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.

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“Everyone should be allowed to bribe”

I had an interesting discussion the other day at a Fundraising event. Sitting opposite me was a businessman who also does a tremendous amount of work for charity. We got into a discussion on corruption – specifically, bribery. The discussion centred on how “the Bribery Act was causing business a lot of trouble” and that the UK “as always” was taking it seriously whereas other countries would not. We would therefore be undermined and lose business.

I argued differently. Working for Global Witness since 2007 (I left in late 2011), I had played a small part in working to get the Bill into law, then to ensure the guidelines made sense and have since worked with organizations like the Chartered Institute of Management Accountants (CIMA) to provide guidance (I wrote their guidance on the Act) and chaired their Bribery Act conference at St Paul’s Cathedral in 2011.

The businessman, actually a very interesting, successful and intelligent individual, suggested that, to make it fair, “everyone should be allowed to bribe” as much as they liked.

It was a Fundraising event, so not the time for a row – nevertheless, it reminded me sharply about how the world works and how it is split between those who understand the chaos that endemic bribery causes and those that see only the micro-economy (through the eyes of individual businesses) rather than the macro-economic chaos and individual misery that bribery causes.

We live in a disjointed world

I have recently been involved in the filming of a documentary on corruption that will go out later this year. So, although I have left Global Witness (which campaigns against natural resource-related corruption and conflict), I have stayed in touch with the issue.

It is easy when involved within an NGO to forget how business folk (as I counted myself for many years) can disassociate themselves from wider issues. I spent most of my career in business and those who are very successful are completely focused – like an athlete focused on winning a gold medal at the Olympics. The best are relentlessly single-minded in the pursuit of gold – the best business people are similar. This means that they are completely focused on what benefits their business.

This is why the US Chambers of Commerce have been waging a war on the Foreign Corrupt Practices Act (FCPA) for some time. The USA has, since the FCPA was brought into being in 1977, been way ahead of the field in anti-bribery law. This has heated up recently as the US authorities have piled into those who are believed to have breached the Act and, mainly through out of court settlements, have gained hundreds of millions of $ in fines and caused real change in US companies and how they operate outside the US especially.

But, the Chambers of Commerce believe that this puts the US at a disadvantage as other countries don’t have similar laws, they believe, or flout them.

Of course, this is no longer the case in many parts of the world. The OECD Anti-Bribery Convention was signed up to by 39 countries and the Convention is a tough one. As a result, the UK was eventually shamed into all-party support for anti-bribery legislation and the Bribery Act was the outcome – which came into law in July, 2011. It is actually a tougher law than the FCPA – making facilitation payments illegal, for example, and making the bribery of anyone (including government officials) a criminal act if it affects a decision. However, if a company has good processes and trains its staff well (Adequate Procedures), Directors of the company are unlikely to be prosecuted. Let’s face it, the funding of prosecutions is also likely to mitigate against major cases being developed.

However, the Act has led to a large industry being developed in training and in new processes. I was on the working group in the UK that brought in guidance for the not-for-profits (charities and NGO’s) in the UK (under the auspices of Transparency International and Mango) so saw very clearly how every organization (business or not-for-profit) could be affected by the Act.

This new anti-bribery industry has seen a number of lawyers move from the Serious Fraud Office (SFO) to private industry – confirmation if needed for business people that the whole thing is a cash generator for law firms and those in them and nothing more.

The equivalent of the “revolving door” that has been denigrated for years when politicians or civil servants enact laws or make project decisions and then move to senior positions in companies, is now taken as a serious concern by business people who see the same situation used against them! There is an irony there somewhere.

Corruption hurts

Business people see anti-bribery legislation as a problem. It makes business (in their opinion) more difficult in the same way that early 20th Century business people saw health and safety legislation as a problem. I am sure that many business people in the 19th Century saw government money being used to build the sewer system in London as a huge drain on their wealth and a public use of funds that proved that their wealth creation was being used against them – even if for the public good.

So, it must be galling to see anti-bribery legislation (which is international in concept and which is aimed at benefitting the poor in the poorest countries) put into force. In the USA, business is working to erode the law that has been in place successfully for 35 years – a law that has led the world. In the UK, there is irritation (maybe mounting anger) at the Bribery Act. And its implementation costs.

Business folk (and I was one for many years) see the short term and their bottom line. They find it hard to associate themselves with the wider questions about how corruption transfers wealth from the mass of people to a few – as, say, in Angola; how it ensures that money is spent on items that are not needed – very expensive air traffic control systems  in Tanzania, for example; how it adds to the price that poor nations pay; how nations like Nigeria are completely beholden to corruption as was England in the 18th Century – a nation where every job, every hospital appointment, every legal decision is likely to be subject to payment / bribes. Look at Greece and its current malaise – not paying tax is a symptom of a society corrupted – so much of the economy is bribery-induced – the black market is a corrupt market and leads to short-term benefits and long-term disaster.

Values are not for sale

The Bribery Act is now in place in the UK; the FCPA has been tried and tested in the USA for 35 years; 39 countries have signed up to the OECD convention. Yet, we probably face a bigger problem. The growth of nations such as China, India and Russia face us with enormous challenges as each nation is, in its own way, a centre of corruption.

China has adopted a Confucian posture – hit hard at home to rid itself of the endemic corruption that is at the centre of its totalitarian heart while allowing corruption to exist where it trades – such as in Africa. The Confucian spirit allows it to leave alone the nations with which it does business at the same time as Western nations attempt to apply governance to aid budgets. This is a time of real challenge and western countries should be working more than ever to instill values not just trying to compete for short-term gains. It used to be “if we don’t bribe, the French will”;  now the same phrase is directed at China, Russia and India (the home of www.Ipaidabribe.com).

We should not allow our values to be for sale for short-term benefits even in times of economic stress.

Is Bribery good for Business?

There are examples of businesses that have high values and most do not engage in bribery. Usually, those with the highest values are large businesses that know their CSR will be shaken by reputational problems. It makes business sense not to take the risk – bribery is bad for business.

Medium to small businesses, where the main opportunity for employment growth exists in most countries, are less concerned with CSR – which most think of as meaningless nonsense. Societal issues are way down the list of priorities – international issues are nowhere.

Hemmed in (in their view) by unjust legislation on all sides that seeks to choke off the spirit of enterprise, small businesses fight to survive daily. To them, bribery may be a necessary part of life. So what if people overseas suffer as a result – jobs are created for British firms and if we don’t do it, someone else (like the Chinese) will.

Globalisation in this context means nothing but cheap supply chains, cheap overseas labour and opportunities for exports. Globalisation does not mean we should take account of international problems.

Like 19th mill owners who fought sanitation bills as bad for business, who (in the main) were not interested in the health of their workers, who were only constrained by legal changes, many business people will only react to changes in the law because they are focused on their business and anything that adversely affects that business is bad – by its very nature. Bribery may allow business to take place – if a British company is not allowed to do it, business may well be lost.

Is bribery good for business? Of course not – just like the death of a worker because of shoddy safety systems, just like the gradual reduction in bullying at work because most acknowledge it is not needed – we inherently know that bribery (the corruption of people to make decisions go our way) is abhorrent. The impact is grotesque and cannot be justified even for a few extra short-term jobs.

Relentlessly focused business leaders know that bribery is wrong (at least most do) and, apart from the most extreme libertarians, understand that globalization means that the rules of business engagement are going to be made international. We cannot for long assume that developing countries will, for long, expect to be treated as the working class of 19th Century England. The class structure of international business will, over time, lessen just as we have made changes to our own class structure in Europe and North America and elsewhere.

Good business cannot “allow everyone to be bribed”. It is not just an ethical position, but a business one. Business should be undertaken on a level playing field where no-one bribes – we should be striving to ensure that bribery is minimized not allowed everywhere. Rules or norms are basic for societies to function. In a global society, the norms need to be widely applied. Bribery is bad – we all know it. Business leaders, here and in the USA, should be leading the fight – not over-reacting and running in the opposite direction.