Social movements and the next phase of healthcare improvement: The View from 2004

What do NHS leaders do when they want to start a grass roots movement? Well, according to Bate, Robert and Bevan, they get 15 policy makers together and hold a colloquium. These authors reported the outcomes of this colloquium in “The next phase of healthcare improvement: what can we learn from social movements?”

This paper from 2004 is a real blast from the past but it presents an opportunity for the contemporary moment.

The authors rave about New Labour’s NHS Plan and, accordingly, the nods to austerity and short-staffing which have subsequently become predominant are conspicuous by their absence. There are the echoes of 1990s postmodernism; I particularly enjoyed the comment about “existing “realities””. (The scare quotes are the authors’).

The bulk of the paper articulates a vision of healthcare transformation as a social movement. The traditional view, where change comes from the top and is monitored by centrally set goals, is labelled “the programmatic approach”. Here, people on the front-line are expected to behave out of pure self-interest.

Under the “social movements approach”, however, staff are self-motivated because they believe in the ideas. Those implementing change are willing to accept personal cost and seek to change themselves and their colleagues in order to reach the goal. This idealised vision suits a more ephemeral language: “releasing energy”, “self-directing”, “structures institutionalise emergent meanings but create nothing”.

This comes right out of the New Labour era when excessive centralisation of power was the public sector’s main gripe. These authors are trying to find a way to reduce conflict between Whitehall and the frontline workers who previously worked undisturbed by central quality control initiatives, specifically highlighting one strength of the social movements approach: “there is no pressure to obtain ‘‘buy in’’ to persuade or to produce a compelling case for change since people have already independently accepted and embraced the need for change”.

Fifteen years later, there is still scepticism towards those running the health service but it is underfunding as opposed to micromanagement that is the bone of contention. Personally, my gut instinct response to the social movements approach is that it is just a way to get people to do more work for free; if front-line workers believe in the cause then they will work longer and for less. That does not seem to have occurred to these authors.

But what gives the social movement approach relevance today is not its propensity to extract labour for free, but the possibility of doing more with what little we have.

At my hospital is there is outspoken support for Quality Improvement (QI) projects, empowering frontline workers to change the way the organisation operates. This means that doctors can improve the way our time is spent, change the information we give to patients, or reduce the number of tests we run. A recent Harvard Business Review article advocated this approach: “Bottom up approaches which empower clinicians to lead and monitor local improvement … are far superior than top-down dictates, generic slogans, and online training modules”. Kate Granger’s #HelloMyNameIs campaign was another bottom-up movement, where a clinician innovated locally to improve patient experience and dignity.

Bate, Robert, and Bevan talked about “autocatalytic” people; those who are self-driven rather than motivated by external reward. The NHS demands autocatalysis because it lacks leadership; the Secretary of State is fixated on promoting new apps. There could not be a bigger difference between the Secretary of State’s plans to replace triage nurses with robots and Granger’s simple idea that we should always introduce ourselves to our patients.

For sure, we cannot sever the connection between national funding and centralized accountability. But once these autocatalytes begin operating within the health service they build their own sphere of influence and their own momentum. Gladwell’s book Tipping Point – mentioned in passing by Bate, Robert and Bevan – argues that 80% of the impact of an organisation comes from 20% of the people. The 20% are adept at networking and sharing information. But this works best when communication and translation are facilitated, so here’s what the authors got wrong: they argued that the NHS was too big for innovation, that it needed breaking into small chunks so ideas could thrive.

This I disagree with. The NHS in England is a relatively unified organisation with many shared structures and horizontal connections. In this respect – if the reader will excuse the comparison – it resembles the Roman Empire during the centuries when classical thought was peaking. Ideas travelled quickly and new movements (most notably Christianity) were adopted across diverse communities. That was because the empire was joined up, shared common language and cultural touchstones, and was free from internal competition.

There may well be other reasons to break up the NHS in England, but fragmentation does not facilitate the dissemination of good ideas.

So in our cultural moment, facilitating grass roots movements within the NHS means promoting connectedness, cross-pollination, and collaboration. The challenges facing the health service have changed since 2004, but enabling frontline workers to change their environments has never been more important.