Thursday, 28 June 2012

Continuity and organisational memory

I've just finished reading Peter Ackroyd's excellent "Foundations of Britain: Volume 1'. I know I've banged on about narrative before, but this book underlines the importance of good narrative: he starts in prehistoric Britain, and creates an uninterrupted story that takes us to the death of Henry VIIth. It is compelling reading.

The history of Britain is a great yarn. It exemplifies the old adage that fact is stranger than fiction. Sometimes, the protagonists over-egged the pudding (I am thinking specifically of the Wars of the Roses, which were frankly a little silly), but it is really interesting to move from speculating about Anglo-Saxon kings that we know relatively little about, to mediaeval Kings, about whom we know a great deal more, although admittedly from often biased sources. Richard IIIrd was no more evil than his contemporaries - he just had the misfortune to lose, and ended up being an historical hostage to his conquerers' spin-doctoring.

The tendency is to partition history up into discrete eras and epochs -Stewarts, Platagenets, Tudors, and so on. But this creates some false effects: it forgets that one follows seamlessly in to the next, and that at the time, there was not the same sense of transition. It's a bit like the quiet shift on-call - much of the appreciation that it was quiet is retrospective: at the time, you spend at least some time thinking that it could kick off any moment. I imagine that this was how a great many usurpers to the throne have felt over the years.

It also over-emphasises the historical details about which we have information. If at an excavation, you find lots artefacts that have managed to survive the centuries to be discovered by future archeologists, the risk is that the role of the objects uncovered will be over-played. A stone tablet may encourage you to conclude that these people recorded their information on stone tablets, whereas the truth may be that they actually wrote on paper, but none of this has survived.

Our view of history is always partial, and always subject to the interpretation of people who did not live at the time, and therefore do not share the same cultural biases, preferences and values. All of these factors can have a profound impact on the conclusion that an historian comes to in trying to make sense of the past.

The mark of a good historian is one who acknowledges the degree of uncertainty that must exist in a post hoc explanation of past actions and events. Good historians are the ones offer you a circumspect view, rather than a rigid one, and offer you their understanding of how to frame  your own consideration, informed by their reading, research and experience. There can never be a right answer, and historians must become comfortable with that.

The role of uncertainty in history has real echoes of what it means to be a doctor. Good doctors acknowledge the uncertainty and build it in to their management plan.

But I didn't really want to talk to about uncertainty today. What I really wanted to address was the role of continuity.

The main theme of Peter Ackroyd's book is just that: continuity. He has the idea that if you concentrate hard enough you can follow a continuous history of Britain from the earliest findings and records all the way through to today. In this respect, Foundations of Britain Vol 1 is a stellar success. He does that annoying thing of making it look easy. One of the important issues that he highlights is that much of the history of Britain is told in aspects of continuity. For example, many villages and towns can trace their history back thousands of years. Churches were often built on the sights of ancient standing stones. Street plans, and field arrangements have survived for centuries. The story of the country can be traced and felt through the way that people have lived, and the way that modern life still has echoes and ghosts of the way that people used to live. There is a direct line from you, reading this blog on your computer or your phone, all the way back hundreds of years. Your own heritage may be complicated and difficult to unravel, but the collective history of Britain is etched over our daily experience, in the names we use, the places we visit, and in our cultural identity.

Around this idea of social continuity, there is resonance with the idea of organisational memory. The NHS today looks very different to the NHS of 1946, both in the the services it offers, the fabric of the buildings, and of course the people who work in it. One could argue that there should be nothing left over from the NHS of 1946, that the buildings should have been replaced, the practices modified and the management structures improved; perhaps if anything still persists, then that is a reflection of an underlying problem.

But let's not get off track - the organisational memory of the NHS is encapsulated by the way we provide health care, the way we divide labour, and the way that we organise the services. Some of these processes will have been designed from the ground up, but a great many will have been derived and adapted from the pre-existing structures and systems. The structure of the NHS today would have been impossible without the structures and systems of the past. With this in mind, ask yourself the question, what would the NHS look like if I designed it today, on a blank piece of paper.

There is no doubt that it would operate and look very different to what we currently have.

But the mistake we often make when thinking about the NHS is that there was a time zero, a day when it all started. And while this may be true in terms of enactment of the relevant Health Acts by Nye Bevan in the 1940s, we must always remember that the institution of the NHS was a triumph of politics in the midsts of some powerful political powers, significant doubts about its affordability and effectiveness, and even about its ideology. From its very beginning, the NHS was moulded to the health systems that had gone before, and these compromises still resonate in the way we operate today. The role of GPs, how they are funded and how they operate all hark back to the pre-NHS era, as does the distribution and provision of hospital care. North West London has a large number of hospitals, which date back to the days before the NHS, when the building of a hospitals had nothing to do with the health needs of the local population.

So many of the decisions that we have to make today, in the name of improving the health care we provide can be understood in terms of the historical nuances that led us to be where we are today. Such a realisation does not necessarily change the debate, but perhaps it can influence your ideas about how we get from where we are today, to where we would like to be tomorrow.

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