The Cost v Care Dilemma

Contention: there are two opposing forces within our care professions (which include the hospitals and broader care industry) – cost v compassionate care. It is often put forward that they are incompatible. They cannot be.

The Dilemma

My previous post looked at whether the NHS and care industry can provide  “care” and how the charity sector has a single-minded pursuit towards compassionate care that could assist the public sector caring professions and should be sought out to advise on care in the medical and social care services.

Someone for whom I have a great deal of respect, Richard Murphy (through his Tax Research UK ), reminded us of a post he made back in 2011:

He reminded in a more recent blog that, in the UK, we have a National Health Service (NHS) which is highly rated in international comparisons.

This high rating (2nd out of seven major nations), was at the expense of one measure where we came 7thpatient centred care. Richard Murphy, who wrote the article shown, declares that “we trade something important here: price for patient focus.”

This shows the dilemma that we appear to face. On the one hand, we (the tax-paying public) may want public sector spending kept down (and thereby keep the taxes we pay as low as possible). On the other hand, we (the hospital-attending public) want our public services to be provided to the highest quality. What does not take place in any rational way is a discussion about the quality of service that we demand and the price we are willing to pay for it. There are reasons for this.

Government, which runs the National Health Service and regulates the rest of the medical and social care industry, has one of two political defaults. It either wants to run everything centrally – which led in the past to doctrinal key performance indicators with its huge range of unintended consequences; or, it wants competition where each hospital trust can do its own thing because they are somehow in competition.

What is not understood (because no-one at a macro-level is putting enough time to do it) is how to establish the qualitative measures that we need so that a real Care Quality Commission (CQC) or other monitors would properly be able to judge performance and adequacy with the same prestige as those who guard costs.

Who Really Cares?

I mentioned in my July post that I was Chief Executive at Willow – where we provide Special Days for seriously ill young adults. I am leaving this month and will genuinely miss Willow. It personifies charitable and compassionate care throughout.

An excellent charity, it was founded in 1999 by Bob Wilson (ex-Arsenal double winner, BBC/ITV broadcaster and now Arsenal Foundation Ambassador) and his wife, Megs, following the death of their daughter Anna from cancer. Willow provides around 1,000 Special Days a year for young seriously ill adults (www.willowfoundation.org.uk) . These Special Days provide benefits on three levels: the day itself – a respite from treatment and an opportunity to do something extraordinary with your family and / or friends; positive emotions that result from the Special Days for at least two months – described by the Centre for Applied Positive Psychology (CAPP) as “Astounding!”; the impact of the Special Day both for those in a palliative condition (where they are able to focus on the Day from the time of application) and for those in a curative condition – where the day often results in a change of lifestyle – providing a momentum to start work again, a drive to get back to family life or something new.

Willow’s stories (and Willow is about to provide its 10,000th Special Day) are many and varied.

What each story shares in common is the ability to provide something way beyond repair – even beyond care. The degree of wellbeing (as evidenced by 1000’s of stories) results in Special Day beneficiaries and their families wanting to give something back to Willow – to fundraise and volunteer – and we have now formed an Alumni Association (maybe the first in a charity) for our beneficiaries and those close to them.

This is charity-provided wellbeing which adds to the excellent repair services from the medical community and the care services of hospices. It provides a respite for families who are the traditional “carers” and an opportunity for all to spend time in a positive mind-set that we know enables beneficiaries to take advantage of whatever life has to offer.

This microcosm of our society (there are 100,000 young adults in the UK at any one time who are suffering from an illness that could require palliative care) exhibits many of the issues that we confront in our trade-off between price and care (between cost and quality).

Willow does not question the treatment that any of our beneficiaries obtain in hospitals and hospices, for example. We don’t comment on them and have no desire to do so. What we witness is the complete desire on the part of our beneficiaries and their families and friends to take advantage of something so different and so positive. That Willow provides, through charitable contributions, something so remarkable is to the good. The question is why there is such a difference between what Willow provides and what appears to be provided within the NHS and elsewhere? Is the desire to remake the NHS from a repair organisation to a wellbeing one as proposed by Norman Lamb (Social Care Minister) real? Or is the trade-off between cost and care too great?

A caring organisation – the control:care plateau

What does it take beyond government rhetoric to make compassionate  care within the public sector real? It cannot be just a phrase that is uttered by a Minister with an expectation that it will immediately be understood and implemented. Compassionate care requires the whole organisation to absorb the need as a key value – supported by processes, training and monitoring. This requires management who can embody the spirit of care and staff willing to take it on. It requires sufficient staff who have the time to provide the care that it needed – sometimes it is the time itself that provides the ability to show the care.

At Willow, we have four underlying values that shape everything we do. We aim to be:

Effective    /    Positive    /    Innovative    /    Compassionate

We aim that each person that works at Willow (whether as a Special Days co-ordinator – who works with beneficiaries and medical professionals to put on the day – to a fundraiser or someone in Finance) embodies each of these values.

  • Effective (rather than efficient) means that we add value and are seen to do so;
  • Positive means that we seek to be pro-active (glass half full);
  • Innovative means that we are continuously seeking to do things better;
  • Compassionate means that we care – and show it to our beneficiaries and to staff and to funders and to whoever else Willow comes into contact with.

So, it is a balance between the two bottom lines that I discussed in my previous post – we have to balance a proper degree of control with a proper degree of care. These are not mutually exclusive. We believe and show that the control : care plateau we have reached is a good one but that we have to continuously strive to raise our sights to a new plateau. For us, a focus on care underlies what Willow is all about.

Within the NHS, this trade off has been seen to be an “either / or”. Richard Murphy’s comment strongly suggests (and Richard never meekly suggests anything)  that the national health service has to make a choice – not a plateau of control : care but a choice between them.

This assumes that the prime requirement is to repair the physical when holistic treatment should be in place. Moving from repair to wellbeing is not just a preventative message but one where the wellbeing of a patient comes from an understanding that they have as much right to a fulfilling existence as anyone else. This does mean that the way they are treated has to be via a care policy that is not just understood but embedded and funded.

From All those Reports to Compassionate Care

The Francis Report showed that the standards of compassionate care were too often far too low. Unfortunately, the remedies that the media have focused on relate to punishment and monitoring. Great quality of care cannot be monitored in; great compassionate care cannot be sought though punishment when things go wrong.

The Berwick Report into safety in the NHS properly focused on what could pro-actively be done to reduce accidents, for example, and that purely quantitative measures (“naïve or mechanistic targets”) are insufficient and, on their own, damaging. The Report stated that the problems in care happens despite the good nature of the staff:

“Most impressive of all, perhaps, has been the consistent dedication to helping their patients among the vast majority of clinicians—doctors, nurses, pharmacists, allied health professionals, mental health professionals and many more—as well as non-clinical staff”.

From all these reports, we now have to move on. I believe there are four, crucial outcomes that include:

  • ·         the need for organisational approaches from the top – values have to embody compassionate care; they include the need for qualitative measures which may best be made around stories like in Willow’s case and a process being followed up in a number of hospitals (in Mental Health as an example);
  • ·         the need for a cost and care balance – an agreed plateau that provides in each hospital satisfactory levels of both;
  • ·         the need for innovation in care and understanding of care needs – just as important in holistic treatment as new equipment or methods of surgery;
  • ·         continuous learning and best in class understanding from wherever this can be obtained – often from the charity sector where compassionate care is the underlying value.

Moving from a sense of mutual exclusivity and away from

Costs v Care

to a

Cost : Compassionate Care plateau

Should be the new normal of 21st patient care wherever practised: no either / or but an acceptable balance of care and costs.

Schools get fleeced – and we all watch

The Bureau of Investigative Journalism recently published an article (http://www.thebureauinvestigates.com/2012/09/25/schools-fleeced-by-it-scammers/comment-page-1/#comment-9117) following the exposure on Panorama (BBC 1) that schools in the UK had been “fleeced” by IT companies (“scammers”). The article and Panorama drew attention to schools which are burdened by the need to run themselves as businesses and are often ill-equipped to do so when set against the complicated requirements of funding, procurement, suppliers and the like.

 

The BIJ summed up the problem with the thought that the FMSiS (Financial Management Standard in Schools) had been wrongly abolished and that the Government should think again. It was abolished after it had become a paper ticking exercise as reported by the Government in 2010 in their White Paper – “The Importance of Teaching” – http://www.education.gov.uk/inthenews/inthenews/a0067711/government-announces-end-of-complex-school-financial-reporting-tool.

 

The BIJ article missed the fact that most of the schemes that Panorama reported on were entered into while the FMSiS was in place!

 

Why is Finance so hard for non-profits (public and private sector)?

 

This does not just happen in Schools – it happens wherever greater knowledge is brought to bear.

 

So, the banks have run out of control and, five years’ later, we remain stunned that the financial regulators did not see this coming – or even understand the huge range of sub-prime schemes, poor management controls, over-leveraging, bad morality, lack of risk aversion, inability for banks to fail, dislike of customers and similar.

 

In the same way, companies like Enron fooled their highly paid auditors (some of whom connived with them) – we never learned much from that or from the countless, other financial scams that have been served up on unsuspecting publics since at least the south Sea Bubble in 1720 and for thousands of years before.

 

But, we expect more from public sector and the third sector organisations that supposedly guard our taxes and donations. What makes it so hard for them to adequately ensure that the financial and support arms of those organisations are able to be a good as all those they work with?

 

Where the incentives are

 

Of course, much has been written about how the wealth potential of banks suck in those with the highest intelligence and motivation (and maybe those with the lowest ethics) and that the regulators are filled with those who cannot compete – maybe those who failed to make it in banking themselves.

 

Enron was full of highly motivated and driven people who bought into a scheme (or schemes) and worked like fury to implement their scam / scheme. The manipulation of an energy market was not understood by the regulators and auditors just as auditors and clients failed to understand how Bernie Madoff was making such returns on their “investments”.

 

In a money-driven economy, which has created tremendous wealth for society, there are, at the margins and even more in the centre, incentives provided to people that lure those who are massively motivated and driven to participate – to work 24 hours a day, to spend their time working up schemes to make money and their companies profitable. Business is a money-driven part of the economy in a way that the non-profit sectors (be they public or private sector) are not. The latter are full of people driven (and maybe just as motivated) by other things – a passion for human rights, for education, for people, for society – but not for the thing that drives those they may meet at the interface of private sector and the non-profits.

 

As Galbraith wrote in The Affluent Society, public goods are always at a disadvantage in a market-driven economy and the crucial problems always exist at the interface between the two.  I tackled this is a previous post – https://jeffkaye.wordpress.com/wp-admin/post.php?post=192&action=edit – and the inability of societies to establish how to provide the “social balance” to which Galbraith refers enables the problems to persist – such as the fleecing of schools in the UK.

 

Enabling the “social balance”?

 

The “social balance” (Galbraith ibid) is about how society reacts to private enterprise. The most obvious example is the automobile – private industry propels the development of cars but it is the public sector that provides the roads, traffic control and policing, emergency services and hospitals (usually), pollution control and similar. India is a great and recent example – http://uk.finance.yahoo.com/news/india-car-sales-soar-where-054302682.html. But, the ability of the private sector runs well ahead of the ability of the public sector to react.

 

Nowhere is this lack of social balance clearer than in the provision of expertise in “back office” areas in the public sector and in the third sector. While their front of office capabilities may be excellent, the non-profit sector cannot, in the main, recruit the best people (it cannot offer financial incentives to match anything like the private sector) and therefore its systems and processes fall well behind.

 

This is compounded by the continuous belief by government that they have to “do something” directly (like the FMSiS above) and in the third sector that anything spent outside of front end is a waste of money. Donors (whether governments, trusts and foundations, companies or individuals) suddenly have a different mindset as soon as they donate. How many would ask companies to stop spending on finance operations – yet, many donors insist that their donations can only be applied to front end work – the cause – and nothing to overheads. While it is good to keep overheads low, governance and financial management dictate that these “enabling” areas of any organization (like people management training) are as good as the front end operations so as not to stymie the work of the charity, NGO or pubic sector organization.

 

Having worked in all sectors (with most of my working life in the private sector) it is clear to me that the non-profit sectors are continuously starved of capability and expertise in the areas that could make them far more efficient and capable – not just to survive but also to enable far better work to be accomplished. If they work well it is in spite of the problems put in their way. Most don’t manage and the failures of the public sector to manage large IT projects, for example or the non-profit sector to survive continue.

 

So, how can the non-profits develop a response to the needed social balance so that they don’t get fleeced?

 

Pro-activity in the social balance

 

Governments and those who provide central governance to the non-profit sectors have undertaken so many actions and some have provided stability. But, each sector and those within it are challenged continuously.

 

What is needed is first, recognition that there is a problem. Each sector should assess where the main problems lie and government has to step up and signal that it will not do everything but begin to be the chief enabler for the non-profits. For example, restrictive funding for charities, whereby donors only provide money for front-end purposes, should not be allowed. The practice is akin to shareholders telling companies which part of the business their funding is allowed on. It is not a loan – it is a donation and restrictions mean more bureaucracy and less ability for the charity to manage itself.

 

If a donor believes that a charity spends too much on overheads, it can withhold donations just like a shareholder can invest elsewhere – but restricting funding in this way is counter-productive.

 

In the UK, this is something for the charities Commission and government to act on.

 

Second, there has to be a stepping up on ability – which will lead to improved processes and systems (although improvements in each need money as well and the proposal above is one way of directing more into this area).

 

This stepping up of ability should be driven by government who should require firms of accountants to do what the legal profession does – provide at least 2% pro-bono capability into non-profits. I have been highly impressed by law firms’ ability to do excellent pro-bono – less so by the finance industry.

 

CSR divisions of companies should also be driving their best finance people into non-profits – in a meaningful way to address the social imbalance.

 

Governments should look to reward those who go from the private sector into the public or third sector (even for a time) with tax incentives (much like students having to repay their student loans). It is not a great time to do this, but it would indicate a lot.

 

Third, the big accounting organisations should ensure that they focus more attention on public sector and third sector – understanding the problems and devising exams and maybe alternative paths to accreditation rather than the one-size-fits-all approach. Certainly, the CIPFA and IPSASB provide the basics for the public sector but the incentivisation for the best to go into that sector let alone education or charities / NGO’s is far less and the number of accountants that enter the charity sector (for example) with the same skill levels and drive as those in the private sector is small.

 

Fourth, trustees from private sector organisations have to become involved – not just from a governance standpoint but setting examples and putting the bar as high as it needs to go to make the enablers work. This is hands-on stuff not just remote governance.

 

Separate sectors, common interests

 

Except in a society where the three sectors don’t exist (e.g. communist states), the challenge is greatest at the intersections of society – where the sectors clash. Yet, as in the example of automobiles above (or any other transportation systems), different sectors live off each other – and the charity sector fills many of the gaps that society does not see fit to fill in private or public sectors.

 

The sectors need to be different, of course, but there does need to be a far better understanding of the problems that our economic structures throw up and how to deal with them or fleecing of our schools will recur but be seen to be a mere tip of the social iceberg.

 

 

 

 

Do we care? Ethics in the 21st Century.

To corrupt: cause to act dishonestly in return for money or personal gain

(Oxford Dictionary)

 

Dishonest: behaving or prone to behave in an untrustworthy, deceitful, or insincere way

(Oxford Dictionary)

It should not be too hard for the world of politics, economics and our society to focus at least occasionally on the ethical foundations on which we have to operate to survive. In order to live with each other and prosper together, there are written and unwritten laws which lead us to reduce dishonesty to a minimum and rid ourselves of corruption.

Society as a concept is one in which all participants should have respect for each other even if we disagree with each other’s beliefs.

The central core of society is that we should not be dishonest or act dishonestly.

Underlying the way society works is the split between the various sections of that society – and, in a well ordered state, the division and co-operation between legislature, executive and judiciary (as marked out in the USA, and less clearly in the UK). Making law, executing the law and ruling on the law are fundamental to any just society – but, the debate (that we hear and see through all the media) is about the mechanisms that rule society more than the ethical under-pinning.

In the UK and the USA (and many other nations), the law (its formation, its implementation and the rulings on it) seems to be the pervasive elements that dominate everything we do.

The debate is constant – no government feels it has done anything without changes in the law on a constant scale. The legal apparatus has overtaken so much of what we do and think. Even though the number of lawyers in parliaments may have diminished in many countries (viz statistics from Dawn Oliver and Gavin Drewry, The Law and Parliament, 1998) the debates in legislatures (which formulate laws, of course) are based on the premise that a range of laws exist and need to be tampered with regularly.

In the UK the situation is made worse by the fact that the Executive (those whose remit is to implement the laws) are also part of the legislature – where they are seen by the public most often.

Ethics in the Centre

Tinkering with laws – whether social issues or economic – represents the norm in many societies where the rule of law has been in place for some time and where the division between the three branches of the system operate. Of course, elsewhere, the attempt is made to copy the tenets of those countries’ already established procedures. This is basic and proper in many cases if it correctly enshrines the ethical basis of a society.

Recently, the new country of South Sudan was formed after many years of extreme strife (and continuing strife with Sudan). South Sudan has recently formulated laws that attempt to take into account the subtle (and sometimes not so subtle) divisions in society between regions, tribes and religions but the society is based on a legal system and laws. The ethical basis of that society in its various legal charters is subsumed within the economic struggle to survive – which is leading to grotesque corruption.

In the same way, many other nations are set up with detailed legal systems (as was the U.S.S.R. under Stalin – which did not stop millions being executed and many more sent to the gulags) but where the law is not enacted as the ethical underpinning does not exist.

It is not just a legal system, which has to underpin society – it is an ethical stance that is the grounding for that legal system and for society in general that has to be formed and around which society has to operate. People do not stop killing each other because of the law except where terror rules (although many in parliament believe that is the only thing that stops us) but because an ethical process and system exist within which cultural norms apply.

Ethics – the moral principles which guide our behaviour may well change over time and geographically. A continuing debate about our ethical grounding is key and often lost in the debate over which tax is being increased or reduced. Often laws overtake the ethical consideration; often economic decisions (many short-term) discard ethical consideration; often politicians have no ethical stance or forget it.

Forgetting ethics

Recently, many examples come to mind (some minor, some major), which highlight a forgotten set of ethics. Here are some but I bet we can all see many more every day:

Example 1: George Osborne slaps a limit on tax deductions by the wealthy when making charitable donations – a tax decision, an economic decision but completely bereft of any apparent ethical standards.

Example 2: the death of Neil Hayward in China highlights the completely different ethical basis on which Chinese politics rests. The hushing up of the death because Bo Xilai’s wife may have been involved is reminiscent of 18th Century ethics in the UK. How do we deal with this? One way is proposed by Martin Davidson, the CEO of the British Council – see: http://blog.britishcouncil.org/2012/04/we-must-engage-with-china-through-culture/

who proposes continuous normalization of relations.

Example 3: Transparency International produces its annual corruption perceptions index. Corruption (see above) is a key indicator of ethics (or lack of) in a society. The index is seen by many yet is not generally held to be a decisive indicator of action by those in power – to whom practical issues like exports are far more important.

Example 4: the death of Sergei Magnitsky in a Russian jail (as highlighted by Bill Browder – a hedge fund owner for whom Magnitsky worked) while investigations were under way over corruption making Browder appear to be guilty of fraud shows a manipulation of the legal system and power in Russia and an ethical framework, which is defunct.

Example 5: care homes in the UK are filmed by the BBC showing mistreatment of patients.

Example 6: reports show elderly patients in hospitals in the UK are malnourished and allowed to die as efficiency statistics become more important than patient care.

We can multiply these examples by millions…….

So What?

Society in the 21st Century moves on. Developed countries are saturated with products so that economic discussion is more about the next iPad or its equivalent. Elsewhere, the production processes are ramped up to meet the rising demands of increasingly developing nations such as China, Brazil, India and, maybe, Africa. Worldwide, short-term economic issues are central to all decision-making.

Other issues are sidelined in the pursuit of short-term economic growth. Externalities (like resource depletion) are sidelined and economic growth, the measure of success, is the politician’s mantra.

So, society becomes focused on a prospective nightmare. We may well now be at a critical point in the world’s history – a point where economics by numbers cannot be the central objective of mankind, where a resurrection of ethical considerations should begin – not just in universities but also throughout all we do. The basic tenet of how we live has to be that we weigh whatever we do against crucial ethical norms.

So what? Well, it becomes essential that our politics, our economics, our legal systems, our strategic decision-making and the way we operate in the world be ethically based. In the 19th Century and before, the ethical basis was religious and formed the backdrop to Empire-building; in the 20th Century, economics and totalitarianism were the backdrops to communism and fascism as human ethics disappeared down the throat of centrist power building.

Today, economic short-termism and a blindness and inability to act on what is right provides societies worldwide with real risks. It is not just climate change that can impact our society in the future (although it will in ways we don’t yet fully comprehend). Just as great is the risk that we have developed simply into short-term, economic robots, where real society-driven ethics are lost.

As John Kenneth Galbraith wrote in “The Affluent Society” in 1958:

“To furnish a barren room is one thing. To continue to crowd in furniture until the foundation buckles is quite another. To have failed to solve the problem of producing goods would have been to continue man in his oldest and most grievous misfortune. But to fail to see that we have solved it and to fail to proceed thence to the next task would be fully as tragic.”

The next task is the re-establishment after hundreds of years of conflict over land and resources of a global set of ethics which should form the bedrock of our societies: an ethics system that swings us away from the corruption-centred economic system so prevalent that we can think that reducing charity income is some sort of solution, that the elderly are a burden, that special needs are wasteful of resources, that we support unethical regimes in order for Formula One racing to continue.

We show every day that we have limited ethical bedrock and that decisions and actions are undertaken in its absence – not after real consideration. Listen to David Cameron on F1 in Bahrain?

“It’s important that peaceful protests are allowed to go ahead. Bahrain is not Syria, there is a process of reform under way and this government backs that reform and wants to help promote that reform,” Mr Cameron said.

We run the risk of self-corruption.

So what?