Thursday, February 27, 2014

Dishonesty in making peace

The Treaty of Versailles reneged on the terms of the Armistice. This dishonesty in making peace directly led to the second world war and indirectly to many conflicts following it, with the loss of millions of lives. Dishonesty in making peace is a dangerous precedent. 

No matter how abhorrent the crimes of John Downey and other criminals who were given what appears to be an amnesty (notwithstanding that these agreements may have been made in less than transparent circumstances), to renege on these agreements is treading on very thin ice.

Wednesday, February 26, 2014

Lean methodologies, KPIs and the NHS: A recipe for trouble?

The concept of lean originated from Toyota and is founded on a model of continuous product and process improvement and the elimination of non-value added activities. The value adding activities are simply only those things the customer is willing to pay for; everything else is waste, and should be eliminated, simplified, reduced, or integrated.

One of the significant aspects of lean is that of key performance indicators (KPI). The KPIs by which a plant/facility or organisation are judged will often be driving behaviour, because the KPIs themselves assume a particular approach to the work being done.

In the NHS, KPIs are used to examine and compare performance across NHS organisations. These indicators focus on areas such as length of stay, costs per episode of patient care and number of staff employed. Many assess efficiency within the service, whilst others examine clinical performance. The intention is to define a service and judge its effectiveness and KPIs also provide benchmarks to implement incentives and sanctions in an effort to improve overall quality. However, there is little or no evidence of what sorts of incentives and sanctions actually work to drive up quality.

For example, a Child and Adolescent Mental Health Service (CAMHS) that has approximately 100 referrals per month, has KPIs that define service levels with regard to how referrals are managed. Urgent cases need to be seen within 24 hours, with a follow up within a week. Another KPI is that young people who require assessment but are not urgent will be seen for a routine assessment within three weeks of the referral being made. There are also limits imposed regarding the number of cases not appropriate for specialised CAMHS who can be signposted to other services, for example local authority family support.

In terms of sanctions, if a young person is not seen within that period, the service will be penalised with a reduction in funding of £30,000. In a team that is already undergoing budget cuts and staff losses, it is hardly surprising that meeting KPIs dominates the management of the team, and leads to an emphasis on getting though as many assessments as possible. The downside of this emphasis is less attention being paid to the actual interventions and therapies provided for young people and their families; caring for desperately troubled young people has become simply a matter of meeting targets.

It is important to recognise that these KPIs were established by the commissioners of the service, and agreed by the senior managers of the service, none of whom have any clinical experience of working within CAMHS. This process also provides an insight into a significant flaw in the artificial ‘internal market’ of the NHS; those specifying and agreeing services may have little knowledge of the service and often do not consult with the practitioners.  

Another KPI specifies a DNA (did not attend for appointment) rate of 10%, so not only is the practitioner's time wasted at a cost to the service, but the service is punished by financial sanctions if the DNA rate goes over 10%.

One of my concerns with the lean culture is that it pays little attention to the wider impacts an organisation can have on the context in which it operates. For example, by ordering parts’ just in time’ from external suppliers, the external suppliers are bearing the costs of uncertain revenue streams and fluctuating demands, which may tempt them to cut costs in other ways; perhaps by employing staff on fixed term or temporary contracts – thus shifting uncertainty down to the workers themselves.

Other criticisms of lean are that lean practitioners may easily focus too much on the tools and methodologies, and fail to focus on the philosophy and culture of lean, or that management decides what solution to use without understanding the true problem and without consulting shop floor personnel. As a result lean implementations often look good to the manager but fail to improve the situation.

Whilst many hold up Toyota as an exemplar for lean working, it might be borne in mind that earlier in February, Toyota announced it is recalling 1.9 million of its Prius hybrids, 30,790 of which are UK-registered, because of a computer problem that could cause the vehicle to stop. This follows a series of recalls over many years as listed below:

Sep 26, 2007 – US: 55,000 Camry and ES 350 cars in "all-weather" floor mat recall
Nov 02, 2009 – US: 3.8 million Toyota and Lexus vehicles again recalled due to floor mat problem, this time for all driver's side mats.
Nov 26, 2009 – US: floor mat recall amended to include brake override and increased to 4.2 million vehicles.
Jan 21, 2010 – US: 2.3 million Toyota vehicles recalled due to faulty accelerator pedals[ (of those, 2.1 million already involved in floor mat recall).
Jan 27, 2010 – US: 1.1 million Toyotas added to amended floor mat recall.
Jan 29, 2010 – Europe, China: 1.8 million Toyotas added to faulty accelerator pedal recall.
Feb 08, 2010 – Worldwide: 436,000 hybrid vehicles in brake recall following 200 reports of Prius brake glitches.
Feb 08, 2010 – US: 7,300 MY 2010 Camry vehicles recalled over potential brake tube problems.
Feb 12, 2010 – US: 8,000 MY 2010 4WD Tacoma pick-up trucks recalled over concerns about possible defective front drive shafts.
Apr 16, 2010 – US: 600,000 MY 1998–2010 Sienna minivans for possible corrosion of spare tire carrier cable.
Apr 19, 2010 – World: 21,000 MY 2010 Toyota Land Cruiser Prado and 13,000 Lexus GX 460 SUV's recalled to reprogram the stability control system.
Apr 28, 2010 – US: 50,000 MY 2003 Toyota Sequoia recalled to reprogram the stability control system.
May 21, 2010 – Japan: 4,509, US: 7,000 MY 2010 LS for steering system software update.
July 5, 2010 – World: 270,000 Crown and Lexus models for valve springs with potential production issue.
July 29, 2010 – US: 412,000 Avalons and LX 470s for replacement of steering column components.
August 28, 2010 – US & Canada: approximately 1.13 million Corolla and Corolla Matrix vehicles produced between 2005 and 2008 for Engine Control Modules (ECM) that may have been improperly manufactured.
February 22, 2011 – US: Toyota recalls an additional 2.17 million vehicles for gas pedals that become trapped on floor hardware.

Saturday, October 26, 2013

Russell Brand’s Revolution: A call for systemic thinking?

Russell Brand’s idiosyncratic but perceptive call for revolution is welcome.  I welcome it because it is one of the most public articulations of the need for us to think differently about our relationships to each other and with the planet.

Brand was invited to edit an issue of the New Statesman  and he outlined some of his ideas in a recent interview with Jeremy Paxman:

Not voting, from Brand’s perspective makes sense; voting to change the system maintains the system.  However, Brand’s revolution is not one of apathy, nor is it a revolution of bloodshed and uprising. It is a revolution in how we think.

This revolution has been slowly gaining momentum since Gregory Bateson outlined what he called a ‘cybernetic epistemology’; a way of thinking in terms of relationship, of recognising patterns, a way of thinking that also requires humility and an appreciation of the sacred.

 “What pattern connects the crab to the lobster and the orchid to the primrose and all four of them to me? And me to you?” he asks us to consider at the outset in Mind and Nature (p. 8).

This focus on both the content and relationship aspects of all messages invites us to think about pattern also in human relationships and how we create patterns that we live and that define us. And it is becoming vital that we heed and respond to this need.

Bateson warned us in his essay Form, Substance and Difference (in Steps to an Ecology of Mind, 1972):

“If you put God outside and set him vis-a-vis his creation and if you have the idea that you are created in his image, you will logically and naturally see yourself as outside and against the things around you. And as you arrogate all mind to yourself, you will see the world around you as mindless and therefore not entitled to moral or ethical consideration. The environment will seem to be yours to exploit. Your survival unit will be you and your folks or co-specifics against the environment of other social units, other races and the brutes and vegetables.

If this is your estimate of your relation to nature and you have an advanced technology, your likelihood of survival will be that of a snowball in hell. You will die either of the toxic by-products of your own hate, or, simply, of over-population and overgrazing. The raw materials of the world are finite.

If I am right, the whole of our thinking about what we are and what other people are has got to be restructured. This is not funny, and I do not know how long we have to do it in. If we continue to operate on the premises that were fashionable in the pre-cybernetic era, and which were especially underlined and strengthened during the Industrial Revolution, which seemed to validate the Darwinian unit of survival, we may have twenty or thirty years before the logical reductio ad absurdum of our old positions destroy us.

Nobody knows how long we have, under the present system, before some disaster strikes us, more serious than the destruction of any group of nations. The most important task today is, perhaps,  to learn to think in the new way”.

Unfortunately, there are the few who will not want to hear Bateson’s warning and challenge, for they have a vested interest in this status quo that in reality is a slow decline into more inequality and destruction.

Brand’s revolution is to reject this status quo in which the very few profit, and the price for this profit is paid by people who are starving, killed in conflict and sick.

Yes, we can reject this system by not voting. We can reject it by becoming critically aware of the propaganda spewed out of the mainstream media that services the needs of the few.

But this revolution is not just about rejection of an old, unfair and destructive system. It is about accepting others, about sharing ideas, engaging in dialogue, and re-evaluating our relationships.

Thursday, October 03, 2013

Blaming the vulnerable

A 'terrorist' with Asperger’s, an abused mother with alcoholism who kept the corpse of her child that died of starvation for 2 years in a squalid home, a murderer who was not being treated for his mental illness....all symptoms of a 'broken society'; a society broken by a lack of resources for mental health and social care, a society where the vulnerable are castigated and the people who work at the front end are blamed for what are systemic failures. The Conservative conference tagline ‘for hardworking people’ and Cameron’s closing remark "Together we'll build a land of opportunity for all” are just empty sound-bites to keep the faithful happy while all the while, the rich carry on getting richer and richer. I am beginning to despair. How many people are suffering right now? How more people and children have to die before we see some real change?

Saturday, September 28, 2013

Addiction to power

When only the 1% are left, there will be no more profit. They will own a barren world created by their addiction to power.

Wednesday, March 06, 2013


In the UK, the public sector is continually being squeezed with demands to improve performance.

Performance is measured by achievement of targets. A focus on ticking boxes rather than thinking about patient's needs led to the appalling Mid Staffs situation.

Why did this happen?  Because ticking boxes keeps the commissioners of services happy.

Who are these commissioners? Believe it or not they are also NHS employees, but they are the purchasers in the ludicrous ‘internal market’ that is the ‘modern, efficient’ NHS.

Why an internal market? Because politicians and ideologues did not like doctors deciding what was best for their patients.

Recent evidence published in the Lancet indicates that health in the UK is lagging behind other countries. The response from Jeremy Hunt (the UK Minister for Health) is "For too long we have been lagging behind and I want the reformed health system to take up this challenge and turn this shocking underperformance around."

Translated: ‘We need more boxes to tick’

He wants more people to go for regular health checks to spot diseases earlier and he is calling better joining up of NHS services so that patients don't get lost in the system.

Well, no shit, Sherlock.

He also says that many deaths happen because the NHS is not good enough at preventing people getting sick or because treatment does not rival that seen elsewhere in Europe.

So let’s blame the NHS, shall we, Jeremy? It makes a change from blaming the population, I guess.

Here is something to think about.

The health of the population in the UK is contextual.

People eat crap food full of corn fructose, starch and horse meat because food producers manufacture cheap, crap food to keep the prices down.

Lots of people in the UK are poor and have little choice but to buy cheap food sourced by supermarkets (who incidentally screw producers to keep costs down – after all, supermarkets are ultimately about profits and dividends)

People drink and smoke too much too. That could be because lots of people in the UK are unhappy.

The context of health (and other issues like crime and education) in this country is that, like in the US, around 40% of the wealth is owned by less than 1% of the population.

We all know politicians lie or are ‘economical with the truth’ and that many politicians represent the interests of the elite.

But the even bigger lie is that politics makes any difference. Even having the vote makes little difference as far as the gap between rich and poor is concerned; nothing has changed in hundreds of years.

Mainstream politics is a sideshow, a diversion from the reality of inequality in our society, and it is this inequality that needs to be addressed.

Anything else is just a distraction, like taking an aspirin to treat a cancer.

Thursday, January 05, 2012

Bateson as scientist and therapist: Steps towards ‘fourfold vision’

 Some thoughts (due to be published and presented later this year) on Bateson and therapy....

William Blake, 1825, Job Affrighted by a Vision of his God

Bateson was a scientist, he was precise and loathed ‘muddled’ thinking but he also advocated being human with patients (he actively treated patients between 1948 and 1963) and part of what he attempted to do was ’help them find valuable patterns in their lives’.

Whilst known more as a theorist than therapist, Bateson,  in this transcript of a patient interview in 1958, revealed a disarmingly transparent way of being with others, here in a conversation with a family about why they often moved location:

Bateson. I agree with much of what you say.
Mother. Moving is just for the birds
B. Having been an old –
Father. (laughing)
M. And even birds stay in the same nest (laughs).
B. – been an old mover myself. I spend time in New Guinea, in the Dutch East Indies, and God knows what else.
M. Well –
B. But –
M. It’s all right if you’re built that way. I mean each person has to do –
F. No.
B. I don’t know.
M. The reasons have to be voluntary. Mine are involuntary, I know –
B. I was frankly running away from all sorts of things.
(Bateson, cited in Lipset 1980 p. 220-221)

Jay Haley, in a personal letter to Lipset, suggested that Bateson would  ‘…stay up all night with alcoholics, to get them through…He felt that being human with people was good for them’ (Lipset, 1980 p. 215). R.D. Laing, who observed Bateson in 1962, considered that, like some of the best therapists, Bateson didn't regard himself as a ‘therapist’, suggesting that “....If I was the patient in the session, I certainly wouldn’t have felt there was anything to be frightened of...he never indicated that he thought in terms of actually actively adopting strategic, practical means to use to pry people out  of the entanglement they were in...” (Lipset, 1980, p.220) According to William Fry, Bateson was like an anthropologist with families; more of an observer than clinician or therapist, and would “...Switch between that role and a sort of friendly mother’s brother...raising tantalising and significant issues...They were very intuitive and hit the nail on the head, and would do all sorts of terrible things...creating insights and stirring family patterns up”. (Lipset, 1980, p.219-20)

Bateson showed compassion and intuition in his interactions, and he often emphasised the importance of therapists and doctors ‘being human’ with their patients, but was simultaneously able to also take on a more ‘scientific observer’ position, too and seemed to shift between these different positions. Eventually, he became disillusioned with psychotherapy, in part because of Haley’s inability to fully understand epistemological issues, particularly with regard to power, and left to study dolphins.

Haley again: “Bateson didn’t like power. He didn’t even like the word...anyone who said ‘I’m going to change this person’. If they said ‘I will offer this person some ideas, and if they change, it’s up to them,’ then Gregory would have no trouble with them. But if you take responsibility for changing people, then you would have a problem...Any influence outside the person’s range is odious to him. Any indirect manipulation is [also] out of the question”. (in Lipsett, 1982, p.226)

‘Power’ is a problem because we believe in it. Bateson agreed with Haley that power is a central human concern; he just wished that us humans would stop believing in power because the pursuit of power entails epistemological errors of thinking that always cause trouble.  At the very least, the extent of our power-seeking seems to be influenced by culture. Instead of thinking of power in human relationships, we would be better served by reflexive dialogue about the ‘metaphor of power’, and see ourselves as simply parts of a larger situation. (Harries-Jones, 1995)

Bateson talks of power and lineal control in the domain of scientific explanation, whereas, as therapists, when we talk of "power," are speaking in the humanist domains of experience and description.  “It is profoundly different to speak of power and lineal causality in the domains of experience or description as opposed to speaking of these matters in the domain of scientific explanation”. (Dell 1989)  We need to be able to move between these different positions of both punctuation and of abstraction – but how?

According to Charlton (2008), Bateson considered that psychology was evolving in two directions:
Humanist – working with clients as one human being with another, intuitively responding from personal emotional resources to ‘act spontaneously out of his own integrity’.
Circularistic – consciously scientific, articulate about methods and results, aiming for predictability and logical coherence.

Bateson saw a way forward as a compromise; a working together of both types of practice; between intuition and examination/description, each informing the other. Charlton adds to this:

“Humanist, scientist, artist and theoretician are all needed to form the cybernetic unity of healing” (Charlton 2008, p. 94)

In my opinion, therapy truly influenced by Bateson would involve moving between all four positions (Humanist, scientist, artist and theoretician) and having the wisdom to value them all.

Now I a fourfold vision see,
And a fourfold vision is given to me;
Tis fourfold in my supreme delight,
And threefold in soft Beulah's night,
And twofold Always. May God us keep
From Single vision & Newton's sleep.
William Blake, Letter to Thomas Butt, 22 November 1802.

A crude description of Blake’s fourfold vision might be:
Single Vision –  ‘Newton’s sleep’ - linear thinking. Knowledge. Rational. Material.
Twofold Vision – Appreciating our connection with nature and the environment.
Threefold Vision – Unconscious processes, memory and intuition.
Fourfold Vision – The delight of experiencing single, twofold and threefold vision, with constant twofold visioning in daily life.

I would like to offer this version for therapists (and others who are engaged in 'people work')

Single Vision – The Scientist: 

  • Good observation skills. 
  • Linear descriptions: 
    • What is the issue? 
    • Who is involved?
    • When does it happen?
    • Where does it happen?
  • Consideration of non-systemic explanations
    • e.g. physical illness, disabilities

Twofold Vision – The  Theorist:

  • Consciously scientific observation of patterns within the family system. 
  • Circular causality. 
  • Relational aspects.
  • Systemic theorising.
  • First order cybernetics.

Threefold Vision - The Humanist: 

  • Being human. 
  • Connecting with personal experiences and intuitions, embodied aspects of practice. 
  • Empathy. 
  • Self of the therapist.
  • Disclosure and transparency.
  • Second order cybernetics. 

Fourfold Vision - The Artist: 

  • The aesthetic delight of working with and between single, twofold and threefold experience.
  • Self of therapist and family located and theorised in wider and wider contexts. 
  • Higher levels of abstraction.
  • Mystery. 
  • Sparkling moments.

Bateson, G. (1972) Steps to an Ecology of Mind. Chicago:  The University of Chicago Press.
Charlton, N. (2008) Understanding Gregory Bateson: Mind, beauty and the sacred Earth. New York: SUNY Press.
Dell, P. (1989) Violence and the Systemic View: The Problem of Power. Family Process,  28: 1, 1-14.
Harries-Jones, P. (1995) A Recursive Vision: Ecological Understanding and Gregory Bateson. Toronto: University of Toronto Press.
Lipsett, D. (1980). Gregory Bateson, the Legacy of a Scientist. Boston: Beacon Press