Federating for the Future?

As a direct result of the new health policy, small community practices are now seeking to federate with one another so that they can now compete (with private providers) for the services they already provide. Although most General Practices in this country are run by private partnerships (which is actually extremely different to a company limited by shares – though they can absolutely be driven by the same kind of greed), all the money they earn comes through the NHS. A practice earns money by providing various services, like vaccinations and smear tests and through meeting various targets (along with target driven initiatives like the Quality and Outcomes Framework aka QOF). The money earned then pays the staff in the practice, including the doctors, nurses, other healthcare workers, managers and administrative teams. If any provider, like Virgin Healthcare, for example, can come in and now say, we will provide all the vaccinations across the county at a lower cost than these GPs are currently able to provide, it might sound like a good idea from a strictly money point of view (I refuse to use the term ‘economic point of view’ here, because we must rid the term economics of the abuse it suffers as being synonymous with money – it really refers to how we order the house!). However, what it actually does is destabilise the economy of a practice and removes key services from a local community setting, causing staff to lose their jobs. What the government really doesn’t understand though is how important it is to form relationships with patients. Taking traditional services out of a local setting breaks some key encounters that doctors and nurses have with their patients, for the sake of saving a bit of money.

With the formation of federations, GP practices are clubbing together to basically try and bid for services en mass, but still provide them in the same way. It’s a colossal amount of work, but is also sadly going to break what has been until now a strong value within the General Practice community. As practices choose to federate with one another they basically have three choices in forming these new companies (and they do have to be companies in order to compete with the companies limited by shares whom they will be bidding against). Their first option is to become a company limited by shares themselves. The share holders would initially be the practices in the federation. In the short term, practices would chose what to do with the profits. One would hope, as they are providers of healthcare for the local community, that they would chose to invest the profits back into the health needs of their population. It is my opinion that to do anything else would be wholly unethical. To seek to make a personal profit from tax payers money, rather than using that money for the benefit of those who need it more is, to my mind, wrong. The other significant drawback of this kind of approach is that in a few years time, GP’s could choose to sell these companies at a profit and make a tidy sum in the process. In essence then, this could make a federation/company limited by shares no better than the wolves they are trying to protect the sheep they care for against. The second option is to become a Community Interest Company. This still allows profits to be made, but tends to safeguard those profits for the sake of the community. As with any legal entity, loopholes can be found to make a CIC look ethical on the outside, but actually allow large dividends to be paid to the ‘directors’ (who would be the GPs). However, one would have to chose to change the original constitution of the federation set up on this basis in order to do this, and so on paper a CIC is more likely to act more ‘ethically’ than a CLC (company limited by shares).

The third option is a potentially kenarchic alternative. Kenosis (to pour out) is one of the root words within kenarchy. However, one can be kenotic, without being kenarchic. It is possible to be a kenotic CLC or CIC, but the power dynamics do not really change. Power is maintained and held by the few and although they may seek to act benevolently, they are not relinquishing their (wrong kind of ) power. Now, power is not wrong. We have power to bring about change. However, power is very distinct from leadership. We need good leadership. But true leadership is able to allow itself to become powerless. True leadership becomes the servant so that the ‘other’ can be fully built up and truly become all that they can be. Jesus was so radical when he talked about leadership. Let us dispel the myth, that the best way to change the system is to get into the top jobs and change it from the top down. For a start, very few will ever manage to ‘get there’ even if ‘getting there’ were a good methodology through which to effect change. The sad truth is, that in aiming for the so called top jobs, much is compromised on the way, and once in the places of power, one can become utterly impotent to effect any change at all. It will also be discovered that the top jobs are really only puppets on the strings of the economic and political higher or ruling powers of the systems.

The third way is the way of co-operatives. Co-operatives give the opportunity for a radical overhaul of power, a true sharing of resource and gift and a letting go of unfair monetary advantages created by our current systems. It means the few let go of the power and benefits and instead everybody is able to share them. In forming co-operative federations (and this can apply for all practices as well – something that would be wonderful to see) there is the choice to allow all staff to become share holders together, not just the doctors. In areas where this happens (like the John Lewis Partnership or Surrey Central Healthcare or the health cooperatives of the Basque region) there is an extremely high sense of morale amongst the staff and high patient satisfaction rates. This is because of an uncomfortable truth for the powerful. It is co-operation and not competition that drives up both happiness and excellence. Of course it takes more time and effort, but relational working is so worth it and the benefits to all far outweigh the costs. However, we can more radical than just all workers being members of the co-operatives. All members of a local population could be members of a co-operative for health and this could then easily expand into education also. A greater sense of interconnectedness and less abuse of the service provided would be far more likely in such a scenario. We have to ask ourselves just how much power we are willing to give away, how much we want to know and love one another, but also to be if we want to be known and to be loved?

Biopower and the NHS

Here in the UK, we are increasingly seeing biopower at work in the national health system (NHS). A target driven culture allows patients to be treated like numbers or labelled as disease entities. It is common place to hear of people referred to as ‘Diabetics’ or ‘Asthmatics’ rather than understood as a person, with a name, in a particular life context and set of relationships who has diabetes or asthma. In my area of work, that of general practice, a huge part of our income every year comes through meeting ‘QOF’ (the quality and outcomes framework) targets. The idea behind such targets is to ‘drive up standards’ and ‘improve patient care’. In real terms, however, people can end up having various changes and increases to their medications, so that their blood pressure meets a government target, for example. The ill effects of this, particularly on old people has been recently well documented. Clinicians work hard to get everybody’s blood pressure below a certain value, but due to a lack of research and understanding behind the targets set, especially for people over the age of 75, lowering the blood pressure too much has been causing an increase in falls, fractures and long hospital stays! This is one of many examples where ‘payment by results’ is actually subtracting from patient centred care.

In the recent top down re-organisation of the NHS, which has cost more than £2billion, despite a government promise that such a reorganisation would not happen, more services are being driven out of a traditional hospital setting into the community with no extra resources or time provided to do this work. The new clinical commissioning groups (CCGs) are the new local governing bodies, which have replaced PCTs (primary care trusts). The idea behind this is that GPs, clinicians who know their patients and areas well, should be those who commission services rather than non-clinically trained managers, as they potentially have a better knowledge of the needs of patients. However, it transpires that if the government don’t like decisions being made, they can simply dismiss a board and replace it with another one which will comply with their wishes or cause them less of a political headache.

The implication of the EU-US trade agreement has opened the NHS in a way, like never before, to the forces of the free-market. This is based on a philosophy that competition drives up standards of care, and that private providers should be able to bid for services. At first this sounds like a credible and plausible idea. If another provider can offer the same service for less money, surely this is a good thing? Actually it is problematic on two levels. Firstly because the philosophy is deeply flawed. Competition does not drive up standards. It increases stress and breaks apart well integrated services. It destabilises services which currently work well in a symbiotic manner. For example, if Spec Savers offer a cheaper hearing aid service than the local hospital, then they can win a bid to provide this service. But it destabilises the hospital audiology department, which then has a knock on effect to the ENT department. The private company benefits, but in the long term the local population does not. Secondly, when companies limited by shares become the providers of care, care begins to play second fiddle to the need to make money. And here is a major stumbling block. The marginalised poor and the chronically sick do not make good financial sense, and share holders who live in another part of the world care little for their needs, but care a lot about making more money for themselves. So, we will find that those who need care the most will be unable to access it, as greed becomes the driving force. This is sadly proven in the US health system, where this philosophy is rife and 50 million people cannot afford healthcare and 40,000 people died last year as they could not afford the operations they needed. It is only media hype that causes some to believe the US to have the best health system. Most consider it to be inequitable and highly wasteful of resources.

My Aunty Judy

My aunty Judy is a heroine of mine (one of many incredible and strong women in my life). She is an example of a life poured out in love for those around her. She is a district nurse, working in rural north Yorkshire in the North East of England. I heard a story about her recently which inspired me and challenged me deeply.

I found out that Judy was visiting a certain patient of hers, who has a severe and chronic airways disease, unable to even leave the house due to her level of breathlessness. Judy went to this lady’s house and had never seen such squalour. The lady was too disabled to do any cleaning herself, and therefore none had been done for ten years! So, on the following day, when Judy could have been a having a well deserved rest, as she already works well over her allotted hours, she went and cleaned this lady’s house from top to bottom. The “system” had turned a blind eye to this lady’s needs, but Judy knew fine well that with the amount of dust and fungus in the house, this lady stood little chance of improving her breathing at all. No extra pay, no thanks from the lady, but rather a disciplinary hearing from the management powers, for going beyond her remit! But the lady now has a clean house, because Judy was willing to be a toilet, forgiving the system for its failings, cleaning up the mess and releasing more life in the process.

To embrace kenarchy is to embrace humility.

But when she’s not nursing, she is caring for children with severe mental and physical illnesses in her own home, to give their parents some respite. And when she is not doing this, she is often trekking halfway across Europe to help her eldest son who is setting up an eco-backpackers place in Bulgaria! And amongst all of that she cares deeply for her 4 other children and their families and her own mum, my Nanna, who’s health is seriously declining. Talk about going the extra mile!

Yet she has learnt the secret of rest and refilling in the midst of it all so that she doesn’t burn out. She has found the secret that God is really with her as she serves others. This is where God is found – with those who are in need! She has learnt about unforced rhythms of grace.

No job is too small for us, no person too unclean to be embraced and no task is beneath us. This is the kind of love that transforms the world.

Devolving Power from the Centre

Earlier this week the UK parliament voted that the secretary of state for health will have new powers to close any hospital in England, should he see fit. There are a couple of caveats attached. Firstly, the local people will apparently have ‘a say’ and the local commissioning boards of GPs will also have to agree. How much of ‘a say’ local people will really get is yet to be seen and how much pressure will be exerted on local commissioning boards to tow the party line we don’t yet know.

What this highlights yet again is the complete lack of joined up thinking that happens around healthcare and the wider economy. It also reveals how utterly disempowering central government really is. How can Westminster decide what the needs and wants of the city of Leeds are, for example? What do they know about the non-economic impacts of closing a hospital? I’m not arguing that all hospitals should stay open, and there’s a good chance that some may well need to close. But it cannot be a decision from on high. Nor can it be an isolated decision. It’s too complex for that.

I find great encouragement from the knowledge that there are several towns and cities in the UK where ‘a people’s assembly’ is emerging. There are some stunning examples of this in Nottingham, Leeds and London. Across a city such as these ones, there are webs of networks and interconnected relationships that represent thousands and thousands of people. I had the utter privilege recently of spending some time with John Battle, a recently retired MP from Leeds. He carries a wealth of wisdom in understanding how to engage people from across a city to participate in key decisions. He was explaining to me that in a people’s assembly, there are representatives from many groups across the city. Each person can speak on behalf of their group and report back to them for further discussion. It’s an incredible way of involving a huge proportion of a city in a discussion.

In Nottingham, for example, at the time of electing the new police commissioner, over 1200 people, representing a vast number of networks, gathered from across the city to have a facilitated conversation about what they would hope for from their new commissioner. They were then able to ask questions to the four candidates, and were able to set up a system of accountability for the eventually elected commissioner back to the people. The commissioner understood in no uncertain terms that he was there to serve the city and the city understood that it was there to partner together with the commissioner for the welfare of the communities living there.

A facilitated conversation gives voice to everybody and sets no-one up above another. Leadership becomes about facilitation rather than dominance and control. When we talk about closing a hospital or a maternity unit or a school in an area, it is often said (as in my previous blogs) that there are some very complex things to consider. This is absolutely true. The problem is that we don’t share the complexity, we leave the decisions to so-called experts (who are at best having a good guess), and then either make them heroes or scape-goats!

National budgeting doesn’t work when it comes to healthcare. Local budgeting in isolation doesn’t work either. It’s all well and good to campaign to keep a hospital open, but we do actually live in a world of finite resources and people and so if we keep the hospital, there may be other tough cuts to make. We have separated out huge aspects of budgeting that really belong together. That is why a people’s assembly in a town/city/region doing the complex task of participatory budgeting is a possible way forward. It isn’t actually that difficult to get people together and budgets aren’t that hard to understand. I know so many people who have extremely tight and complex budgets to manage when it comes to their own households and they do it with finesse. Multiplying the numbers up, ain’t that tricky.

When a town/city understands what it’s budget is for a year (or longer) and the people can decide what the priorities need to be I think the results could be amazing. Firstly, there might be genuine partnerships formed across cities to work in more innovative and creative ways. Secondly, there would be greater engagement and social responsibility. Thirdly, there would be less waste. Fourthly there would be emerging partnerships of gift (rather than competition) between cities for various resources.

Some argue that in such a situation, the most needy and therefore least empowered in a city could miss out. This happens currently in the national setting. For me, this is where leadership comes in. Leadership is not about riding into town to shut a hospital here, or rename a school into an academy there. Leadership is about emptying power out and reassuring all that they are already empowered. It is also about helping protect and promote those who could potentially be down trodden or forgotten. It is giving a voice to those who feel voiceless and oppressed by the dominant systems. For me that would mean promoting and protecting the needs of women (for whom there is still an incredible amount of injustice), children, asylum seekers and refugees, the marginalised poor and homeless, those with physical and mental health needs and prisoners.

Power needs to be devolved from the centre to the margins (just as Gordon Brown MP stated this week). And once the power is more regional it still needs to be continually emptied out so that communities find and serve one another, so that cities become gifts to one another and we find that the order of the house (economics) is the responsibility of all.

The Ring of Power

I’m currently reading Tolkien’s ‘The Lord of the Rings to my eldest son. We have just finished that part in ‘The Two Towers’ in which Gandalf has returned to Aragorn, Legolas and Gimli at the turning of the tide. He makes this awesome statement about Sauron the dark lord:

‘That we should wish to cast him down and have NOONE in his place is not a thought that occurs to his mind. That we should try to destroy the ring (of power) itself has not entered into his darkest dream.’

There are still the stirrings of revolution in many nations. But revolution that is based on violence and only replaces one form of dominant power with another sort of hierarchical dominance is no revolution at all.

Kenarchy is about the emptying out of power. It comes from an understanding that the politics of Jesus were about emptying out power and utterly transforming it. Leadership is not only to be kenotic (that is poured out for others), it is to be kenarchic (that is emptied out) so that we begin to understand that the lowest place is the highest place. We begin to understand that level playing fields are the order of the day. We are not looking for new political parties, but a new politics, that is a new way of relating to one another. We are not looking for new economic regulations, but a new economics. We are not searching for peace maintained through violence but a genuine love of one another, including the love of our ‘enemies’ that transforms how we live together as humanity.

William T Cavanaugh gives a radical reinterpretation of the christian eucharist in the light of this. We live in a divided world in which the ‘powers’ crush and break the multitude. When Jesus breaks bread and gives it away, he is not looking to form an exclusive club. He is, rather inviting us to partake of this kind of givenness, to embrace brokenness in the face of violence and to find that this way of life-poured-out-love finds hope in resurrection. As we eat the bread, we receive life, we become life and we give life as we share with others. The bread is given and is available to all who will receive it. Our barriers are broken down, our borders and our flags lose their relevance. We become part of this trans-local body that only exists to bring life, love and peace. There is no politics (way of doing life) that is more radical than this.

The nation state project holds power at the centre. It uses the components of money, law and control through violence to do this. I believe that as we build relationally in our localities we can find new ways of being. This is happening on a vast scale already and many stories are emerging of alternative ways of being that provide a different narrative to the dominant (economic and political) one of our day.

The Myth of the Nation State

Here begins a mini series, which will take a few blogs to get to where I want to go, but please bear with me, as I give some background to where my thoughts are currently!

I had until fairly recently misunderstood what is meant by a myth. I thought it to be a story which lacks truth. This can be the case but is only one of its meanings. It can also describe “a traditional/legendary story which may or may not have a factual basis and is used to explain some part of life.” Or it can refer to “an unproved or false collective belief that is used to justify a social norm.”

If we are going to reimagine the future, we must become more aware of some of the myths we believe to be true and question their basis for having shaped our thinking. I have recently been reading a book entitled ‘Theopolitical Imagination’ by a chap called William T Cavanaugh. It is deeply challenging. Cavanaugh argues that all politics is a practice of our imagination. The state itself, he argues doesn’t actually exist. It exists only in our imaginations. What actually exists are things like buildings, tax forms, border patrols and aeroplanes. “What mobilises these into a project called ‘nation-state’ is a disciplined imagination of a community occupying a particular space with a common conception of time, a common history and a common destiny of salvation from peril’. Our belief in this myth is so strong that a young man (or woman) from a rural village can become convinced that he/she must travel to another part of the world to kill people he/she knows nothing about. (Think on that for a minute or two). We have become reliant on the state for our provision and protection.

The nation state, as we know it, is relatively young, having only found its place in history within the last four hundred years. Cavanaugh argues that the myth was born out of the context of the ‘religious wars’ in Europe (in the sixteenth and seventieth centuries) to ‘save us’ from the ill effects of religion and enable us to live peacefully. The hope being that the borders and flags to which we would give our allegiance would save us from the divisions that plague us. Yet this has not been the case. The borders and flags in fact deepened our sense of the ‘other’ and created barriers where previously there had been less. Cavanaugh would argue that it was the ‘spirit of empire’ that used religion as an excuse for the wars, that was the real culprit. Mitchell would argue, however, that it was a complicit agreement between Church and Imperial powers that lead to the vast blood shed in the 30 years war that in turn gave way to the enlightenment and the creation of the nation state. What’s the point? The point is that the nation state is not our saviour. It is built on exactly the same foundations of empire and employs the same currencies – money, law and violence.

If you don’t believe me, then witness the economic threat of Westminster towards Scotland, or see how much clout the banks and huge corporations play in their lobbying power of government and ability to run the show. Or think about those who are held in the state of exception in our eleven detention centres around the UK alone (plenty of examples in other countries) where law is put aside to maintain the status quo, revealing the true foundation of ‘the law’. Or have you noticed how we now talk of those who die in war as being ‘martyrs’? I am not saying that we shouldn’t remember the lives of those who were given so appallingly in war, but let us also clearly see the undergirding message that strengthens the myth of the nation state. “War brings peace”. ‘dulce et decorum est pro patria mori’…. it is sweet and right to die for one’s country…….

The nation-state project is both waning and failing. But the myth which perpetuates it is incredibly strong and acts as a huge barrier to our imagination of anything different. Peace will not come through a remodelled version of empire. True nationhood will not be recovered whilst configured as states. But there is a hope rising of something different, of new ways of being. Sometimes we have to tear down some mindsets in order to think in new ways……

An Open Letter to Theresa May, Home Secretary

Dear Theresa

I hope you don’t mind the informal greeting, as I’ve never had the opportunity to meet you, but I believe in a level playing field when it comes to communication and I find that titles can get in the way of that. I also wanted to use your first name, because it is somehow more human and I want to appeal to you as a fellow human being, before addressing you as our current home secretary. There is a very high probability that you will never read this, so I thought I would write it as an open letter to engage others in a vital conversation.

The reason for my letter is to appeal to you on behalf of the hundreds of people you are currently detaining in any one of the 11 Detention (Immigration Removal) Centres located throughout the UK. There have been several reports of the dreadful treatment of fellow human beings, people we call our brothers and sisters, in this wide and varied family of humanity. Even your chief inspector of prisons calls the conditions ‘appalling’. Many of these people have been victims of torture and abuse from which they have fled only to be treated in a simply disgusting way in this nation. You are even detaining pregnant women and children (141 children that are known of in the last 5 years). These beautiful human beings are treated in an altogether sub-human way.

Georgio Agamben writes of the ‘State of Exception’. I’m sure you are aware of his writings, but if not, this ‘state of exception’ describes how a human being can be both simultaneously bound and abandoned to law. It reveals what really undergirds a nation; that which we are willing to put aside to maintain the status quo. The detention of people in this way reveals a vile underbelly and a rotten foundation to this nation state. These detention centres are our very own example of Guantanamo Bay, where people are held without hope of a fair trial, justice or human kindness. Essentially, by keeping people who are deemed to have failed in seeking asylum in these detention centres, you “erase any legal status of the individual, thus producing a legally unnamable and unclassifiable being.” (Agamben, State of Exception p7). To treat any person who does in fact have a name and a face in such a manner, is altogether inhumane and utterly wrong.

In our house, we try to live with the following kind of philosophy:

In this house

As home/house secretary, I wonder if you think the home/house we are creating in this land is reflected in these removal centres? I know you will argue that this land isn’t their home, which is why we are sending them back to their country of origin (which I doubt they could really call home or they would not have fled it). But there is something so very wrong about how you are allowing them to be treated. You know fine well from serious case reviews that terrible errors have been made in sending people back to their country of origin, leading for example to the death of a lesbian woman in Uganda. You know there have been and continue to be atrocious abuses of basic human rights in these detention centres. You know that people are being denied access to vital medical treatment (www.medicaljustice.org.uk). You know that at least one person has been unlawfully killed at the hands of your profit making making friends, G4S, who run these centres for you. Yet you are allowing it to continue. Theresa, how is this loving? How is it kind? How is it human?

I am sure your job is filled with complications and difficult decisions, and I am sure that there are some who may well need deporting to another land, but do not let the office you hold become separate from your humanity. I appeal to you as a fellow human and I appeal to you as the home secretary to do an urgent review of these centres.

I would like to suggest the following:

1) Please would you spend a day in each of detention centres and simply hear the stories of those you are detaining there. Then please look them in the eye and justify your decision to allow them to be treated as sub-human.

2) Please remove G4S from the management of the detention centres, as they have demonstrated a recurrent lack of love or concern for human welfare.

3) Please consider that detention centres could be managed instead by asylum charities, who have a far better understanding of the needs of those they would be caring for and can ensure that they are given appropriate access to legal help and medical intervention. This can be backed up with security if needed, but by changing the environment and approach of how we ‘detain’ people, I imagine we will have less security issues.

Thank you for taking the issues of human love and justice seriously,

Yours most sincerely

Andy Knox