Tuesday, 18 January 2011

Third time lucky?

A few rather more abstract and random thoughts today. And they come from listening to the morning radio show about the health service changes, for which the NHS Bill is being presented to Parliament this week. I have an odd feeling of rather liking what they are up to,despite everybody from all corners shouting about what folly it is - particularly how they are abolishing the PCTs and giving 80% of the total NHS budgets to GP consortia, all at a reckless speed. Maybe it's just because I have always advocated 'creative chaos' as a therapeutic change mechanism, and prefer to trust the imagination and ingenuity of good people, than lumbering systems that have seem to have been set up to mostly serve their own survival and growth. Not to mention their rather irritating need to measure everything ('evidence based practice'?), predict everything ('there should be no surprises') and then control everything (which they call 'good governance').

Well I don't know. Is it really so fast? And don't we need to do it pretty fast to make sure that all the old hierarchically promoted ways of working don't just get replicated?.(I mean this in Tom Main's psychoanalytic sense, rather than as organisational hierarchies). I hear arguments that the expertise in the PCTs will be lost - but just how much of that 'expertise' serves to cause monstrous insititutional constipation - and actually makes spontaneous local innovation almost impossible? I'm probably just being a hopeless old romantic here, but I do believe that my GP colleagues might be 'feeling this in their bones'.

I was trained as a GP, and the one thing I remember my trainer saying to me (it must have been 1987) was 'Don't go back into hospital practice. You won't like it'. Being young and set on a career in psychiatry, I didn't understand. But I don't think he was talking about the oppressive nature of biomedical psychiatry I was soon to encounter, but the freedom to think. And to do so with all the non-specific skills, understandings and attitutes that you can't avoid picking up during a good medical education. Like what to say to people who are naturally frightened of what you are going to do to them, how to be professional and human at the same time, and how to be with somebody who is dying.

So the way I currently feel about the NHS reforms is that this is the third major relocation of power - and I have more confidence that it might be for the good than the others.
The first was before my time - when the NHS was formed, and power (in abundance) was given to the consultants. Sir Lancelott Spratt was still alive and well when I trained, and I think there are a few echoes of him left in the fustier more self-important medical schools.

The second relocation of power has been happening since the 1980s - and has been chilling my bones ever since. I remember meeting the chief executive of the newly formed trust, where I was appling for my first and only job as a consultant, back in 1994. He said that he felt a bit sorry for consultants, as they had been disempowered by the Griffiths Report, and several other things that were going on. Little did I know it then, but 'modernist managerialism' was going to change the world as we knew it, and not only in the health service. Modern management, with its ugly sisters of corporatism and risk aversion, was on the way in.

I can only hope that the current upheaval will preserve the best of both those power bases, the traditional and the modernist if you like, with something that is less one-dimensional, dogmaic and brutal. Perhaps it will be complex, reflective and post-modern; better able to tolerate and cherish differences, and to understand underlying layers of meaning. I would have described it in therms of 'the unconscious' once upon a time - but that word seems to have become rather tainted in the last decade.

But if the authotitarian days of Sir Lancelott Spratt were traditional, the micro-managed days since the 80s have been times of high managerialism, and perhaps we're now moving into a new era of openness, plurality and web-based life!

Funnnily enough, I said something very similar at one of the first 'big talks' I every got invited to give, in 1996, as the invited lecture to the 'closure conference' of an Essex therapeutic community, Greenwoods. At that time I called the three different ways of running things 'traditional', 'administrative' and 'therapeutic'. I've been waiting fourteen years since then - but I do just wonder if number three is finally coming round the corner.

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