As some-one who values justice and fairness as one of my core beliefs, I feel it is important to explore how justice and fairness links to our understanding of healthcare.
Co-operation is evolutionarily important for our daily lives and social norms have become part of human nature. The rulebook identifies from these social norms, our frameworks for justice. Social justice encompasses the relationship between individuals and their society and considers how rewards, opportunities, and wealth should be distributed among individuals.
Our perception of fairness and justice is a socially constructed concept and therefore different for everyone and how we apply this to the real world setting of health and care is not simple.
Our preference for fairness has been proposed as a basic human impulse and therefore when we perceive unfairness, we experience a negative emotional response whereas fairness is associated with positive feelings and we build from these our sense of ‘Justice’.
Some people consider that fairness is the belief that we should be rewarded for our efforts, which may lead to the thought that those who ‘may not be able to work’ are less deserving than those who are ‘hard working’. Alternatively, we may consider fairness to be that we apply the same procedures to everyone, which can be seen in tax systems or as part of human resources and equality practices.
Fairness does contribute to our need to feel safe, as it allows a sense of control over the unknown.
Fairness is protective, as the alternative is to accept the fact that life is unpredictable and that negative things can occur to us at any time.
The unintended consequence of the concept of fairness, is that when bad things happen, the person is considered deserving of a negative outcome. This ‘victim blaming’ is an unconscious bias so when we notice this in ourselves, we need to sense check our cognitive distortions. Equally, for those who experience bad things, we blame ourselves, feeling shame and guilt and this should also be challenged.
As many of these traits are seen in healthcare settings and form part of the basis of disproportionality, we need to talk more about our true thoughts and feeling and be able to sense check and challenge.
Justice for Patients: Personalised Care and Population Health
We know that the burdens of ill health are unevenly distributed both within and across populations, and that the benefits of health care are not always available to those who need them.
Avoiding discrimination and ensuring fair distribution of effective treatments is required to achieve greater justice in health and social care. In addition, we need to respond to the barriers created by the social determinants of health and that diversity is represented in our models of service delivery.
The care of an individual patient needs to be our top priority as part of our professional duty of care, however in order to achieve justice, we need to juggle these individual requirements against the need for equity at a population health level.
In order to achieve this:
• Clinical training must go beyond history taking, clinical examination, differential diagnosis and treatment towards judgment and shared decision making skills.
• Policy makers need to consider an agenda which is broad, interdisciplinary, embracing the experience of illness, the psychology involved, negotiation and sharing of evidence, and how to prevent harm from overdiagnosis.
• The co-creation of a shared understanding of needs at an individual and at a population level will be required to ensure everyone can access care, meet the wider social determinants of health and move away from the traditional medical model.
Justice for our Staff
The Equality Act and wider workforce legislation protect our labour markets yet we still have differential achievement and lack of representation across the landscape of employment and the concept of social justice builds on this.
In our NHS and wider social care settings, we need to work together to improve the experience of work for everyone and should be committed to equality, diversity and inclusion reinforced through role modelling psychological safety within a trauma informed organisation,
Well-being should be prioritised.
Mentoring and coaching opportunities for individuals and their teams should be available to help meet the ambitions of all.
We would like people to be able to identify with the statement “I feel free to be my authentic self at work.”
Justice for our Organisations
How does justice and fairness work within the landscape of organisations that contribute to social and health care systems?
Businesses traditionally engage in competitive practices within a capitalist market place and even in our statutory organisations, have capitalist principles embedded to gain market share or to be the best in relation to the provision of services.
Justice tends to take the form of legal challenge, where organisations have failed to meet their legislative obligations.
Competition between organisations may provide comparison information, which can lead both organisations to set higher standards and motivate them to greater achievement or create cost savings.
Competition also leads to behaviours such as self-enhancement and self-preservation. Although competition does not necessarily create overt hostility, it does sow the seeds for potential problems.
So moving from competition to collaboration is a transformational shift in culture.
Seeing the Individuals in our Boards as People
We need to see our Board level members of staff as people who are subject to emotional responses, unconscious bias and will see themselves or others as victims. This is crucial to transformation rather than assuming that Boards are a single entity that can absorb all impacts.
My belief is that our Boards are exhibiting trauma responses which is translating into signs of organisational fight/fright/freeze/compliance with defensiveness, tunnel vision, lacking creativity and being unable to form connections as typical signs of trauma.
So how do we move to collaboration in our social and healthcare landscape.
Judgment not rules
Currently the health and social care landscape is bound by rules.
- Is this decision legal?
- Is this decision an evidence based process?
- What is the right way to progress?
These back and white rules need to shift to conversation and shared understanding with an appreciation that most complex problems have multiple solutions in which different groups or outcomes may be amplified or compromised.
Beware of the Unintended Consequence of Regulation
Despite the importance of external scrutiny as it is impossible to mark your own homework, the regulatory framework of proxy measures, black and white thinking, reward and punishment is not fit for our new world.
Our regulators need to be trained on organisational psychological safety and trauma informed inspections, creating shared understanding and moving to measuring progression not comparison.
Our current regulatory bodies cannot function safely within the current statutory and legislative frameworks in which they operate where rigid measurement and benchmarking is the mainstay of assurance.
Informally, even where organisations, boards and registered managers have a good rating or an outstanding rating, they do not believe the inspections to be a positive experiences. Many believe the time taken to be compliant detracts from patient care, with process being more important to evidence than culture.
History has revealed that patient safety appears not to be improved as significant events including our current maternity scandals are not identified by our regulatory framework.
Many believe these inspections to be variable, lack objectivity and are often found to be traumatic for those involved. Most worryingly, areas of deprivation or diversity of professionals appear to receive poorer inspections outcomes. Our regulatory frameworks therefore feel unfair and appear unjust.
Although inspectors may demonstrate insights into the systemic challenges faced by organisations, the consequences of their actions have led to further staff depletion, burn out, closure of community beds and focus on process improvement. There is a lack of independent appeals process and disagreement is considered, defensive rather than valuable. This lack of system level oversight has meant regulatory action on one part of the pathway impacts on another.
We need to urgently review how we can have external scrutiny that is independent and robust but allows organisations to feel supported. I believe that we should walk along side our organisations to create change ensuring that all decisions related to risk is managed at a whole system level and that a shared approach to risk and consequence is adopted.
Justice in Evaluation
We therefore need to adjust our perspective on how we measure outcomes and evaluate progress in evidence based medicine, our workforce strategies and from regulatory and commissioning infrastructure.
Models can be found that fit a whole system approach.
Logic modelling is one methodology for representing various components and how they are expected to fit together to achieve outcomes.
A logic model is designed to:
• Assess the strength of the assumptions being made about how your programme will achieve change
• Identify cause-effect relationships
• Build an in-depth understanding of how a programme is intended to deliver results
• Raise awareness and build common understanding amongst stakeholders Identification of outcomes should happen at an early stage of the process and ideally not be retrospectively fitted to a predetermined and funded set of activities or interventions.
Alternatively a Realist Evaluation as part of a Context: Mechanism: Outcome evaluation model could be used.
Realist methodology is based on the assumption that the same intervention will not work everywhere and for everyone. The focus is on “what works, for whom, under what circumstances and how”. The key questions in realist evaluation concern causation (the act of causing something) and attribution (the act of attributing something). The term ‘realist evaluation’ was first used by Pawson and Tilley.
This evaluation methodology considers non-observable entities and processes such as culture, class and economic systems that can have a real effect on whether programmes work. Social systems such as the family, schools and economic systems have dynamic boundaries in terms of the flow of people, resources and information. These social systems interact with each other and the interventions themselves are open and dynamic systems. These can interact with other social systems, and so causation is not a simple linear process. They can be the result of changes in, and interactions between, different social systems.
Realist approaches are appropriate for evaluating complex interventions such as community based public health programmes and are particularly useful for those that produce mixed outcomes to better understand how and why differential outcomes occur.
By changing our Perspective and Unlearning our current method of assurance and evaluation, we should be able to shift to creating a health and social care system that can respond to our current challenges.
Considering how ‘fairness’ and ‘justice’ are created is key to this new way of looking at the world.
