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.


Relational leadership, group dynamics and personal identity

Kim Ryley

There is a general consensus from researchers that many of the skills and behaviours of leadership can be learned and acquired. But recent research in the United States and Britain, on the particular challenges facing public sector leaders over the next ten years, has revealed not only the need for a new skills set, but also the importance of these being underpinned by a particular personal mindset and attributes. Indeed, these explicit values, attitudes and behaviours appear essential to operating effectively in the emerging new environment – not least in generating the support and loyalty of others that will be necessary to shape the development of that environment.

It is already clear that the leaders of our public services must prepare for the future on the basis of dramatic, fundamental and irreversible change. The complexity, scale and speed of this paradigm shift requires an unusual degree of adaptability, tolerance of uncertainty and ambiguity, and the courage and resilience to take responsibility for inventing the future without the benefit of any clear blueprint to follow. The adaptive challenges involved in this are not the same as previous technical problems – they cannot be fixed by experts!

In this context, leadership is not simply about creating shared intellectual understanding. Rather it is about engendering the trust necessary to persuade and motivate people to let go of what is now expendable. Overcoming the emotional resistance involved in this is about overtly challenging the beliefs, identities and feelings that will obstruct the extensive innovation necessary to thrive in the “new normal”. That is why leadership of change is so difficult – it threatens people’s sense of professional identity and self worth.

Fundamentally, the new leadership approach is about changing behaviour, through the distribution and acceptance of loss, so that people can, themselves, make the changes necessary to adapt to the new reality that is now emerging. Whole system leadership of “place” in local public services means acting in conjunction with politicians, partners, staff and local communities to create cohesion around what needs to be done, through shared identity and purpose, and a new sense of reciprocity or “neighbourliness”.

Tomorrow’s public sector leaders will be those who feel compelled to connect with others, As well as being politically astute, they will understand the dynamics of power, be able to read other people’s behaviour, and have the credibility to secure co-operation beyond their formal authority, Like a good Buddhist, their role will be to break through the illusion of constancy by inviting uncertainty, to challenge the status quo – and to change behaviour. But, doing this will depend on them being able to demonstrate that they live the values that drive them.

The changing views of local authority leadership emerging from research surveys of council chief executives by SOLACE in the UK, and of city managers by IMCA in the United States, rate highly the ability to manage complex inter-relationships and inter-dependencies. Indeed, performance is likely to be evaluated increasingly in terms of expert use of the enabling skills necessary to create new alliances, as well as to facilitate and operate in (formal and informal) networks. These include conflict management, negotiation, problem solving and communication. The challenge for leaders in this collaborative context is to be both authoritative and participative.

What the new research also shows, however, is that successful leadership in this context will depend on behaviour and individual attributes which engage and instil confidence in potential collaborators. These attributes include being:

  • Open Minded
  • Flexible
  • Positive
  • Patient
  • Persistent
  • Decisive
  • Risk taking
  • Reflective
  • Accessible
  • Accountable
  • Friendly
  • Trustworthy
  • Unselfish
  • Honest
  • Respectful
  • Empathic
  • Attuned to others
  • Ethical
  • Committed/Passionate
  • Consistent

For leaders of complex social systems, relationships and relatedness will be primary, all else will be derivative. The new research has illustrated what skills public sector leaders need in future to be effective. But it shows also that they are extremely unlikely to actually be effective unless they also pay attention to how they exercise those new skills – and keep their attitudes and behaviours under constant observation, as others will.


Kim Ryley is a recent Past President of the Society of Local Authority Chief Executives and a Trustee of the Leadership Centre. He has 14 years experience as a Chief Executive in four upper tier local authorities. Kim is currently a freelance Leadership Development Consultant and Director of Torque Leadership Associates Ltd.

The Health Act 2006: Behaviour change in action?

Catherine Staite

The Health Act 2006 is a very dull title for an Act of Parliament which has had such a profound and universally beneficial impact on all our lives.  It enacted the ban on smoking in enclosed places to which the public have access.

When I was training to be a solicitor in 1976, I shared an unventilated basement office with an etiolated, chain smoking Welshman.  He chain smoked Gauloises and I went home every night with a bad headache, smelling like a kipper.  His right to smoke – and the social acceptance of smoking – trumped my right to breathe. How things have changed! But why have they changed so much?

In the 1950s the UK had one of the highest rates of smoking and consequently one of the worst rates of death from lung cancer in the world.  However, smoking began to decline in the 1960s and death rates began to fall from 1965.  In 1979, 45% of the population smoked but by the 1990s that number had fallen to 30%.  Between the introduction of the smoking ban in 2007 and 2010 it fell a further 9%.

There was much controversy at the time with dire predictions of damage to businesses, particularly pubs. Smokers argued that their human rights were being attacked. The tobacco industry complained that it was leading to a reduction in the number of cigarettes smoked and a significant rise in the number of people quitting. Fancy that!

So why has the smoking ban been such a success?  Firstly, the time was right.  Research at the time showed that there was very strong public support for the ban.  It has been largely self-policing; note how quickly people react if anyone breaches the ban. That is because the reasons for the regulations are well-understood and the benefits are now clear, in the same way our air is now clear.

The smoking ban did change behaviour but it achieved it by building on and reinforcing longer running changes in behaviour and attitudes.  It made it clear that the right to breathe trumps the right to smoke.  In 1976 I didn’t feel able to assert my right to breathe clean air in our dank little office.  In 2013, I don’t need to, because Parliament championed and legitimised my right not be harmed over the rights of others to harm me.

At INLOGOV we are very interested in behaviour change and how changing public expectations and behaviour can impact, both positively and negatively, on public services.  Behaviour change has come to be seen as a’ quick fix’ for all sorts of perceived ills.  The experience of the smoking ban shows that it is all much more subtle and complex than that.  It also demonstrates that the right legislation, at the right time, can work with the grain of changing  social attitudes and can help both to change the behaviour of the unwilling and to embed that changed behaviour in new social norms.

Catherine Staite

Catherine Staite is the Director of INLOGOV. She provides consultancy and facilitation to local authorities and their partners, on a wide range of issues including on improving outcomes, efficiency, partnership working, strategic planning and organisational development, including integration of services and functions.

Catherine has recently co-authored INLOGOV’s latest book, Making Sense of the Future: Do We Need a New Model of Public Services. The chapter ‘Beyond Nudge‘ by Catherine Mangan and Daniel Goodwin deals specifically with behaviour change.

Beyond Nudge is behaviour change and demand management

Catherine Mangan and Daniel Goodwin

A three-fold change to the design and delivery of public services has been taking place over the past decade. Expectations of user choice or personalisation, the drive for localism and most particularly the implications of cuts in public spending, all increase tensions within the public service framework. One key factor underpins all of them: they require fundamental change in the expectations of individuals, communities and service providers if best use is to be made of ever diminishing resources whilst securing public well-being.

Many experts have said that the critical public service challenge of the decade is to encourage behaviour that benefits both the individual and the state, whilst preventing long term expense. They want to discourage behaviour which creates user dependency and attracts further costs. Behaviour change is vitally important, they say, because we can no longer provide the services we have always done, in the way we have always provided them. Various approaches to altering the behaviour of citizens have been outlined in a growing body of evidence.

Councils are navigating within a ‘perfect storm’ of reducing funding and increasing demands from demographic change, public expectations and the rising cost of delivering services.  We know that we cannot continue to meet the level of demand for services in social care and children’s services. Councils’ financial modelling shows that at the current levels of demand, by 2022 the council’s entire budget will not be enough to cover the costs of children’s and adults social care services.

Somehow, the level of citizen demand on services needs to be contained, and reduced. Merely changing the way in which existing services are delivered will not save enough money. For example if the current trend of people needing care continues and the use of personal budgets in their current form is extended, there is a clear risk of double pressures on the public purse, as current services such as day care continue to be provided rather than de-commissioned.

We believe that following simultaneous outcomes will be required in the future, some of which will be the responsibility of public services:

  • Reduced dependence/reliance on state to pick up the pieces.
  • Improved individual well being and resilience.
  • New and improved community/social networks.
  • Sustainability – both in terms of the environment and also the future of public services.
  • A better understanding in the community of the cost of public service and its relation to taxation.
  • A shift in the underlying expectations of individual citizens and communities of the ‘deal’ that they have with the state as to the provision of public services.

There is a need to change the contract between the individual and the state. There has been a range of reports and statements from think tanks and central government departments extolling this approach. The RSA 2020 Public Services final report provides a good summary of many of the more detailed points. It calls for a new ‘social citizenship’ approach where as citizens we should have a duty to contribute as well as a right to receive support. This takes us beyond the simplistic ‘Nudge’ theory towards a better understanding of how to navigate the challenges of the present to achieve a better future.

This blog summarises some of the key messages in:

Beyond Nudge – How can behaviour change help us to do less with less? By Daniel Goodwin and Catherine Mangan in  Staite, C. (ed.)(2013). Making sense of the future: can we develop a new model for public services? (Birmingham: University of Birmingham/INLOGOV).

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.