is the Latin ‘ cum’ (con-) which means ‘with’ or ‘alongside’ and labor-āre, which means ‘to work.’ Collaboration is ‘working alongside’ (others). A little speculatively, it is perhaps possible to press labor-āre back a little further: there may be an etymological link between labor (‘work’) and labrum, (‘lip’). Shared work is shared speech. Etymologically, ‘competition’ is also a joint venture – hence the ‘com-’ (Latin cum) of com-petition. But here, people do not ‘speak’ alongside others, they ‘seek’ alongside others. The Latin verb peto-ire means ‘to seek’ or ‘to strive.’ ‘Others’ are implied in both collaboration and competition. We compete with others. We collaboarate with others. One may inflect toward the differences, as between competition and collaboration, (speaking and seeking), or one may lean toward their common feature, their shared ‘withness.’ Put another way, these terms can be viewed as polar opposites, as either-or, or they can be construed as variable and movable points along a continuum of ‘with-other-ness.’ So, in this continuum concept, ‘competition’ and ‘collaboration’ are mobile along the continuum, rather than fixed. In the most extreme configuration, that of war and peace, competition and collaboration do appear as opposite (if linked) polarities. But, in most workaday situations, they each move nearer the centre of the continuum, depending on particular exigencies. This latter scenario is precisely the case in the world of commerce and industry, which NPM attempted to build in to public services: As long as collaboration and competition are viewed as a one-dimensional dichotomy, their respective emphases on maximizing either the integrative or the distributive efforts in strategic alliances tend to cloud the important fact that both the integrative and distributive dimensions exist simultaneously in all organizational interaction.24
Commercial enterprises regularly network, or engage in dyadic collaboration, to enable knowledge exchange, and to facilitate joint projects, which they cannot do alone. Yes, there are competitive risks in knowledge exchange and joint work, but there are equal or greater risks in trying to plough a lonely furrow: The more mutually transferred knowledge, the more opportunities to generate new knowledge through combining different pieces of existing knowledge.25 ...collaboration enables firms to develop difficult-to-imitate organizational capabilities through the transmission or sharing of resources... From this perspective, collaboration is a critical source of competitive advantage.26
18 We define constellations as a group of firms that interact directly and reciprocally to coordinate their efforts for a complex service or product during a finite period of time, which may last from several weeks to several years.... Constellations are a solution for creating complex tasks under intense time pressure, in environments with high uncertainty that inhibits integration of required resources...27
Collaboration has particular advantage in health and social care: As a society, we rely on the differential strengths of the for-profit, public, and nonprofit sectors to overcome the weaknesses or failures of the other sectors and to contribute to the creation of public value.
28
The network governance literature suggests network forms may be particularly effective in tackling ‘wicked problems.’ The concept is taken from social planning... referring to problematic social situations where there is no obvious solution; many individuals and organisations are involved; there is disagreement amongst the stakeholders; and there are desired behavioural changes. Public policy problems are ‘wicked’ ...where they go beyond the scope of any one agency, (e.g. health promotion strategies), and intervention by one actor not aligned with other actors may be counter productive. They require a broad response, working across boundaries and engaging stakeholders and citizens in policy making and implementation...29
The English NHS crucially needs to innovate, in order to make better use resources. Networks and collaboration are essential here – and this understanding derives not from Marxist ideology but from business studies: Under the conditions of fast technological change, networks, not firms, have become the actual operating unit...30 ... the locus of innovation is no longer the individual or the firm but, increasingly, the network in which a firm is embedded... ...While the biotech industry illustrates the importance of networking for innovation, the review highlights the need to network when seeking to innovate as a prerequisite across the majority of sectors... ...Gemser et al. (1996), for example, demonstrate the impact of networking in the global pharmaceutical industry, the US computer industry and the Italian furniture industry. They demonstrate that the annual growth rate of 18% in the pharmaceutical industry was largely linked to networked research and development.31 What is important in the location of advanced services is the micro-network of the high-level decision-making process, based on face-to-face relationships, linked to a macro-network of decision implementation, which is based on electronic communication networks. In other words, meeting face to face to make financial or political deals is still indispensable, particularly when discussions must proceed with absolute discretion in the case of decisions
19 that provide a competitive edge... The key innovation and decision-making processes take place in face-to-face contacts, and they still required a shared space of places, well-connected through its articulation to the space of flows...32
Bonds of Connection allow Energy Exchange within the Structural Body of the NHSE maṇḍala. The NHSE sub-maṇḍalas, (for example, hospital trusts), can still compete for custom with one another, or with independent sector treatment centres. There can still be a separation between purchaser sub-maṇḍalas and provider sub-maṇḍalas. But, where there are shared interests, it is crucial that there are mechanisms like AHSNs to broker, foster, and catalyse collaborations. Networks are quite as important in private enterprise as they are in the state sector. A right-of-centre, or centrist, government need not fear collaborations and networks. Competition and collaboration are complementary, one with the other. In some senses, it can even be proposed that competition and collaboration are dialectically intertwined, feeding off and catalysing one another. Arguably, the 2013 NHSE architecture over-egged competition and under-resourced collaboration. These complementary modes of human and business behaviour – competition and collaboration – may now need to be rebalanced in NHSE, in order far more ambitiously to energise grass roots innovation within the system.
20
Competition and Collaboration: Quasimarkets
Hybrid quasimarkets such as NHSE have arisen from impulses to collaborate, and yet to engender the kinds of efficiency engendered by competition: The welfare state has improved the quality of life of many people by granting them a basic guaranteed income, access to good health care and affordable housing. In the Western world, fewer people than ever starve in the streets. Their well-being has been successfully wrestled from the clutch of market forces. In recent times, though, policymakers and public managers have looked back at these market forces with some envy. The provision of public services has often proved wasteful and uncontrollable; quite different from markets, where competition supposedly weeds out the inefficient and keeps people on their toes. This is why recent decades have seen attempts to combine the benefits of both: public goods and services such as home care, education and social housing would be provided in a competitive market context, but one carefully controlled and regulated to avoid the return of inequalities. In these so-called ‘quasimarkets’, provision would be efficient and fair... ...The source of much confusion ...is the habit of looking at these new systems through the lens of old ones. It is not always recognised that quasimarkets are truly different from other types of provision. They are examined as though they are market or state, or both stapled together, when in fact they are neither: they are something new altogether. They combine elements from different systems...33
Networks and hierarchies combine within these quasimarkets: ...quasi-markets are by definition ‘mixed’ systems. There is of necessity an element of hierarchy in the state’s supervision... The welfare state character of quasi-market goods and services means that relationships with clients may be infused with elements of moral obligation and sympathy. Also, long histories in non-profit provision and a focus on local services are conducive to the development of social networks among the organisations involved. Such elements are not alien, but part of what a quasi-market essentially is: a hybrid form. An analysis should take account of these other mechanisms and motives, because it stands to reason that they will influence how providers (can) operate. 34
Hybrid quasimarkets like NHSE are sui generis, of their own kind, and not best studied as examples of collaboration or competition, pure and simple. In designing them, one must have competitive and collaborative elements. This is because they have social purposes which run beyond free market models, but that doesn’t mean that unbridled dirigiste statism is the best way to construct them, because that breeds complacent monopolist inefficiencies. The trick is to get the balance as near right as possible. Is the balance right in the NHS England quasimarket?
21
Public Action and Responsibility: The Missing Link
Competition and Collaboration need not be antithetical. Biologically, anthropologically, psychologically, metaphilosophically, philosophically, and throughout the world of commerce and industry, pragmatism favours their mutual complementarity. In a quasimarket, they are both necessary. Is the organisational architecture of NHSE an optimal design to enable this? Optimal both in its innovative cost-effectiveness and in the delivery of its social intentions? Maybe not entirely – and this, arguably, for two reasons:
Structurally, and in terms of resource allocation, the architecture undervalues (1) strategic leadership and (2) strategic collaboration. There are too few “Bonds of Connection” in its maṇḍala, and too few Structures of Command in its hierarchy. There needs to be a greater capacity for strategic direction and rapid action. Alongside this, far more resources require to be allocated to collaborative ventures between academia, commerce, industry, and healthcare – ventures such as the AHSNs, whose very considerable innovative potential has been undermined by unadventurous funding.
The architecture understates, undervalues, and under-resources public contribution, public potential, and public responsibility. Redesigning healthcare in England, at manageable cost, does not require a passive, grumbling public, of the kind engendered by current forms of public participation. It needs an active and enthusiastic public, prepared to consider cultural change. It is not that government needs to ‘put the patient first,’ or to station patients and the public pictorially at the centre of cosmetic cosmological propaganda. It is that the public, themselves, need to take responsibility, and to work with politicians and healthcare professionals, at a level of equality with them. Nobody needs to be first – or last – in this collaborative architecture.
Quasimarkets, we have noted, are sui generis. They cannot be judged solely as social provision, or only as the place for consumerism and raw market forces. If the public want a successful quasimarket – and they certainly appear to value the NHS – then public contribution to, and involvement with, health and healing almost certainly will need to take quite new forms. Neither politicians nor healthcare professionals can make the population healthier, on their own. They need citizens to be active in taking responsibility for their own health, wherever possible, and they need citizens, who are able to do so,
22 actively to support the running of the service in new ways. Those citizens who volunteer their skills, energy and time to assist, then need some measure of state recognition. This requires a new social contract.
Citizen
Healing Caring Healer
Patient
This is the maṇḍala of ‘Additive Cooperation’ in the English NHS. Its Central Principle, the middle triangle, is a process – the process of healing and caring. This is seen as requiring three complementary and contributory roles: those of Citizen, Healer and Patient. During our lives we move between some of these roles. The role of ‘Healer’ here is also the role of professional carer. Within this triangle are included not just frontline professionals, like doctors, nurses, and care assistants, but also health and care managers, ancillary workers, and health and care civil servants. The role of ‘Patient’ is largely self-evident, but can be expanded to the longer ‘Recipient of Health or Care.’ The role of ‘Citizen’ is taken to include at least all adults of voting age. It includes all politicians. ‘Cooperation’ is defined as ‘working-with and working-together,’ in the process of Healing. The process of healing and caring by the method of Additive Cooperation is more inclusive than architecture which contains (in both senses of the word) public ‘participation’ or ‘involvement,’ because Additive Cooperation includes those who heal,
23 and those who enable healthcare. In Additive Cooperation, the agents of healing – citizens, healers, patients - are all seen to be of equal value. Each agent has a different part to play, but all are equally necessary – and equally valuable – to the process. The roles of citizen and patient are about added value. They add something from outside, which healthcare organisations and professionals cannot, by definition, supply from within. This is the core meaning of Additive Cooperation in healing. It is not about being gracious, pragmatic, or wise enough to ‘involve’ the public and patients. It is about realising that the public and patients are equally valuable – and utterly necessary – partners in the healing and caring process. What might this mean in practice? The work of Jean Lave and Etienne Wenger addressed: ...all the everyday situations in which people coparticipate to a limited extent, thereby gaining access to modes of behaviour not otherwise available to them, eventually developing skill adequate to certain kinds of performance... spectators at any public event, faculty and students in a university setting, new friends..., patients being treated by doctors – all of these interactions initially involve limited, highly asymmetric forms of coparticipation. 35
Lave and Wenger considered what they called “situated learning” in “communities of practice.” Their ‘communities of practice’ were most often situations of apprenticeship, but their model comes close to describing the role of Cooperating Citizen in the NHSE quasimarket. Lave and Wenger understood social learning in this way: As an aspect of social practice, learning involves the whole person; it implies not only a relation to specific activities, but a relation to social communities – it implies becoming a full participant, a member, a kind of person. In this view, learning only partly – and often incidentally – implies becoming able to be involved in new activities, to perform new tasks and functions, to master new understandings. Activities, tasks, functions and understandings do not exist in isolation; they are part of broader systems of relations in which they have meaning. These systems of relations arise out of and are reproduced and developed within social communities, which are in part systems of relations among persons. The person is defined by, as well as defines, these relations. Learning thus implies becoming a different person with respect to the possibilities enabled by these systems of relations. To ignore this aspect of learning is to ignore the fact that learning involves the construction of identities. 36
“Learners,” they wrote, “inevitably participate in communities of practitioners. The mastery of knowledge and skill requires newcomers to move toward full participation in the sociocultural practices of a community.”
37
Appropriating Lave and Wenger’s notion of apprenticeship to the task of Cooperating Citizenship, the idea emerges that Cooperating Citizens are not those who need school
24 citizenship classes, and that citizenship is not a formal body of knowledge to be inculcated, but that citizenship is learnt by joining communities of practice. Charles Peirce, the American democratic pragmatist, saw the potential for this scientifically, in what he called ‘Communities of Enquiry:’ Charles Sanders Peirce originally conceived of pragmatism as a philosophy of science with inquiry at its center. To Peirce the scientific method unlocks or at least leverages the power of individualism as people work together to address problems. Science is distinguished from all other methods of inquiry by its cooperative or public character. 38
More recently, the English philosopher Simon Critchley commented: ...democracy does not exist. ...one must not restrict oneself to conceiving of democracy as an existent political form (and... certainly not as an apologetics for Western liberal democracy). Rather, one must begin to think of democracy as a task, or project, to be attempted.
Democracy does not exist; that is to say, starting from today, and every day, there is a responsibility to invent democracy, to extend the democratic franchise to all areas of public and private life.... To say that democracy does not exist is to say that democracy is always democracy to come... Democracy is an infinite task and an infinite responsibility directed towards the future...39
John Dewey wrote, long before: We now have to create by deliberate and determined endeavor the kind of democracy which in its origin one hundred and fifty years ago was largely the product of a fortunate combination of men and circumstances. We have lived for a long time on the heritage that came to us. ... The present state of the world is more than a reminder to us that we have now to put forth every energy of our own to prove worthy of our heritage. It is a challenge to do for the critical and complex conditions of today what [those] of an earlier day did for simpler conditions.40 The end of democracy is a radical end. For it is an end that has not been adequately realized in any country at any time. 41
There is already an often unsung army of citizens who volunteer in hospitals and care homes, who assist in the governance of NHS institutions, who join patient participation groups in primary care, and who assist with health research, but the scale and nature of this embryonic public movement requires substantial additional investment and complete rethinking. Additive Public Cooperation aims to be a cycle of activities operating across all areas of health and social care:
25
CoInitiate
CoResearch
CoDistribute
CoDesign
CoProduce
Characteristically now, the public and patients are consulted after decisions, at least in principle, have been formulated by professional civil servants. The lay public are not present when actions are first hatched. Yet many citizens have transferable skills, and could volunteer and assist, even at this strategic level. So, at one end of a public continuum, one has ‘patient leaders’ and other contributing citizens with high level skills, whilst at the other one has members of the public who assist in more modest but equally vital ways – and all are needed. But, in this model, proactive patients and citizens are mobile on the continuum of cooperation. Within communities of practice, public contributors develop their skills by apprenticeship, and by working alongside other members of the public who have developed these skills. They develop a notion of what it means to be a citizen contributor, by contributing alongside professionals, and other citizen contributors. In a new social contract, a new NHSE architecture, an innovative new hybrid quasimarket, Additive Public Cooperators need to up their game, at all levels of public contribution, so that NHSE can move from a place where some professionals involve citizens tokenistically and grudgingly, to keep this or that public body sweet, to a place where healthcare professionals recognise Additive Citizenship as its own profession. This moves the English Conservative idea of the Big Society to the ‘Great Society’ of John Dewey. It moves from a place of largely inexpert voluntarism accused – perhaps unfairly – of being primarily a strategy to reduce state expenditure, to a place of real and valued contribution, in which democratic responsibility is reinterpreted and reinvigorated. The professions, (most of them), have royal colleges – for example, the Royal College of General Practitioners (RCGP), the Royal College of Surgeons (RCS), and the Royal College of Nursing (RCN). A very large philanthropic endowment is now needed for a
26 completely new Royal College. This Royal College will place Public Contribution and active, responsible citizenship on the same footing as service delivery by professionals. It will develop standards, training, and research for democratic citizenship, across all areas of national endeavour – state services, yes, but also commerce and industry, where more public and lay involvement will increase public understanding, at the same time as widening the skills base and fostering creative innovation. The new royal college might have the acronym RCPAR – the Royal College for Public Action and Responsibility. The ‘PAR’ is significant. It’s all about parity of influence, effectiveness, usefulness, and esteem. Voting is never enough. In a new democracy, engaged, expert and active Citizens can take fuller responsibility for their own health and wellbeing, and can be co-equal contributors to democratic deliberation and social action.
27
References
Bernstein 1966: Richard J Bernstein John Dewey 1966 Brandsen [nd]: Taco Brandsen Quasi-Market Governance, an Anatomy of Innovation [nd] Bryson et al 2006: John M Bryson et al The Design and Implementation of Cross-Sector
Collaborations: Propositions from the Literature, Public Administration Review December 2006 Castells 2010: Manuel Castells The Rise of the Network Society, Second Edition 2010 Critchley 1992: Simon Critchley The Ethics of Deconstruction. Derrida and Levinas 1992 Di Domenico et al 2009: MariaLaura Di Domenico, Paul Tracey, and Helen Haugh The
Dialectic of Social Exchange: Theorizing Corporate – Social Enterprise Collaboration Organization Studies 2009 Ferlie et al 2010: Ewan Ferlie et al. 2010 Networks in Health Care: a Comparative Study
of their Management, Impact and Performance (HMSO) 2010 Foucault 2003: Michel Foucault (t. A M Sheridan) The Birth of the Clinic. An
Archaeology of Medical Perception, (Naissance de la Clinique 1963), 2003 Fuentes 2009: Agustín Fuentes Evolution of Human Behavior 2009 Goldschmidt 2006: Walter Goldschmidt The Bridge to Humanity – How Affect Hunger
Trumps the Selfish Gene 2006 Grint 2008: Keith Grint, Wicked Problems and Clumsy Solutions: the Role of
Leadership, Clinical Leader, Volume I Number II, December 2008 Grint 2010: Keith Grint Leadership: an Enemy of the People, The International Journal of Leadership in Public Services Volume 6 Issue 4 November 2010 Hickman 1998: Larry A Hickman (ed) Reading Dewey. Interpretations for a Postmodern
Generation 1998
28 Jones et al 1998: Candace Jones, William S Hesterly, Karin Fladmoe-Lindquist, and Stephen P Borgatti Professional Service Constellations: How Strategies and Capabilities
Influence Collaborative Stability and Change 1998 Jullien 2000: François Jullien (t Sophie Hawkes) Detour and Access. Strategies for
Meaning in China and Greece 2000 Larsson et al 1998: Rikard Larsson, Lars Bengtsson, Kristina Henriksson and Judith Sparks
The Interorganizational Learning Dilemma: Collective Knowledge Development in Strategic Alliances, Organization Science vol 9 no 3 1998 Lash 2010: Scott Lash Intensive Culture. Social Theory, Religion and Contemporary
Capitalism 2010 Lave and Wenger 1991: Jean Lave and Etienne Wenger Situated Learning, Legitimate
Peripheral Participation 1991 Pittaway et al 2004: Luke Pittaway, Maxine Robertson, Kamal Munir, David Denyer and Andy Neely Networking and Innovation: a Systematic Review of the Evidence International Journal of Management Reviews, Sep-Dec 2004 Shields [nd]: P M Shields The Community of Enquiry: Classical Pragmatism and Public
Administration [nd] Tucci 1969: Giuseppe Tucci The Theory and Practice of the Mandala 1969 Vigoda and Golombiewski 2001: Eran Vigoda and Robert T Golembiewski Citizenship
Behavior and the Spirit of New Managerialism - a Theoretical Framework and Challenge for Governance American Review Of Public Administration Vol 31 No 3 Sep 2001 Ziarek 1994: Krzysztof Ziarek Inflected Language – Toward a Hermeneutics of Nearness –
Heidegger, Levinas, Stevens, Celan 1994
29
Notes 1
Nick Leggett is a graduate medieval historian, currently seeking the publication of a 111,000 word
MS on the early history of Wells Cathedral. After uncomfortable hospital experiences from 20042011, Nick transferred all his hospital treatment to a university hospital over a hundred miles from his home, where he discovered just how good an English NHS hospital can be. This learning led him to become involved as a Public Contributor to the NHS in his home area. From 2014-2016 Nick served on the Board of the West of England Academic Health Science Network and in the strategy group of People and Health West of England. From 2014, Nick has been a member of a lay research and innovation panel at NHS North Bristol Trust. Nick is a Public Research Associate at Bristol University Centre for Academic Primary Care, where he is a member of the Advisory Group, and Co-Author, in a project funded by the NIHR School for Primary Care Research, into barriers and facilitators to seeking treatment, for primary care physicians (GPs) who experience personal mental health difficulties. In 2014, Nick submitted a patient idea in the public ideas round of the NHS NIHR Collaboration for Applied Health Research and Care, West of England (CLAHRCWest). This idea was accepted. As a result, Nick now holds Honorary Academic Status at the University of Bristol, and is the joint principal investigator of the project which developed from his idea. Nick has been trained to co-produce at all stages of the project’s current systematic literature review, and he is a member of the project advisory group. Nick’s main academic undertaking, aiming for book publication in 2021/22, is an investigation of competition, collaboration, innovation and public contribution, within NHS England. 2
The view of maṇḍala here comes from two main sources: the work of Professor Giuseppe Tucci,
(Tucci 1969); and oral teachings of the Longchen Foundation, given in 2015 by Caroline Cupitt, and in 2014 by Tim Malnick, but derived from the work of Rigdzin Shikpo (formerly the Oxford physicist, Michael Hookham). Giuseppe Tucci and Rigdzin Shikpo each have close links to Tibetan Buddhism, but explain ‘Maṇḍala Principle’ differently. I have used capital letters in this essay for each of the nine Aspects of maṇḍala principle, delineated by Rigdzin Shikpo. These Aspects are: ‘EVAM’ (Involution and Evolution); Central Principle; Structural Body; Bonds of Connection; Energy Exchange; Boundary; Gates; Guardians; and Messengers. 3
Vigoda and Golembiewski 2001 p 275
4
Vigoda & Golombiewski 2001 p 277
5
Quotation from John Dewey ‘The School and Society’ in Bernstein 1966 p 41
6
Foucault 2003
7
Grint 2008; Grint 2010
8
Fuentes 2009 p 18
9
Fuentes 2009 p 20
10
Fuentes 2009 ps 21-22
11
Fuentes 2009 p 129
12
Fuentes 2009 p 153
13
Fuentes 2009 ps 204-205
14
Goldschmidt 2006 p 14, my highlighting
15
Goldschmidt 2006 p 140, my highlighting
16
Goldschmidt 2006 ps 148-149, my highlighting
17
Lash 2010 ps 225-226
30
Notes (Cont) 18
Jullien 2000 p 39
19
Jullien 2000 p 219
20
Jullien 2000 op cit p 227
21
Jullien 2000 p 228
22
For a detailed understanding of inflection in modern and postmodern philosophy, read Ziarek
1994. 23
Lash 2010 ps 221-222
24
Larsson et al 1998 p 290
25
Larsson et al p 290
26
Di Domenico et al 2009 p 889
27
Jones et al 1998 p 398
28
Bryson et al 2006 p 46
29
Ferlie et al. 2010 p 30
30
Castells 2010 p 187
31
Pittaway et al 2004 p 144
32
Castells 2010 p xxxvi
33
Brandsen [nd] p 4
34
Brandsen [nd] p 15
35
Lave and Wenger 1991 p 18
36
Lave and Wenger 1991 p 53
37
Lave and Wenger 1991 p 29
38
Shields [nd] p 7
39
Simon Critchley The Ethics of Deconstruction. Derrida and Levinas. 1992 p 240
40
Quoted by John J Stuhr in Hickman 1998 p 86
41
Quoted by John J Stuhr in Hickman 1998 p 87
© Nick Leggett 2016
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