From repression to co-production with citizens: Why we need behaviour change in healthcare

Jörgen Tholstrup

What’s the mission of health care?

Highland Hospital, Sweden_2

I’ve been working as a physician and gastroenterologist both in Denmark and Sweden for more than 30 years. Over time, I’ve become more and more puzzled about our healthcare system and how otherwise responsible human beings can tolerate the way that common behaviourial rules are suspended when you access healthcare.

In my role I am supposed to order people named ”patients” to behave the way that I or the ”science” believe is the right way to behave. At the same time, most medical practitioners know that their patients will not in fact behave the way recommended. Most studies on “compliance” with recommended treatment show that only 40-50% of patients actually follow therapy recommendations (WHO, 2003). This behaviour is most often a result of their conscious choice and does not arise from stupidity or ignorance. This mismatch is remarkable and the result is devastating to health as more than 50% of patients will be untreated for treatable or preventable diseases.

So, how did we get into this paradoxical situation?

To understand the modern healthcare system and its rules of behaviour, it is necessary to look back in time and try to understand how and why the system has developed. The healthcare system reflects society and is the result of the outlook and the values of citizens. From the beginning of the 16th century, the institutionalisation of health care started in monasteries. Naturally, the rules of behaviour (i.e. obedience and silence) were in accordance to monastic rules. The history of silence, and how we as humans can use the expectation of silence as a tool through which to rule over others, is fascinating. The monasteries aimed at helping people in need – but to get help you were expected to conform to the rules of the organisation.

In the early industrial period, and continuing into the post-world-war era, there was a widespread Western European political vision of the perfect society, in which blessed citizens would live happy and productive lives and where the state would look after all citizens. As a result of industrialization and urbanization, individuals who were not productive or who were a danger to public health (e.g. those suffering from tuberculosis or other infectious diseases or psychiatric conditions) were isolated in hospitals or sanatoria, which was a generally accepted approach. In Sweden this idealized state was named  ”Folkhemmet” (”the people’s home”) but the fundamental ideas and dreams were quite uniform throughout Western Europe.  Moreover, there was a belief that the State would help vulnerable groups by creating special enclaves designed to meet their specific needs.

The organisational models of the healthcare systems evolved by inspiration from the most advanced industrial model of the between-the-wars era, namely the car industry in Detroit. Therefore, healthcare was organized in departments and special units in order to focus upon production  outputs instead of supporting people. The idea that the employees of the healthcare system should and could dictate how “patients” should behave is probably a consequence of the roles and rules arising from history, reinforced by the influence of an industry handling production outputs and seeking very hard to standardize. The term “patient” is revealing, as a problematic and stigmatizing construction. It is not connected to “patience” (although often you do need to be patient to put up with the wait for healthcare). It actually comes from the Greek word ”pathos” – ”to suffer” – which marks the people concerned as different from “us”, making a repressive approach more possible.

This first post-war era ended when politicians such as the UK’s Prime Minister Margaret Thatcher recognized that this vision of an ”idealised” society went beyond the bounds of possibility and that, even if it could be achieved, this would only be at the price of an intolerable repressiveness towards individuals. What politicians like Thatcher realized (I believe) is that society actually is a conglomeration of individuals. This led inevitably to marketing the ideas of individualisation and personalisation.

However, this led to many health care workers getting stuck in an antiquated system with an extremely conservative structure. The reason why it has been so hard to change is difficult to understand. However, I think that one of the key reasons is that it is a very hierarchical system and that people at the top of the system are comfortable with it, so they do not have much motivation to change. Furthermore, it is becoming increasingly obvious that modern public management systems are focusing on processes instead of results, which preserves the current system.

How can we change healthcare towards a more human system?

Co-production with patients_Sweden 1We have to accept that the behavioural rules underlying the traditional system are unacceptable and out of line with citizens’ expectations in the 20th century.  So we need to redesign the system. To do this we will have to change the way we think about healthcare. In particular, we need to develop an alternative approach, harnessing the skills and capabilities of human beings instead of continuing to use repressive approaches. We have to incorporate principles of co-design and co-production into how we think and interact – with staff, clients and their families, friends and networks.

This is how I started to transform my ward at in the Highland Hospital in Eksjö hospital in 2001 as described in the Governance International case study.

Co-production with patients_Sweden 2

One important driver of co-productive forms of behavior in healthcare may be greater transparency. Since we have moved to giving patients a much greater understanding of their own conditions, and how to interpret all of the information which we have on how their condition is progressing, we have had great improvements in our results. New ways of reinforcing this are now becoming available. For example, in the US and Sweden the rules are now changing so that patients have internet access to their own health record in order to help patients make proper choices. In the future, patients may even have the opportunity to add their own notes to health records which will open new possibilities.

Fundamentally this is a political issue, the basic question is how to let individuals take control of their own lives in a way that is in accordance with the 20th century.

Joergen Tholstrup

Jörgen Tholstrup is the Chief Medical Officer  at the Highland District County Hospital in Eksjö, Sweden. Until December 2013 he was the head of the gastroenterology unit in that hospital.


A view from Barnet’s Chris Naylor: how the class of 2014 are responding to perma-austerity

Chris Naylor

Two weeks ago I gave the lunchtime pep talk to a dozen young hopeful students each vying for a coveted place on Barnet’s graduate programme. Furiously clever, ambitious for Barnet and public services more generally – I didn’t envy those with the task of making a final selection. Like the alumni who have come through the Council’s programme before them, many of whom a decade on, as senior managers, continue to make a profound contribution to the success of the borough, the Class of ’14 will truly be the 21st Century Public Servants. Over the course of the next 40 years (probably 50….) they, with others, will come to define the scale, purpose and breadth of public services locally, nationally and perhaps beyond.

Along the way, the challenges that they will face are beginning to take shape. There are three striking features:

  •  deficit reduction and growing service demand, particularly in health and social care will mean public sector spending reduction and then restraint that has the potential to last deep into the second quarter of the century;
  •  meanwhile customer service expectations are rising exponentially and the public sector has so far proved too slow in response. From an inability to book appointments with the doctor, to the maddening requirement for the citizen to constantly re-provide to the state, information about themselves the state already knows and in some cases originated – serves to frustrate, erode trust and catalyse disengagement. And this coming at time when the scale of change facing the public sector requires greater proximity, not less; and
  • traditional interventionist measures to promote social mobility and other social outcomes will be challenged by a scarcity of public resources. Furthermore, rising health and social care demand, highlights the need to ensure that the public sector can properly demonstrate that services are provided fairly. Indeed there may well be a need to properly demonstrate that services are withdrawn fairly too. Fairness, of course being a concept that is ripe for debate and challenge!

Over the last 12 months Barnet Council has been working hard to develop ideas and options that address these trends, particularly as we expect them to manifest in the second half of this decade. The Council’s “Priorities and Spending Review” sets out a range of ideas to save money and achieve priority outcomes. They include many of themes identified by those interviewed by the 21st Century Public Servant Project: efficiency-particularly through the application of new technology; measures to promote economic growth; demand management; greater community enablement and facilitation and partnership working/integration. In Barnet, over the coming months these ideas and others will now be considered politically and with service users, residents and other stakeholders so that a conclusion can be reached. These decisions won’t be easy, by the end of the decade Barnet will be spending roughly half what it did in 2010 on the provision of public services.

In this context our workforce will quite understandably be concerned about job security. Not least because on the 1st April 2016 our workforce budget will be £68m per annum, while our savings target for the period 2016-2020 will be higher at £72m. All other things being equal – that will feel like a circle that can’t be squared. But the public sector will not disappear, realistically Barnet will still spend some hundreds of millions of pounds and employ many hundreds of staff, directly or indirectly, to provide services that require heavy personal involvement – Google has not replaced teachers, even if it has changed and enhanced the way they teach.

More importantly local government will continue to consist of good people doing good things for people – and it is this sense of moral purpose that attracts the Class of ’14, in much the same way it has attracted others before them. In this context, for public service leaders, at all levels and at all points in their career the truth is that the magnitude of change before them is not just a challenge to their skills and capability, but for some – many perhaps – it is a challenge to their philosophical outlook. To exemplify the point,consultation we undertook to inform the Priorities and Spending review revealed that many residents want Barnet to effectively market council services and the talents of staff – they are willing our organisation and workforce to be more entrepreneurial. It’s not, however, an attribute that universally characterises the culture of most local authorities. Indeed some folk will find the very notion alien to a public sector ethic. In Barnet the desire to be entrepreneurial has led us to establish ‘Re’, a joint venture with Capita to market our development and regulatory services. Several of the staff in the service/company have joint employment contracts, enabling them to provide a commercial service alongside their regulatory responsibilities. From its inception, it is a proposition that has had its supporters and opponents, notwithstanding the fact that the business model for Re sees a growth in employment and not a reduction. Winning the support and commitment of those staff transferring to the joint venture has been the leadership challenge both during the development of the proposal and for the post go live period. At the risk of sounding glib, the only way to win the hearts and minds of workforce in question has been to appeal to both their hearts and their minds. Reason, coupled with an on-going conversation and debate about their motivation and conviction to achieve good outcomes in Barnet.

One final observation: The 21st Century Public Servant research, rightly alerts to the tension between technology-led commoditisation of public services and the desire/requirement for a more ‘relational state’. But I would challenge a view that asserts too strongly that both responses are mutually exclusive. Insight derived from joined up data gives us the potential to engage more directly with individual residents based specifically on the services they use or the place where they live. For example we can already send details of a planning application in a resident’s street directly to the phone in their pocket. Ideally they could use that phone to work out their chances of getting their child into a particular school.  And if we know they’ve been looking at catchment areas, much as Amazon directs to similar products, we too should point “here are some children’s events in our libraries”. We hold that information, we just need to get it packaged and sent in a way that is useful to a resident.

The Class of ’14 were born between 1992 and 1994. They’ve been using social media and the internet before they became teenagers. The application of new technology to re-design services and better engage service users isn’t a novel idea – to them it’s both obvious and assumed. Over the coming years we should expect them to adopt the best levels of personal engagement from the most customer orientated parts of the private sector and develop new forms of civic engagement – using big data to make small but regular differences that change our residents lives for the better.

Chris Naylor is Chief Operating Officer at Barnet Council.

How can the 21st century public servant survive an era of perma-austerity?

Catherine Mangan

We are launching the first theme from our 21st Century Public Servant project – the need to survive a seemingly unending period of austerity – to coincide with the Local Government Association conference, where austerity is a central theme.

Our research with local government and other public service delivery organisations found that ‘perma-austerity’ is both inhibiting and catalysing change, as organisations struggle to balance short-term cost-cutting and redundancies with a strategic vision for change.

In our interviews with people working in public service delivery and in national stakeholder organisations (more details on research design are here) some talked about the current ‘narrative of doom’ is preventing progress – some talked about a sense of loss and grief for the past; with organisations paralysed by the impact of the cuts, and unable to provide a new vision to work towards. As one put it, ‘No message of hope – leadership is putting council into survival mode by the language they’re using. Nobody is planning for post austerity.’ One interviewee spoke about the effect of losing large numbers of staff: ‘You hear the language of loss everywhere. I get affected by it.’

Although interviewees accepted that the financial context offered opportunities for doing things differently, some commented on the challenge of moving forward whilst dealing with the reality of the impact of large scale redundancies: ‘The cuts are forcing us to confront change. In public service, change doesn’t necessarily happen unless there is a crisis or a disaster, or it happens very slowly. But think tanks and consultancies can find it exciting, for them it’s a massive playground. We have to remind them that people are losing their jobs, services are being cut. There has to be a balance.’ Others commented that the enormity of the challenge needs to be recognized and responded to: ‘It’s not salami slicing because you wouldn’t have salami that big, it’s hacking things off. It’s about rethinking the role of the state in light of the changing economy, technology, the changing ways that people live their lives. The cuts are so big that we have to confront the questions we have been putting off: what is a library service, what is a leisure service?’

The biggest shift being driven by austerity is developing a different relationship with citizens: ‘We won’t have the money so we will have to focus on the enabling and facilitating, enabling the rest of community to do it.’ As one interviewee put it: ‘You can only get so far by being a supply side mechanic, cutting and slicing. You need a better sense of what your people are like, who they are, what their networks are, how they can do more not for themselves but how they can be more a part of the value that you create about what you do as a council.’

However another interviewee described the difficulties she encountered in reconciling the austerity agenda with more relational ways of working: ‘There is a complicated tension between the desire on the one hand for efficiency and rational processes versus the expectations and needs of customers which is more relational and focused on the personal and local. We are expected to do both, to move to the more relational in the government’s commitment to localisation and neighbourhoods. But elsewhere we are moving to customer relationship management and call centres. You phone or visit a call centre, pick up a ticket, it’s not a holistic relationship with the person on the other end of the phone.’

The 21st century public servant will have to ‘find a way through that knot’.

Portrait of OPM staff member

Catherine Mangan is a Senior Fellow at INLOGOV.  Her interests include public sector re-design, outcomes based commissioning and behaviour change.  Prior to joining INLOGOV she managed the organisational development and change work for a not-for-profit consultancy, specialising in supporting local government; and has also worked for the Local Government Association, and as Deputy Director of the County Councils Network.  She specialises in adult social care, children’s services and partnerships.

21st century public servant: the discussion phase

Catherine Needham

After nine months of researching the 21st Century Public Servant, we are today formally starting the discussion phase of the project. We have undertaken a literature review, we have spoken to over 40 people working in public services in public, private and voluntary sector bodies, and to national stakeholder organisations. From that we have identified key themes of what it means to be a 21st Century public servant which we will be blogging about over the next few months.

We begin this week with a focus on ‘perma-austerity’ which is the key contextual factor for public services, and a major theme at this week’s Local Government Association conference. As well as sharing the findings of our research we will have guest blogs from people working in and close to public services about ways to address the challenges of austerity.

A clear finding from the interviews we’ve done is that there is no unified vision of the future of public services and the people who work to deliver them. The future will be messy and tentative, with paradoxes being managed and lived with rather than solved. In the same spirit we don’t feel we have come up with the answers in this project, but rather with a series of themes that we want to test out with you. If you feel inspired to blog or comment that’s great.

We will be discussing the themes at the IPPR today, beginning a series of project events. You can also come along to the Inlogov stall at the LGA conference to find out more.


Catherine Needham is Reader in Public Policy and Public Management at the Health Services Management Centre, University of Birmingham, and is developing research around public service reform and policy innovation. Her recent work has focused on co-production and personalization, examining how those approaches are interpreted and applied in frontline practice. Her most recent book, published by the Policy Press in 2011, is entitled, Personalising Public Services: Understanding the Personalisation Narrative. Follow Catherine on Twitter: @DrCNeedham.