Transformation: change for improvement in healthcare

Opening Reflection. Working in the NHS culture has required focusing on ‘doing’ things, making things happen as quickly as possible, as the context is driven by huge budgetary concerns. Targets have to be met and measurable outcomes designed and applied to short deadlines, influenced by different political agendas acting ideologically or in response to national, regional and global politics. These factors make the context ever-changing. This creates the conditions for change agents to be more engaged with firefighting and reactive changes than concentrated on developing visions shared by all the stakeholders for sustainable change to ensure the future of an equitable high quality NHS. Throughout the course of these public works, what consistently emerged from my reflective engagement was the value of people and people as an untapped resource, beyond being instruments of processing and delivery. There are two important considerations in bringing about successful change: the mechanistic elements and the behavioural elements. The mechanistic elements of change are usually the focus in the NHS, for example project management, performance management and reducing waste. However, the behavioural side of addressing change is a neglected area (Keller and Aiken 2008). Over time I came to understand this as a situation encouraging a culture of addressing the urgent rather than the important; more profoundly, ways of ‘doing’ rather than ways of ‘being’, as described by Heidegger (2000). Maybe it is not just cultural but the way we have evolved. The key issue that Kahneman (2012) talks about is the dichotomy of our two decision-making systems: System 1 is fast, instinctive and emotional; System 2 is slower, more deliberative and more logical. Kahneman delineates cognitive biases associated with each type of thinking and suggests that people place too much confidence in human judgment. System 1, the more instinctive, is great at accessing plenty of ideas, making connections and pulling together a story or ‘best guess’ answer. Often this kicks in first and the more logical system never questions it. In short, we are hardwired to make up information or stories on the flimsiest of facts. We therefore need to handle this throughout the change process and in our reflective processes. In the first public work, Improvement Partnership for Ambulance Services, having seen the impact of its use with ‘challenged Trusts’ I used appreciative inquiry. Appreciation can be lacking in these difficult settings. As the works progressed my thinking deepened and I came to realise that the work of Ganz (2009), along with the values which had arisen in my formative years, had been operating within me at some level and informing my choices. Perhaps one of the greatest challenges of undertaking this programme was extricating myself from the NHS culture so that I could think and feel this engagement with my works rather than just do it. I came to realise that I had become more institutionalised than I initially thought, acknowledging my own habitus. Mauss (1934) defined habitus as those aspects of culture that are anchored in the body or daily practices of individuals, groups, societies, and nations. It includes the totality of learnt habits, styles, tastes, and other non-discursive knowledge that might be said to ‘go without saying’ for a specific group (Bourdieu 1990, pp. 66-67). I think this has some similarities with Schein’s (1992, p. 12) definition of culture as: A pattern of shared basic assumptions that the group learned as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think and feel in relation to these problems. Bourdieu (1993) describes habitus as a reference to lifestyle, the values, the dispositions and expectation of particular social groups that are acquired through the activities and experiences of everyday life. So I had to reflect hard in an objective manner to distance myself from my habitual way of seeing the world in which I work: my typical behaviours within my context. I do not claim through this critique of my works to have become an expert on Ganz, appreciative inquiry or be an amateur philosopher, but to have had the opportunity to reveal their influences and to encourage in myself a more conscious engagement with works and ideas that support the whole human being. I believe this is captured in the notion of a way of being. Heidegger (2000) maintains that our way of questioning defines our nature. He argues that philosophy, western civilisation's chief way of questioning, has lost sight of the being it sought. Finding ourselves ‘always already’ fallen in a world of presuppositions, we lose touch with what being was before its truth became muddled. As a solution to this condition, Heidegger advocates a return to the practical being in the world, allowing it to reveal, or ‘unconceal’, itself. Heidegger opines that ‘questioning is the piety of thinking’ (cited by Haar 1993, p. 107). In these works I have ‘unconcealed’ much to myself and have learnt a different kind of questioning.