Month: February 2013

Secret funding by Billionaires against progressive causes


George Monbiot is a well known left leaning environmentalist. He writes for the Guardian. So you may dismiss his views or accept them according to your prejudices. “Comment is free but facts are sacred” – make of this what you will. However uncovering secret funding by vested interests should be of interest to those who think democracy should be exercised on the basis of truth. What George reveals in the article is a list of organisations funding right wing, anti progressivist positions. You may check the sources, you may think that this activity is a good thing. You should however at least know what is going on. One example is the Institute for Economic Affairs (IEA). This organisation has charitable status and is often quoted on the BBC as if it was independent of right wing funding and policy making. Democracy becomes debased when powerful groups, who can spend billions supporting their cause and often in secret, can set the agenda and the frame of reference for debate for billions of citizens. Like mushrooms, we are being fed shit and kept in the dark.




The image above is copyrighted, ©   at where it can be purchased.


End Ecocide in Europe

Ecocide is the extensive damage to, destruction of or loss of ecosystems of a given territory. Let’s end Ecocide in Europe together!

What’s our aim?

We  want Ecocide to become a crime for which companies and individuals can be held responsible according to criminal law and the principle of superior responsibility. With the European Citizens’ Initiative we want to achieve that Ecocide becomes a crime in three cases:

  • when the Ecocide happens on EU territory (including maritime territories)
  • when EU companies are involved or
  • when EU citizens are involved

In addition, market access to the EU market for products based on Ecocide as well as investment in activities causing Ecocide will be prohibited. A transition period of five years is suggested to give the relevant stakeholders the time to adapt to doing business in a world without Ecocide.

A new fad for the NHS: ‘zero harm’ ?

As the dust settles after the Francis report we can expect Trusts around the country to respond. The nature of that response of course will be crucial. Will the focus be on the structures (e.g. poor skill mix, lack of training, minimal staffing, bureaucratic target led mangement) that produced the ground for poor and abusive care, or will clinical staff be subjected to more management ‘initiatives?’ We may also wait for top down government advice and policy direction, but will there be resources to support it?


Roy Lilley on alerts us to the latest initiative from the United States, that is coming our way: Don Berwick ‘s Zero Harm. Berwick has been invited to the UK to speak to David Cameron. A good deal of the leadership and management theory comes from the United States and developed within the private sector. Will Berwick’s ideas travel?


Roy points out that we have had many management initiatives before:  ‘The Organisation With a Memory’, ‘Quality Circles’, ‘Six Sigma’, ‘Evidence Based Management’, ‘Process Reengineering’, ‘Matrix Management’, ‘TQM’.


Clinical staff working to provide good quality care have seen these processes come and go. These processes develop into a form of organizational culture that require bureaucracy creep, and let’s not forget that it was culture that was heavily criticised by Francis.

The culture of NHS organisations is characterised by increased bureaucracy and the application of rationality to problem solving. One of the founders of sociological theory in the 19th century, Max Weber, suggested rationality involves an individual cost-benefit calculation, wider bureaucratic organisation and the opposite of understanding society reality through mystery and magic, the waning of a religious and spiritual understanding of modernity which he called ‘disenchantment’. This has an upside in that social practices were now subject to analysis and examination rather than based on the authority of Popes and priests.

Weber’s theory of ‘rationalisation’ thus suggests that modern societies become increasingly rational and bureaucratic whereby social life becomes more and more prone to scientific analysis, measurement, bureaucratic control and the application of ‘instrumental rationality’ to social problems and issues. Instrumental rationality is a mode of thought and action that identifies problems and works directly towards their solution, often focusing on the most efficient and cost effective methods of achieving certain ends. It may not stop to ask what those ends should be, or what effect the efficiency has on human relationships or the cultures of organisations.  A falls risk assessment could be seen as an efficient and cost effective measure to reduce the number of falls and it is part of the overall instrumental rational approach to risk management in an acute hospital. Actually constraining a patient’s mobility to prevent a fall may be rational but it may not be human.

What clinical staff require is a proper structure to work in, not more bureaucratic processes that spuriously attempt to deliver and measure ‘quality’ or the eradication of risk entirely as part of an unattainable ‘zero harm’ process.


According to Roy Lilley these ‘fads’ all fail because they don’t always have ownership and backing by top management; in addition pressurised managers end up leading organisations to take short-cuts in deployment, bits of the latest fad are cherry picked and I would say importantly clinical outcomes are never measured. So how do we really know they work?


Berwick’s ‘Zero Harm’  is an approach used in industry to stop accidents. Roy is not impressed, he argues that “There are hundreds of consultancies flogging it. Here’s an example of some of their snake oil:


“…sustaining a work environment which supports the health and safety of our people and minimises the impact our business has on the environment… building strong relationships with the community, governments, shareholders, contractors, our supply chain and growing our business in a sustainable way.….”.


Fine words indeed but what is the effect?


The goal may be unattainable, and getting there will require data collection, comparisons, benchmarking, recording, measuring, goals, targets, bureaucracy, labels, tables, blame…..just the sort of processes that form a particular management culture obsessed by target reduction and corporate objectives rather than clinical care.


This is the context in which cultures develop. In this post called ‘undignified care’ I refer to a paper by Hillman et al (2013) who argue that in an analysis of poor care:


“Cultural and institutional contexts of healthcare delivery are often missing…the maintenance of dignified care has…been focused upon individual attitudes and behaviours…(while) maintaining dignity depend(s) on more than the commitment of individuals” (p4).


It is as if we consider that individual nurses’ attitudes and behaviours are the most important aspect of the care experience, forgetting that the organisational context in which they work may seriously degrade their ability to do so. The need for a contextual analysis is supported by Hewison and Griffiths (2004) who argued:

“Too much emphasis on leadership without an equal concern for transforming the organisations nurses…work in, may result in leadership being added to the list of transient management ‘fads’ which have characterised health care in recent years” (p 464).


Roy Lilley’s concern seems to be that Berwick’s  ‘zero harm’ approach will be just another fad, that will not deliver. He argues:


“The concept of Zero comes from the language of the past. As important as the ethos of ‘Zero’ might be, as a management philosophy it is past its sell-by date. Zero lives in the world of strategy and bureaucracy when we need tactics and techniques. Nimble organisations, empowered to deal with what needs to be done where they are, not Whitehall. A focus on training, front-line and dumping the rest”.



Watch out for ‘zero harm’ coming to place near you… will sound plausible but will it work?  Listen to your patients, exercise your duty of candour, network with like minded clinicians and wrest leadership back to the front line.




Roy Lilley:  ‘A better start’  13th February 2013

The Francis Report and poor quality care

Roy Lilley has argued:

Francis talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will.  Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have have stood still.


“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”

A nurse was quoted on… wait for it….the ‘One Show’ saying that she came in on her day off to feed a patient, another story was that two male nurses laughed at a half naked elderly man with a catheter. Two ends of the same care story that is the NHS. There is a problem with attitude/culture but there is a problem with structure (e.g. poor staffing) which gives rise to poor culture. Cultures arise out of structures, they do not just appear out of nothing. The way people relate to each is influenced by so many variables but in an organisation set up with a purpose in mind, those variables start to filter down into the structures that are in place to fulfill the stated purpose. If the purpose is to diagnose and treat a minor illness in an otherwise healthy person, the structures you need are relatively straight forward. The structure of staffing: A doctor or suitable qualified nurse with enough time to take a history, carry out an examination, come up with a diagnosis and then initiate treatment. The structure of place: A clean, well lit, warm private space. The structure of resources: for example assessment tools, stethoscopes, sphygmomanometer, examination table….  These are the foundations to encourage a culture of respect and co-operation. Of course having the structure in place does not guarantee a patient centered culture. The reverse is true, take away the GPs structures and you will more than likely get a little less respect and quality care.

The emphasis on culture and NHS leadership has let society off the hook because we then don’t talk about structures. No doubt the culture and leadership in some Hospitals must change…in addition society has to accept that care work costs money. We just don’t seem willing to put in the extra resources to ensure that the vulnerable are not abused. Feminists have long argued that because patriarchal societies view ‘care work = women’s work’ and women’s work has been seen as ‘domestic’ and unskilled (i.e. required very little training because it is ‘natural’ to women) , care work receives little recogniton and value and sinks into invisibility. The structures to support care work in the UK and in many ‘advanced societies’ are creaking to breaking point, relying on armies of unpaid and unsupported family members.

The analogy is with motherhood and the structures that support it: unpaid, hard work, no training, no sick pay, little support…many mothers go the extra mile every single day, some crack under the strain and abuse or neglect. A minority of mothers abuse because they know no better, they are ill or have given up caring. Any care work that is not properly valued recognised and supported runs the risk of increasing the ratio of abuser to saints. Just as mothers need all the support they can get from society, so do nurses. If you isolate, divide, and undervalue their work do not be surprised when there is an increase in neglect. Society ascribes value to work through pay, status and perks….and so you can get an idea of what society values by examining who gets the pay, status and perks. Capitalism has long divided ‘proper’ work (men’s work) in the public sphere which it has paid for on the one hand, and ‘non’ work (female work) in the private sphere, i.e. the home, which it is unwilling to pay for, on the other. Socialists and feminists arguments have tried to get this private sphere work as being properly recognised in the patriarchal hiearchy and so we have child benefit etc. Historically, if men were nurses, and care work the preserve of men, this would have elevated its status and hence support, education and pay. Roy Lilley is calling for funding the front line, to support the structures of care. Watch however how we turn ourselves inside out trying to correct cultures.





Francis Report into NHS care

This is a wide ranging report into the failings at Mid Staffordshire NHS Trust. The above link takes you to the home page. I cannot do justice at this stage but this affects everyone working in the NHS.

This is not a new issue. I ‘trained’ in the 1980’s and saw nurses struggle to give care to the standard they wanted to. I knew students who gave up because of the gap between the ideal and reality. In 2001 the department of health published ‘essence of care for patient focused benchmarking, which are the sort of standards discussed in the report. This did not prevent Mid Staffs. A ‘patient centred NHS’ is not a new conceopt either. Nightingale once said “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm”. [1859]. Francis kept mentioning culture today and I agree. In our book ‘Psychology and Sociology for Nurses’ the power of culture and socialisation was discussed as mechanisms which allow poor care to flourish. in the leadership literature, there are warnings that leadership development could be just another fad if the organisation of the NHS does not change. Quality and Leadership have been core aspects of nurse education for well over a decade as exemplified in the Dept of Health document ‘Making a Difference’. There is a plethora of models, education, literature, quality improvement provisions, leadership development programmes, for nurses but all to no avail it seems in some NHS hospitals. Kath Melia described the difficulties students faced when in practice back in the 80’s, not being able to put into action what they might have been taught. The concept of the Theory-Practice gap has been known for decades. This refers to theoretical knowledge (such as ‘holistic care’) not being applied in clinical practice, or clinical practice rendering theory irrelevant. The NHS has been badly managed and resourced. Care work is invisible and not measured and so does not show up in Trust accounting and priorities. Being able to drink a cup of tea is a priority for patients in many wards but this may not help the Trust acheive its targets, save money on its budget or acheive its Foundation status. Nurses and patients know ‘its the little thngs that count’ – count that is for patients and nurses but not it seems to organisations. Society must also shoulder some responsibility for our structures for care of older people – dehumanised, isolated, institutionalised and underfunded.

Ecocide – a necessary but insufficient step to sustainability?

Ecocide – a necessary but insufficient step?

Polly Higgins proposes a new law against peace: Ecocide. The hope is that international law will make capitalism adopt greener practices and turn it away from such rapacious and dirty economics such as that of the Athabasca tar sands extraction. Will ecocide take us beyond capitalism or merely make a dirty economics clean? Can ecocide help the transition to a no growth economy or merely make the growth economy cleaner in environmental terms. Growth is the key point. Current capitalist growth is the father of its bastard child ‘ecocide’, if we eradicate this bastard we still have the father to contend with. Without growth we don’t have capitalism. With dirty capitalism we have dirty growth, and we have ecocide, without ecocide we have green growth. But in both cases we have growth, which means capitalism and its spawn: inequality and resource depletion. Ecocide will channel capitalist dynamics into greener activities but will not necessarily help make those green activities sustainable or diminish the dynamic for growth.

David Harvey spells out the internal dynamic of capitalism: the surplus capital accumulation problem which predicates capitalism upon growth. Growth brings more and more resources into play and growth on a finite planet transgresses the safe operating spaces for humanity. So unless the legal framework goes beyond making growth green, making growth itself illegal, we will not have solved earth’s sustainability issues. All we have done is channelled energy into a cleaner, greener demise. The law might want to address making capitalism itself illegal and focus instead on problems of distribution and exchange as well as on production. Not to do so will allow inequality and resource depletion to run in the space that ecological degradation leaves behind.

Care, Compassion and the Social Structures of Oppression

Care, Compassion and the Social Structures of Oppression


Nurses are asked to consider dignity and compassion as nursing issues. However if media reports such as ‘my husband died like a battery hen in hospital’ are correct , and  there are far too many to be dismissed, certain practices can squeeze compassion out of nursing care.  We therefore need to be critically self-reflective and critically thinking (Morrall and Goodman 2012) of the ‘social structures of oppression’ (Harden 1996).  Jeremy Hunt has recently described ‘the normalisation of cruelty’ in NHS organisations. If this is correct we need to analyse why this might be so. However, and accepting that there is poor care,  this phrase is part of a campaign of criticising public sector organisations in order to soften up the public mood for privatisations. It is part of this wider public relations exercise. That being said, we cannot overlook the real pain and suffering of patients as being only down to ‘them’ (whoever ‘they’ may be).


Thus, it is necessary for nurses to reflect upon the reasons we see such poor quality care. This is not just or only a case of failing, uncaring individuals which require calling them to account, although there is truth to this. There will always be individuals who ‘do not give a stuff’ and see care work as only a means to an end, i.e. the pay.

Up to the point when the struggle for material conditions no longer becomes an issue, money is an extrinsic reward and motivator. The fundamental basis of most work in a capitalist system is the ‘cash nexus’ i.e. the starting point for work is the pay. This is an extrinsic motivator. Take away this extrinsic motivation, and then take way all other intrinsic motivations (to care, be compassionate, to make a difference, because it is fun….) work then becomes meaningless. Many nurses and care assistants are relatively low paid and this is their sole extrinsic motivator. Nurses don’t get much in the way of other extrinsic motivators such as status or privileged/free access to important goods and people (perks). Thus to keep working they rely on their intrinsic motivators just mentioned.

To demonstrate the importance of pay, just consider how many nurses would stay at their posts if they a) won the lottery b) came into a decent inheritance c) were independently wealthy. There would no longer be the extrinsic reward and motivator to work.  Would any intrinsic motivator that one still has (the sheer love of caring) still make one go to work? So let’s be honest with ourselves first. Without pay many of us would not nurse. That being said nurses do then bring into their daily lives their intrinsic motivators. Then they are paid just enough to care, just enough so that any innate compassion can be exercised. However that is a fine line.

Nursing work is often dirty ‘body work’ that few would willingly take on just for the love of it. The ’emotional labour’ involved also takes its toll. However, there is still a caring ethic underpinning nursing and most nurses wish to be compassionate and nurse because of the pay yes, but also because they want their work to ‘mean something’. This compassion can be trampled upon by the context in which it has to operate – job losses, poor staffing levels, poor skill mix, lack of clinical supervision, poor access to professional development, lack of social status and esteem, patient complexity and consumerism,  hierarchical, patriarchal and bureaucratic managerialism to name just a few oppressive social structures.  So, in essence, poor care is a political and social issue not just an individual one. Too often we pick on the failing individual nurse(s) when we should be stripping away the layers of context which promotes uncaring attitudes or does nothing to weed it out. The Francis Report into Mid Staffordshire NHS Trust, for example, shows certain management cultures that hardly supported good care, and the Margaret Haywood case shows what happens to whistleblowers.

However, we also need to consider the fact that within similar organisations experiencing the same funding and staffing issues, why there are differences in compassion and care? What are some ward managers and individual nurses doing that demonstrates that care is not being compromised? I suspect there is a complex interplay of various social and local factors which play out in hospital and care homes that results in horrific experiences for one and superb care in another. I also suspect that articulate, confident, intelligent nurses give high quality care despite and not because of the social and organisational contexts they find themselves. As nurses and care assistants in the NHS come under increasing pressures, the bad apples will have more space to operate and compassion fatigue could set in even further.

So students of nursing and nurses are being exposed to savage criticism of nursing care, we have to be honest and say that in some cases this is justified. However this is complex and the analysis of the antecedents of poor care must take us beyond simply blaming failing individuals. Indeed a recent, February 2013, Nursing Times survey indicates that nearly 50% of staff consider ward staffing levels to be dangerous. This is part of the context ‘failing’ individuals find themselves.

Undignified Care

The report into poor care at Mid Staffordshire NHS trust is due very soon.

Undignified care.

Why do patients, particularly older patients, experience indignities such as being denied wearing their glasses (“in case you roll over on the pillow and break them”) or being made (forced?) to sit in an armchair (“you know you get dizzy and might fall”). One reason is because of the increasing use of a particular approach to risk management and its procedures that characterise not only society, as exemplified by the ‘high-viz jacket’ phenomenon, but also by healthcare organisations.

This paper on

discusses a research report and the implications for care and care management in the NHS and other organisations that links a particular way of thinking, risk management and poor quality care.

new website

If you are reading this you obviously have found your way to my new web site:  This has been set up and designed by Jon Bennallick at dododesigns (, so many thanks to jon for his input. This site is my general site for all purpose blogging and nonsense, and you will find links to my 3 face book pages:!/groups/NursingSCC/     for health, sustainability and climate change resources and discussions.!/groups/227744857337921/   for Sociology and health resources and issues.

In addition you will find on this site direct access to my more academic sites: and

I am always happy to enage in discusion and blather! Dont forget the tweets: @bennygoodmanUoP



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