The following post is written by Rob Warwick. Rob works in areas of strategic change in the UK’s National Health Service. He is particularly interested in how policy makes its way from Government to the front line. This is currently the area of research for his doctorate with the Complexity Management Centre at the University of Hertfordshire.
There has been much talk in the UK press recently about spending cuts to curb public expenditure as a result of the recent economic downturn. Politicians talk of 5%, 10% 15% cuts – conveniently rounded numbers. What is absent is the detail of how this will or could play out. Whichever government comes to power after the general election is likely to take these rough (but neatly rounded) percentage figures and turn them into targets, budgets, action plans and the like. It reminded me of a book by Michael Barber called Instruction to Deliver, retelling his account of how he led Tony Blair’s “Delivery Unit” after the 2001 General Election. A book comes with a new word “Deliverology” and a “Delivery Manual” at the end. I don’t intend to write a book review here, but I would simply like to point out how little the actual experience of the practitioner (the teacher, nurse, or even the manager) features. Take for example the then Health Secretary’s (Alan Milburn) mission: “He was very clear what his task was – to drive through the reforms, take on the vested interests, bring in private sector providers …and build on … choice … to ensure results were met” (Barber, 2007, p132). No mention of what was valued by nurses or doctors as practitioners whose job it was to make people better.
Much has been written about the necessity and/or the deficiency of targets and performance measures. I would like to highlight one area; that of the depleting effect that targets can have on the work of the practitioner. Although this is not new, I would like to take a different slant on this by drawing on the work of Henri Bortoft and his interpretation of the work of the German polymath Goethe.
In a description of the act of reading, Bortoft makes the point that in moving from a word to a paragraph, to a chapter of a book, a person loses awareness of an individual word or words (unless they make a particularly memorable quote). However, this is not to say that they have become nothing, as Bortoft says:
We do not take the meaning of a sentence to be a word. The meaning of a sentence is no-word. But evidently this is not the same as nothing, for if it were we would never read! The whole presence within parts, but from the standpoint of awareness that grasps the external parts, the whole is an absence. This absence, however, is not the same as nothing. Rather it is an active absence inasmuch as we do not try to be aware of the whole as if we could grasp it like a part, but instead let ourselves be open to be moved by the whole. (1998, p286)
Bortoft then goes on to provide a further example that relates to actors performing a play at a point of transformation between a group of separate performing players and the emergence of the wholeness of a play in performance:
The actors no longer impose themselves on the play as if it were an object to be mastered, but they listen to the play and allow themselves to be moved by it. In this way they enter into the parts in such a way that the play speaks through them. This is how, their awareness occupied with the lines to be spoken, they encounter the whole of the play (p286).
A more vivid, but more simplistic, example is when I see my son, building a complex model out of Lego. The blocks are physically there but his mind is tuned to what the model is becoming. In this sense the building blocks are receding to “no-thing-ness”.
To return to the issue of targets and performance measures. Regarding health, targets related to how long a patient waited in Accident and Emergency (4 hours), how long for an operation (18 weeks), bacterial infections such as MRSA and so on. In education the work of teachers was often assessed on the quality of lesson plans or marking. There are many other examples I could cite. In a discussion on the nature of the “expert” Stuart and Hugh Dreyfus (Dreyfus and Dreyfus, 1986, p30) describe him or her as someone who acts intuitively and becomes immersed and at one with what they need to do. Targets however rarely relate to the higher wholeness by which practitioners and experts work. What tends to be the focus are those atomised building blocks, the active absence; the Lego blocks, the words that makes the sentence, the lines within the script of a play. Although vital, they do not constitute the wholeness and expertise of practitioners, from different disciplines, working together, to improve people’s health and education. This is possibly one reason why the practitioners I meet, from different walks of life, feel disconnected from what they value and what they have been asked to achieve.
More detail can be found in:
- Barber, M (2007) Instruction to Deliver – Fighting to Transform Britain’s Public Services, Methuen
- Bortoft, H (1998) Counterfeit and Authentic Wholes – Finding a Means for Dwelling in Nature, in Seamon D & Zajonc, A (1998) Goethe’s Way of Science, State University of New York Press
- Dreyfus, H & Dreyfus, S (1986) Mind Over Machine, Free Press