If you have not followed my theoretical arguments and don't want any more of them or if you lose the thread then go to the bottom of the page - to KISS (Keep it Simple Stupid)
In the pages of this www I have attempted to develop a frame of understanding built around an analysis of the patterns of thinking which determine our actions and the "starting points" which lie behind the logic of these patterns or paradigms.
I have looked at the relationships between context - the situations in which we find ourselves and these paradigms. I have examined the way in which we establish our identity and lock ourselves into particular patterns of thinking by taking actions framed within these paradigms. To understand what is happening I have looked at discordance between paradigms, and discordance between context and paradigm. I have looked at the impact of pressures introduced by society generally or by another structure to adopt a particular paradigm which is discordant with the context. These www pages describe the way health care has been required to turn itself into a corporate market - and the consequences. The paradigms are totally incompatible.
I have looked at the ways in which people respond to conflicting paradigms. I have identified a group of people most likely to adopt discordant paradigms by using the concept of open and closed mindedness, with an extreme I have called successful sociopathy. This reveals how in discordant situations closed minded people or sociopaths are more likely to prosper. These are people who are least suited to the context and most likely to behave in disturbing ways. I have characterised this as a dystocian form of Social Darwinism.
I have spoken about Eva Cox's ideas about a Civil Society. In doing so I examined formal structures, contrasting them with the informal structures which play an important role in a civil society.
The paradigm or framework for understanding human behaviour that I have advanced lies behind most of the pages on this www site and emerges overtly in a number of them.
The ideas are introduced in a page entitled "Understanding the corporatisation of health care". This links to some other pages which are more explicit in addressing theoretical concepts. A page "Analysis of Corporate Culture and Practices - Lessons (Sun Healthcare as an example)" is recommended because it explores and elaborates the ideas further in a practical analysis of corporate activity. The concepts become clearer. The significance of the starting points which underlie belief systems is examined in a page "Starting points". The conflict between paradigms is addressed in a page "A clash of worlds" The significance of language in defining the way we see the world and the way we distort it by creating unreal abstractions to support ideology runs through the pages. John Ralston Saul is quoted on a number of occasions. A page of quotes is illuminating, both in exposing the paradigm conflicts and in analysing the impact of language. There is more in an introductory page to the section on analysis and criticism. The extent to which paradigm conflicts can distort the provision of humanitarian services is exposed particularly well in an analysis of Tenet/NME. There are so many revealing documents available and the consequences are so bizarre.
Eva Cox's ideas for a civil society also dot
the pages but not in depth. They appear particularly in a page on
which examines formal and informal structures.
I have expressed some ideas about human behaviour and the importance of the way we think. I have used them to criticise the corporatisation of health care. The ideas I have used have nothing to do with the actual ideas which we use in a particular situation. It is useful in criticising and critically evaluating. I cannot use a theory about ideas to design a health system or any other system for that matter. it would be a serious mistake.
Usefulness:- I find these ideas valuable because they explain why dysfunctional outcomes occur and suggest ways in which we might encourage the development of paradigms which are more likely to have beneficial outcomes. We can look at what is happening and what is proposed and form opinions about likely positive and negative outcomes.
The analysis reveals that there is a clear discordance between the starting points of market theory and the provision of health and aged care. The idea of building corporate empires and profitable businesses from the money society provides to address the misfortunes of our citizens jars most horribly. There is also a clear concordance between health care and the paradigms of community and Samaritanism. Different groups in society carry these contrasting and mutually exclusive paradigms, They build their lives using them.
Context and Concordant Groups:- Central to the health care context are two groups of people, health care professionals and citizens interested in preventive and therapeutic care. Although there are subgroups, competitive conflicts, power disparities and social separations which lead to somewhat differing perspectives they share common starting points arising from community and Samaritan traditions. There is much common ground to develop provided cooperation and trust, rather than competition and distrust drives the debates.
Outside Groups and Discordance:- I have suggested that politicians, economists and the business community are discordant entities promoting paradigms which are discordant in the health care context. They have priorities which differ from those directly involved in the health care context. They are not directly involved in the health care encounter.
Politicians are the representatives of the people and should be vitally interested as facilitators and implementers for health care changes. Economists and businessmen embrace paradigms which are discordant in health care. They should accept that health care is not a socially legitimate domain in which to exercise their entrepreneurialism.
Once they understand this and grant the health care paradigm legitimacy then they will be in a position to offer suggestions. They can help to build relationships and processes which mediate between different structures and different paradigms. health and the market intersect at multiple points. Together they need to confront and handle conflicts.
For the market and health care to live in harmony it is essential that each recognise and respect the legitimacy of the other in its own domain. They are interdependent. The market is a very important part of society. By reaffirming concordant paradigms, addressing paradigm conflicts, establishing shared values which define their relationship to one another, and by developing norms of legitimate conduct when dealing with one another we might have some hope of addressing the serious problems in health care identified by both Ray Mohnihan and Marilyn Walton in Australia.
Advancing the Health Care Debate:- Paradigms concordant with the health care context are best developed in the health care context by the people most directly involved, trusting and communicating freely with one another. Conflicts develop when people distance themselves from one another and meet behind closed doors to plan how best to outwit perceived opposition and promote their own position at the expense of others. If as a group we grant someone else status we build trust. They are less likely to be threatened and more likely to reciprocate. The idea of stakeholders each negotiating for personal advantage is part of the competitive market paradigm. It has no place in a civil society. Here the community based concept of "common good" holds sway.
Competition:- In a context where responsibility to others is the prime starting point, the impact of competition needs to be carefully examined. While competition is a potent motivating force it creates pressures for personal advancement which potentially threaten the community paradigm. The structure of services should define legitimate areas for competition as well as norms and values which constrain it. Paradigm conflicts within health care as well as conflicts with paradigms in other sections of society need to be confronted and addressed. Norms and values to handle the complexities and nuances of society grow in the informal structures of society and should then be reflected in the formal structures and the relationships between them. In a civil society their legitimacy would be recognised by all sections involved and then be given legitimacy by the wider society.
Using Informal Structures:- It is inappropriate to use formal structures and processes, imposing laws and regulations as the starting point for change. This is how our governments have operated. It alienates and is seldom successful. It creates an uncivil society.
The debate can be lead by representative groups but must extend into and involve all of those providing health care and those receiving it. By doing so we develop the informal structures, which become the repositories for concordant paradigms, - the norms and values with which people identify. In a civil society formal structures when they are developed represent and give objective form to informally developed paradigms, norms and values. They consequently rest lightly and are seldom used. The system is inherently more stable and less likely to fracture and need recurrent patching.
We must take great care that politicians do not frustrate the process by setting the agenda and so obtaining the outcomes they want. Another debate like that on a republic would be a great disservice to Australia. Politicians must learn to relinquish power if they want to retain it.
Critical Considerations:- Clearly the increasing cost of health care, the aging population and rationing are critical issues to be resolved. Paradigms and structures congruent with the health care mission will be required to deal with these. What health care needs is sympathetic advice and suggestions as to how these matters might be addressed and economists can help. It is the responsibility of participants in health care to select which strategies are appropriate for the health care context and congruent with health care paradigms. Open mindedness and a secure constructivist approach would identify and address paradigm conflicts. Once they are acknowledged, norms and values can be developed to handle them and subjugate them to the primary staring points.
Integration:- Medicine has developed to a stage where decisions have very major impacts on the lives of citizens and the knowledge base is so wide that none of us can grasp it. Personality differences, identity issues, closed mindedness, plain forgetfulness, mental lapses and a plethora of other factors threaten our patients. Some form of professional integration is therefore essential. A sense of personal responsibility cannot become professional isolation. Horizontal integration across members of a group as well as vertical integration with highly specialised supportive specialties are required. Technology makes this possible in ways which were previously unimaginable. My use of the words vertical and horizontal integration is very different to that in the marketplace. They are mutually exclusive.
The process of reform:- I want no part of grand ideas and tightly defined models. There is no place for scare tactics, a sure sign of ideological solutions which do not stand up to scrutiny. I am not arguing for any particular model for health care. I am promoting a carefully thought out and coordinated process as a means of generating understanding and setting directions. We need to set a sense of where we want to be, and a careful exploration of the steps in getting there. It then becomes a step by step process of trial and evaluation and not a revolution to change everything at once. We already have something which has served us well.
While grand plans should be suspect there should be many ideas and clearly I have some of my own. I have hinted at some of them on these www pages. What is important is not any particular solution, but the nature of the participants and a process which involves all the groups both centrally and at a grass roots cultural level in the hospitals and the clinics.
Personal views:- If I tried to promote my own ideas here it would divert attention from the failures of the market, and the processes for progressing the health care debate. I would undermine the points I am making. I would direct attention to the solution I proposed and criticisms of it and this would be counterproductive. What I am looking for is something which comes from the people directly involved. I would I see this as the recipe for success. I see this as the message of postmodernism - the broom to sweep away the debris of the 20th century. If I can progress the process and promote constructivism by debating my ideas that would be exciting.
Optimism and Pessimism:- It is encouraging that groups of interested citizens such as the health issues centre in Victoria are forming in each state and that the consumers association, nursing groups, and a number of medical groups are meeting to talk and plan. It is discouraging that a study from the Sydney University of Technology (Courier Mail 16/10/2000) reveals that the proportion of citizens involved in voluntary work and not for profit organisations has fallen from 30% to less than 20%. I see this is a marker of a civil society. If we are looking for a sense of community on which to build a civil society and a health service which encourages community participation then this is very depressing.
Away from a civil society:- Society and its structures are intimately interwoven and exert a profound influence on one another. An effective health service cannot exist is a society which does not support its ideas and what it does. The market cannot operate effectively unless society believes that what it is doing is legitimate and supports its ideas. There is every indication that the market has gone far too far in redefining beliefs and practices, and in attempting to subjugate society to its views. The community are patently distrustful and cynical. Society is fracturing along new lines and there is a new militancy. There is a struggle to develop paradigms to define this discontent. We are moving away from a civil society.
Returning to a civil society:- If society has a responsibility to nurture health care then health care has a responsibility to play a positive contributing role in society. Health and aged care more than any other activity embodies the ideas of a civil society - groups of citizens working together for the common good. It is ideally placed to build social capital by involving the community in planning, structuring and running a health care service. The public have consistently performed well in confronting failures in the health system, particularly those created by the marketplace. The hollowness of the government's commitment to a civil society is revealed by the use of Shell Petroleum to promote their commitment. Shell has a tarnished human rights record and is looking for a positive image to counteract that - something to do with marketing.
Progressing Democracy:- Two party democracy is a great advance on totalitarianism - but it is a compromise. Democracy is continually threatened and cannot stand still. Choice in the two party system is limited to bundles of policies. We may not like a party's health policy but prefer its economic policy. We have to choose and cannot have both.
Democracy is particularly prone to influence by powerful groups and is seriously threatened by the dominance, wealth and power of corporate groups - particularly multinational megacorps. There is much to suggest that in some countries they already use their market positions and wealth to control government and buy the policies they want. There are good reasons why the community may wish to address many issues themselves using a modernised technology based version of Athenian democracy.
This imbalance of power is particularly apparent in globalisation where multinational corporate groups have imposed their own version of democracy. It is clear that many citizens have realised what is happening and have very different ideas about what globalisation entails and the benefits it offers - including truly representative governance.
Postmodern thinking as I interpret it would call for a devolution of democratic process returning, decisions and operation of some activities to community settings. Technology makes this possible. The community can take back functions which it delegated to government. There is no reason why government should control all funding and the distribution of all public monies.
It is possible for the community itself to decide how certain activities are funded, what levies should be raised and how they will be spent. Health care is a good starting point. It is of vital interest to us all and politicians have not done well. The community is well placed to decide how much money it can afford to spend, how it should be raised, how it should be expended, what it will pay for and what it will ration. There is no reason why every facet of national activity should be tied to the particular party in power. The wild fluctuations in health care policy over the last 20-30 years have simply destabilised the service.
This may sound radical. About 15 years ago I tried to promote computerised medical records, and digital support for clinical decisions. This was considered way out and unlikely. What a difference 15 short years have made.
Theoretical basis for the pages on this
www site:- Few of us have truly independent ideas. We grasp the
ideas of others and bend them to the contexts of our lives. Clearly I
have done so. I have filtered the ideas of others through my own
Health care is about our responsibility to others. Most politicians, businessmen and economists come from a world where the prime motive is the generation of profit for themselves and their shareholders from the situation they find themselves in. They lose credibility in the marketplace if they deny this. This is totally out of step with what we want to accomplish in health care. These groups have created a dogs breakfast out of health care. They should learn from their mistakes and in their own words "butt out".
Health care is a "social structure" - a system of ideas and people working for society. What is does and how it works is something which has been developed by people providing care and those receiving it. This is a social process. It is how a civil society works. However much practices have deviated from what they claim to believe the underlying ideas these people bring to their involvement are all about care, responsibility and helping one another. They lose credibility if they deny this. When there are pressures in the system then clearly it is these people who should start talking to one another, throwing around ideas, and developing new ideas - making changes.
Politicians, the representatives of the people have an interest in health care and a responsibility to the community. They should be facilitators and implementers of social processes. They pass laws to give objectivity and legitimacy to the beliefs and practices of the community. This is not a role they always accept.
The market is a core structure in society and intersects with health care at multiple points and the number of these is increasing rapidly. The market must recognise the legitimacy and primacy of the patterns of thinking in health care. They need to be helpful, make suggestions and together they should manage the points of intersection. The consequences of not doing so are revealed in the disturbing findings of Ray Mohnihan and Marilyn Walton in Australia.
I have not suggested a new system of health
care, nor have I suggested that we keep what we have got. I have
suggested a process by which we can advance the provision of health
care. It is the very opposite of that used to turn health and aged
care into a market and fill it with market listed corporations. This
has been a disaster. When Colleen Fuller examined similar
developments in Canada she concluded that we had taken the wrong road
and that we should try another. I have developed some ideas, a
compass which I suggest will help us to find a better road to where
we decide we want to be.
(Colleen Fuller "Caring for Profit")