A number of transformative journeys for both patient and the NHS communities are set out in a recent Health Foundation report published as an HSJ supplement Mutuality ‘The patient will see you now”.
It is tempting to dismiss this report as yet another proof that writing about patient participation and engagement is much more interesting and perhaps rather easier than doing it. But the report’s varied perspectives did help me develop a new perspective on the elements that go to make up the NHS ‘semiosphere’.
I am indebted to Rachel Polonksy for this useful word. She writes in her book – of this ‘capacious neologism’ which she defines as denoting “the ‘vast intellectual mechanism’ of which we are all ‘both part and likeness’, and which contains and brings together everything from the religious ideas of archaic cultures to the advertisements of our modern age.” In the words of Bob Dylan “Come all without – come all within; You’ll not see nothing like the Mighty Quinn”.
Within Us and Us Within
It is clear to me that the NHS is the nearest we get in British intellectual (actually that is the wrong word when discussing the NHS – religious is better) in British religious life to such an all-encompassing organism. To adapt a line of the original author of the ‘semiosphere’ concept, Yuri Lotman wrote ‘Thought is within us but we are within thought’. So it is with the NHS. The NHS is within us but we are within NHS . The NHS is an external reality but similarly is within us as it embodies our aspirations and ideas of such elemental political and social values as compassion, dignity and respect.
Consumer vs Citizen = Secular vs Religious
These last three are cited by Stephen Thornton and Adrian Sieff of the Health Foundation – the first as being at the heart of the NHS with dignity and respects as the associated values. They spurn the consumerist Tesco model and stress that it is as citizens that we make our contribution to supporting the NHS. The Tesco model (i.e. customer service as practised everywhere except the NHS) is the model for lay people, the secularists: the citizen model is the religious one for the NHS believers – the fundos for whom the 1947 tablets of stone are sacred.
Transformative Journeys – paths well-worn
Authors of these guides to successful engagement and participation are in the business of advice shading rather easily into sermonising. Here they urge those interested to make transformative journeys along fairly well-worn paths: from individual to community; from representative to participative. Irritatingly enough for those whose focus is on implementation, it is a characteristic of participative advice that it oscillates from one pole to another – community one day and individuals the next. Participation managers are pragmatic folk – they need specifics and they need to know what the animal known as ‘community organisation’ looks like. Is a LINk a community organisation? Is the word ‘community’ only definable by reference to its opposite – the unfavoured consumerist model? Elsewhere we find the word ‘architecture’ being used by the Department of Health’s director of patient and public affairs. Prior to world class commissioning and quality accounts, there was according to Joan Saddler “no health architecture to indicate that community engagement was important”.
And that’s what all these reports do – they build the area – in this case the cathedral – they design the roads, the signs to the building and publish the map but unlike Kevin Costner’s baseball park, it is by no means certain that the people will come.
I take refuge from all this in the specific. So I very much enjoyed the analysis of the consultation between patient and clinician characterised by the three types of fear which come together in an “opening up and closing down” anxiety. Doctors are energetic and involved until the moment of diagnosis – ‘job done’ they think breaking off the conversation just at the moment the patient begins to get involved/ understand/ interested in what is happening. At all times, clinicians control the dialogue. This approach scaled up a bit is the characteristic of many consultations where the consulter controls the questions, gets the answers (they want to hear) and then moves quickly to close down the dialogue to avoid all risk of spontaneity, surprise and human feelings.
No Training for Turbulence
To be fair, clinicians and their colleagues do not have enough training for their role as barefoot priests of the last widely practiced religion in Britain- the NHS. Torn between their fact-based education and the faith-based political environment of their work, they have no dials or screens on their professional dashboard telling them how to navigate the turbulence within the semiosphere. They cannot embrace their own feelings, let alone those of the patients and so we are back in 1978 and the world of the House of God as illuminated for us by Samuel Shem where a brutal system destroys the humanity of the interns whilst making the patients iller.
If the NHS semiosphere is to be a healthy place to be for both health workers and those they are supposed to care for, the former have to understand that the patient they see is both part of them and indeed their likeness. The patient is within them and they are within the patient. That is all the architecture that we need for the House of NHS.
Not sure what the PCT participation manager will make of that.