The clumsy progress of the NHS
People often ask me (OK, someone once asked me), ‘do you have any examples of clumsy solutions?’ A clumsy solution, as you will recall, is one which engages the active paradigms (egalitarianism, individualism and hierarchism) of cultural theory (as well as being aware of the ubiquity of the fourth paradigm, fatalism). In his book ‘Organising and Disorganising’ Michael Thompson offers the example of the successful relocation of Arsenal football club, involving as it did an alliance of the hierarchical actor (Islington Council), the egalitarian (the local community) and the individualist (the Club itself).
I will offer a much bigger, and more controversial, example: the NHS. Benefiting as it has done from several years of growing revenue and capital budgets the NHS is in pretty good shape. Long waits – for decades the public‘s greatest complaint – have been abolished, outcomes are improving in key treatment areas such as cancer and heart disease, and patient satisfaction levels are at an all time high. Despite the flu, the weather and the norovirus, another winter is passing without the kind of crisis we used to think inevitable. The test will be when the flow of cash starts to slow down next year but there are reasons to believe the NHS has developed broadly the right balance of change levers.
Of course, there is no shortage of hierarchical levers in the form of targets, regulation and expert frameworks. But the individualist devices of competition and patient choice are also embedded with, for example, more and more patients being aware of, and taking up, choice. The possibility of individual budgets for those with long term chronic conditions could bring another individualist driver into the system. And the recent Darzi review, with its recognition of the need for local discretion in developing health strategies and closer local collaboration between the NHS and local authorities, provides an avenue for benign forms of egalitarianism, focussed, in particular, on addressing public health.
More evidence that the balance of drivers may be broadly right can be found in the modest tone of the Conservative critique; a long way this from the hyperbole of Labour 1997 pledge to save the NHS and its subsequent disastrous dismantling of the internal market (only for it to be rebuilt five years later).
In a huge enterprise like the NHS clumsiness is a framework, not a solution. The inevitable dilemmas of the health service – national accountability versus responsiveness, integration versus competition, public health versus the medical model, and (the most difficult of all in years to come) universalism versus patient empowerment, will continue to create challenges for policy makers, managers and clinicians. These dilemmas will never be resolved but if the NHS continues to be a clumsy system they can be the context for, and not a barrier to, further progress for patients.
Maths, small children and neural pathways – ‘proving cultural theory’
I promised yesterday to offer some evidence that the four categories of cultural theory are fundamental and ubiquitous. I will stick to this despite the temptation to respond to the fascinating conversation about CT taking place on my comment pages.
I offer three ways of supporting the claims made by cultural theorists. The first comes from game theory, mathematical modelling and computer simulation. This comprises various ‘proofs’ that cultural theory’s four paradigms are the only types of solution that can emerge from organisational problem solving.
Michael Thompson refers to the modelling of mathematically minded sociologists Manfred Schmutzer and Wylles Bandler which he says identified the four paradigms before cultural theory had even named them. Michael also describes in the book and in his RSA Journal article some modelling he did with Paul Tayler in which 30 firms followed the four strategies:
‘To our delight, this stylised ‘world’ with its few and simple micro level rules, once set in motion gave rise to some remarkable,…life like, whole system behaviour’
Lacking expertise in modelling and maths I don’t know how strong this evidence is. I’ll leave it to Marco and Michael to comment on whether there is more compelling, and more recent, evidence of this kind.
The second kind of evidence lies in real world examples of cultural theory. Here, cultural theorists tend to be better at identifying cases of failure than ‘clumsy’ success. Even in the one example Michael provides – the successful relocation of Arsenal football ground – it turns out that the critical factor was not just the engagement of the different paradigmatic actors but that one – the egalitarians – has enough sympathy with another (the club) to temper its instinctive oppositionalism.
However, there is a cute piece of evidence that the paradigms naturally emerge from human interactions. This comes from research with children undertaken by the philosopher Mark Nowacki. When primary school pupils who had been asked to answer questions were suddenly told that their performance would now result in an allocation of sweets, Nowacki found the same basic patterns of response emerged every time:
Nascent Egalitarian – “We should all get the same. We have to share the candy with those who didn’t get any.”
Nascent Individualist – “The candy is mine. I got it because I answered the questions.” (A fairly typical response to the Egalitarian.)
Nascent Hierarchist – “Teacher, is this right?” (These kids looked to their regular teacher to see if I was playing by the class rules)
Nascent Fatalist – “I never get any candy anyways.”
Nascent Hermit – One student exempted herself from the discussion entirely and went off to play with the toys in the corner. She wanted nothing to do with all the fuss and was perfectly happy without the candy.
Finally, and where I hope the RSA can make its own contribution, there is the idea that the paradigms are associated with hard wired neural pathways. If the five are reduced to elemental psychological responses to a problem they are:
Hierarchical – I’ll do what I’m told
Egalitarian – I’ll do what the group says
Individualist – I’ll do what I want
Fatalist – it doesn’t matter what I do
Hermit (not sure about this one) – I’m not part of this problem
I was told that Alan Fiske at UCLA had done some research that showed different activity in different parts of the brain when subjects were confronted by stories/images that reinforced different paradigms, but I can’t locate this in Fiske’s web references.
My big and highly speculative question is whether the experience we have of free will (nb ‘experience’ – I am not here asserting the existence of free will) is structured by these five basic options (although the content of any actual decision will be much richer as well as context dependent).
We hope to test these ideas in a collaboration on cultural theory and neuro-science we are developing with colleagues at UCL.
Sorry, this has been so long. Next week I want to explore the ways things go wrong when we ignore clumsiness and some idea about how managers and other social problem solvers might use CT to develop creative and inclusive organisations.
PS There is one part of the conversation on my comment pages I can’t resist mentioning. Marco Verweij admits that the term cultural theory is confusing, he prefers the clearer but more cumbersome ‘theory of plural rationality’. That’s not the only terminological problem. Trying unsuccessfully yesterday to persuade the great Steven Lukes of the value of CT I couldn’t get past his objections to the word ‘egalitarian’ especially when I suggested egalitarian impulses could sometimes be seen in right of centre political movements, for example against the European Union or opposing immigration. He offered ‘solidaristic’ as an alternative which does strike me as a more accurate term. However, Michael Thompson calls the four/five paradigms ‘solidarities’, so that may not work. One thing is clear – if social theories can’t be easily explained in clear language they are unlikely to gain purchase. Is that why CT keeps popping up in interesting places but never quite makes it to the mainstream?
Cultural theory – and the link between George Washington and Gordon Brown
Cultural theory has changed the way I think about policy dilemmas and organisational problems. It can provide insights to everyone from political commentators to community activists to managers of large organisations. Over the next few days in some – hopefully – short, accessible posts I intend to lay out the key tenets of CT as I understand them by reference to concrete examples and contemporary issues.
I have the good fortune to be in regular correspondence with two of the world’s leading cultural theorists, Marco Verweij and Michael Thompson (who wrote a piece in the last RSA Journal). They are busy guys but I am hoping to persuade them to check in and comment on the blog and any follow up chat.
The first question is what kind of explanation does cultural theory offer? At its most simple it offers a way of understanding how people try to solve problems which is more powerful than many conventional approaches.
Here are some common ways of understanding why people adopt different strategies to solve problems:
• ‘Nowt so queer as folk’: We all see a problem in the same way, but people come to different conclusions about what should be done for reasons that are random or perverse
• ‘It’s who you are in society’: People come to different conclusions depending on their own interests and status; e.g. class, status, race, gender
• ‘It’s what you believe’: People come to different conclusions reflecting their deeply held values and political attitudes
• ‘It’s the type of person you are’: People come to different conclusions because of their personalities.
Cultural theory doesn’t deny that all these factors may be relevant but it argues that social problem solving exhibits the interaction of four basic categories of response: the egalitarian, the hierarchical, the individualistic and the fatalistic.
These responses are more systematic than the ‘nowt so queer’ account allows for; they are more complex and dynamic than fixed social interests imply; they cut through and across systems of belief and political affiliation; and – while people may have personalities that predispose them to certain options – the strategy a person advocates will in practice reflect the dynamics of each different problem solving process.
Tomorrow I want briefly to describe the content of the perspectives and summarise some of the evidence for these responses being fundamental and ubiquitous. But I’ll end today with an historical and a contemporary example of cultural theory in practice.
In ‘Dilemmas of Presidential Leadership’ cultural theorists Richard Ellis and Aaron Wildavsky use CT to explore the ways Presidents from Washington to Lincoln have dealt with the circumstances and dilemmas they faced. You need to read the book, but it is typical of a CT perspective that the authors explain George Washington’s tendency to adopt pomp and ceremony whenever he could, his refusal to back the new French revolutionary Republic in its conflict with the rest of Europe, and his heavy handed crushing of the Whiskey Rebellion as examples of the dilemmas facing a hierarchical President operating in a fiercely anti-hierarchical (individualist and egalitarian) culture.
Fast forward 220 years and we see another insecure hierarchical leader, coping with what was, until very recently, an anti-hierarchical culture. Here is Rachel Sylvester writing yesterday in The Times about Gordon Brown;
“there is a sense in which the Prime Minister is dealing with the economic downturn so confidently partly because it requires greater state intervention – something with which he is instinctively comfortable”
Brown’s standing has risen because the world has come back to him; at a time of fear and insecurity, when the individualist consensus of the last thirty years has crumbled with the casino capitalism it sanctioned, we crave the certainties offered by hierarchy.
The four strategies of cultural theory are ever present options for those seeking social solutions. At certain times events strongly favour a particular response and those that advocate it. That is why a man who was just about our most unpopular ever Prime Minister six months ago has seen his standing rise and his impact grow (at home and abroad) despite being in the midst of a crisis for which most people hold him at least partially responsible.
RSA Book of the Year – and the winner is ….
Time for books nine and ten in the RSA Books of the year. Before unveiling them a special mention for Stephen Pinker’s The Stuff of Thought, a wonderful, engaging and authoritative book about the structure, evolution and purpose of language. Unfortunately, although Stephen spoke here in 2008, the book was published in 2007 and so doesn’t really count.
Michael Thompson – Organising and disorganising
Regular readers will have had quite enough of me banging on about cultural theory. Suffice to say that this is a fascinating, quirky and convincing way of getting into the theory and understanding why some people (like me) think it is so powerful.
And number ten and my overall winner is…….
Da da
Clay Shirky – Here Comes Everybody
A lot has been said about this hugely entertaining and visionary book. I will say simply this: there have been a thousand and one books about how the internet changes everything. This may not be the longest or most scholarly, it is certainly not the most over-blown, but it is, for the general reader, simply the best. Why not buy it at the RSA Bookshop!
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