Guest Blog by Diane Plamping with commentary by Becky Malby
NHS Rules of Thumb
We wrote an article in 1998 in which we suggested that stability in complex systems emerges from the rules that guide behaviour of agents within the system (Plamping 1998). These ideas arose from our work discovering what shapes behaviour in a ’self organising’ systems which can help us understand why many structural changes do not generate the hoped for changes. We suggested the rules or guides that kept the NHS the same in spite of many structural reforms and numerous attempts to reform the NHS. To be instantly useable they have to be short and pithy so the rules of thumb in service provision we posited were:
- Can do should do
- Doing means treatment
- Treatment means cure
- I am responsible
This approach to understanding systems is akin to Gramsci’s concept of ‘common sense’ (2011) as in ‘that which is held in common and is an expression of hegemonic ideology’. This is not the same as the English language version, which implies ‘good’ sense. It can be understood as the means by which everyday patterns of behaviour are generated by individual social actors rather than imposed by hierarchical controls (although these exist too). In this way of thinking, ideology does not operate through the conscious application of theory or analysis but rather through a series of so-called ‘rules of thumb’. This is a phrase derived from tradesmen making judgments about length without recourse to using a ruler. The phrase suggests practice is shaped, not by direct reference to underlying design principles, but through rules that can be applied in the moment whenever a decision is required. Similar processes of translation from theory into practice are identified in many fields such as social psychology. In Eric Berne’s there is the concept of ‘scripts’ these are the ways deeply embedded assumptions ‘show up’ in behaviour. E.g. ‘hurry up’ is the behavioural prompt to a deeply held but unspoken injunction ‘ don’t think’. Both behaviour rules and underlying assumptions are probably left unspoken – ‘Going without saying because it comes without saying’ [after Gramsci]
Interest in rules that can shape autonomous agents’ behaviour arises from their capacity to shape the outcomes in complex social systems, where decision-making is held in myriad places and by multiple actors. They can be described as the dominant set of cultural rules. There is much interest in the idea of organisational ‘culture’ in change management and organisational development practice. However much of this interest is applied to identifying typologies of organisational culture. Whilst these may be accurate descriptions of what can be observed in a system, they may not be useful in generating change. An alternative approach might be to identify what guiding principles operate in the ‘sub-cultures’ that are always present and where appropriate find ways to for autonomous agents to amplify these and therefore generate new patterns of behaviour a the system. We called this Whole System Working.
The Current Rules of Thumb
In the decades since we posited the original rules they may have been evolving. Reference to ‘long term conditions’ appeared in policy formulations and ideas about ‘living with’ rather than ‘curing’ cancer are now current and there is a struggle between these and the other rules posited above. Despite our recognition of the ubiquitousness of health care practice within teams, we struggle to make find ways to operationalise ‘we are responsible’. So their original formulation may still be useful in generating conversations about service development.
If we were to apply this same way of thinking to current organisational development practice, I suggest we would produce a system which looks like our current public service management if the following rules of thumb were commonly in operation:
- Private managers practices are more effective [than public service managers]
- Outcomes can be measured easily
- Human services are like manufacturing processes
- Professionals are always resist change
I would of course reject these guiding principles but I am suggesting they are held commonly enough to shape our public service systems, and we could reflect on how and why previous rules were able to be supplanted. I am itching to offer justifications for why I think they are not fit for purpose but for now I offer these in the spirit of starting a conversation which we could use to generate the rules of thumb for a ‘Twenty First Century public services’.
Whilst Diane has set out the Rule of Thumb that guided service from the foundation of the NHS, through to the Rules of Thumb that seem to guide the NHS now. I’ve had a go at the Rules of Thumb that we should use for an NHS fit for the 21st Century and beyond. My proposition is that if we used these rules to design services, we would shape a very different NHS. This is my first draft:
- Partnering with people as owners secures better health
- We are responsible – partnership means everyone contributing [Not I am responsible]
- Do what matters to people (health is contextual) and this will reduce demand
- If we don’t know what’s going on now we can’t adapt.
- Health is relational
My rationale is:
- People are coproducers of their own health, and people as owners will contribute to wider service delivery, and help shape services that address their needs. Institutionalisation of health services has gone too far.
- If we are responsible then we see health services as collaborative and take responsibility for our part in that. Abdicating responsibility to experts creates dependence and assumes passivity.
- The multiple attenders come to GP surgeries and to A7E, they come because their complex health issues are intertwined with their social context. We cant divorce the two.
- We need real time data to know what’s actually happening now and as we try out service changes, and new approaches to health.
- We heal through relationships, and we generate new possibilities and take action together.
This is an amalgamation of observed rules of thumb in high performing health systems and those teams and systems who are innovating and making an impact in the NHS.
I’d love to know what ‘Rules of Thumb’ you think we need to guide our services.
Berne E (1975) A Layman’s Guide to Psychiatry and Psychoanalysis . Penguin Books Ltd, Harmondsworth, middlesex, England (1975)
Gramsci, Buttigieg, Joseph A, ed., (2011) Prison Notebooks (English critical ed.), Columbia University Press