Scotland’s independent think tank
Scotland’s independent think tank

A Paradigm Shift is Needed – John Sturrock KC

To address fully the challenges in the provision of health care and social care in Scotland, I sense that we may need a paradigm shift. In other words, a fundamental change in our way of thinking about how we deliver health care and social care. To paraphrase Einstein, it may not be possible to solve our problems with the same thinking which was used when the NHS was established in the 1940s. Things have changed so much since then and we need to frame the discussion in terms of the circumstances which exist today.

As the OECD said, boldly, in a report a few years ago:

“We’re beyond quick fixes to address the discontent of people. There is no returning to the past. Too many things are not working for too many people. The only way forward is not to patch up …, but to shake it up.”

To achieve such a shift is not easy. It may mean examining some of the very foundations of how things are currently done and challenging some of the basic precepts upon which present thinking is based. That doesn’t necessarily involve throwing everything out of the window. But it does mean having the courage to ask important – and possibly challenging – questions about what we have been doing and what we may take for granted, to look at things in a way we may perhaps not have done before.

We need to be aware of the ‘danger of the single story’, of assuming that there is only one way to view things. There may be multiple perspectives, each one having validity from the viewpoint of those observing or commentating. Perhaps only by considering many views, even if apparently outlandish, provocative and contrary to current ways of thinking, will we open up the possibility of really creative and innovative solutions.

Such an approach also requires humility, and an admission that we don’t have or know all the answers. Humility takes real courage and can be the source of much wisdom. The leading economist, Sir John Kay, in his latest book ‘The Corporation in the 21st Century’, describes how leaders in large organisations can never have all the information needed to make decisions, nor can they anticipate what might happen in the future. We must therefore abandon the pretence of knowing the answer – ‘the pretence of knowledge’ as he describes it. Perhaps only then can we embark properly on the process of exploring change.

If we do so, we might conclude, for example, that top-down solutions are unlikely to work and cannot be imposed, that centralised control and hierarchical management is not the way forward. The modern NHS is one of the most complex institutions we have yet devised. Things are arguably just too complex, volatile, radically uncertain and multi-faceted for a one-size-fits-all approach. That may mean enabling – and trusting – people in different settings and localities to make decisions, based on their own experiences and knowledge. Empowering them to make choices, with all the benefits that would bring. That carries the risk, of course, that some of these decisions and choices may turn out to be wrong. It’s a balance. But we learn from what doesn’t work as well as from what does.

John Kay writes that, in large organisations, it is not possible to issue peremptory instructions to subordinates. It is necessary, he says, to assemble and share the collective knowledge and experiences of many people in the organisation, resulting in what he describes as problem-solving ‘collective intelligence’, enabling better use of resources. In such an institution, relationships cannot be purely transactional; indeed, a transactional approach is both repellant and mistaken he says. Might this analysis apply to the provision of health care and social care in Scotland too?  In particular, in order to adapt to a rapidly changing environment with rapidly evolving needs and technologies, might leaders and others need the freedom to do new things without central approval?

New thinking would require genuine collaboration in practice, not just talking about it. It could mean a shift from what some may see as a transactional, incentive-driven, reward/punishment model, in which individuals sometimes feel like heavily monitored cogs in a wheel, to one founded on strong, respectful relationships throughout the system, where skills and contributions are valued and affirmed. The stronger the relationships, the more resilient the system, as it was once put. Strong relationships are ‘the catalyst for everything’ as another describes it.

That may mean encouraging, prioritising and valuing in-person encounters, however informal, rather than relying on remote, distant communication. ‘Room not Zoom’ is a phrase one hears more and more although, of course they are not mutually exclusive. Creating safe spaces for real and sometimes difficult conversations may be as important as any other policy shift. The very recently published book ‘Informality in Policy-Making’ emphasises just this point. And it might just make the really difficult stuff easier to do.

This approach aligns, it seems to me, with what John Kay describes when referring to Mihaly Csikszentmihalyi’s idea of ‘flow’: “the elation that comes from complete engagement in the successful performance of a difficult task”, emphasising the meaning and purpose that reflects the intrinsic motivation that drives so many to work in health care and social care. Let’s re-engage those drivers.

New thinking might, therefore, entail a move from targets, possibly unachievable, to greater trust and empowerment, perhaps acknowledging the illusion of centralised competence and permitting fallibility and vulnerability in the quest for vision, innovation and creative leadership. Financial resources may be limited; imagination, ingenuity and ideas are not.

Fear cannot be the driver. We should encourage a culture of taking responsibility, not avoiding blame. Political point-scoring, hyperbolic language, personal attacks, the narcissism of small differences – all of these will tend to undermine, create defensiveness and mitigate against new thinking.  There is a pressing need to take health and social care out of the party-political arena and approach it on a consensual basis. Finding a shared vision for the future and relegating small differences to the margins seems vital.

This need to transcend sectoral interests and support longer-term thinking and outcomes applies to other influential stake-holders also, not just politicians. Setting aside some well-established interests for the sake of the common good seems likely to be necessary.  But there’s the rub: how many of our politicians (and others) will feel that they have the latitude to work across boundaries?  Of course, we must recognise the pressures politicians and others face and acknowledge that sacrificing short-term gains is really hard to do when so much of modern life requires quick fixes and easy answers. Yet, somehow, we must create the environment to enable brave steps to be taken. The urgency of the situation demands no less.

Cooperation, connection and communication are key. We need to work together, enabling people within the system to thrive and feel valued and affirmed, recognising the inescapable network of mutuality, inter-dependence and reciprocity upon which a properly functioning health care and social care system surely depends. All of this is easy to say … achieving this may be a national imperative.

John Sturrock KC is Founder and Senior Mediator at Core Solutions and, in 2019, conducted a review for the Scottish Government into allegations of bullying and harassment in NHS Highland. This is a revised and expanded version of an article which appeared in print only in the Scottish edition of The Times on Monday 6 January 2025.

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