Benefits off the Back of the Envelope

Governments come, governments go. And when they come, they have to translate ideals that raised a cheer among the party conference faithful into practical policy. It’s not easy, and the new coalition deserve credit for trying. So, this week, comes the first draft of a radical shake-up of benefits. This can’t be a sacred Cow, because it’s the Biggie. Any reform that doesn’t affect the largest elements is just tinkering. However, benefits is where rubber hits road for the poorest and most vulnerable members of society, and it is a test of character, a window into the soul, how the system (= the rest of us) chooses to treat them.

So this week the PM has announced:

1. Universal Child Benefit will be scrapped for people earning enough money to pay higher rate income tax because surely they don’t need it.
   
   
2. Benefits out will be capped at £500 a week because, er, surely poor families can’t need it either. The people who write the Daily Mail won’t think they do, anyway.
   

Both these notions sound promising, perhaps, until you try to enact them. The scheme for doing the first, assuming it is OK to depart from the principle of Universality, will be wildly inequitable because of the Income Tax system. Household A have one earner of £44K a year. Household B have two partners each earning £42K = £84K. The £84K couple keep their benefit, and the £42K one loses it. Duh? this also puts a hefty premium for the middle classes on not staying home to look after their children, something else people thought this government didn’t want to penalise

Meanwhile in £500 a week Benefit land, presuming people aren’t on the fiddle, if you really do have 13 kids, you really do need £500 a week. Penalising the poor little rats because there are so many of them is positively Dickensian. They can’t help being born.

Oh Dear.

On the back of an old envelope from years ago is even more radical thinking, associated by some with Sir Brandon Rhys-Williams. He was Tory MP for Kensington (and an MEP) back in the eighties. On the back of his envelope, if I remember it right, he calculated a radical shake up that really was radical.

I don't remember every detail but I think the essence was that everybody, universally, got paid their tax allowance (in those days about £1500) in cash. You abolished all benefits, except child benefit (because children don't have tax codes) and a few given through the NHS for specific care purposes. You then radically simplified the tax system along Isle of Man / Jersey lines so that everybody paid income tax with no allowances, but at a lower rate. On eighties figures, once you abolished all loopholes but reduced the rate so it wasn’t worth cheating, things panned out such that to get the same tax take you would need a marginal rate of taxation around 18%.

This would suit everybody except those who make their livings by playing the system, or helping other people play the system. But transitioning to it would not be easy, and along the way, any government that tried it would pretty much annoy everybody. wonder how an approach like this would model, thirty years on?

True Leadership: getting real

We Brits have a maddening love / hate relationship with the NHS. We know, frankly, we’re damned lucky to have the services of some of the world’s best medical carers freely available at the point of need. The past thirty years in the UK has seen neonatal death plummet and that most basic statistic of all, life expectancy, increase — all this at a significantly lower cost in relation to GDP of private systems.

In a peculiarly British way many of us seem to be saying that the whole thing is terrible but the people are wonderful. We often express profound admiration for the people who actually look after us, but frustration with the system — bureaucratic, Balkanised, political (in a bad sense). Of course medical carers are not infallible, and some degree of snafu occurs in all human endeavours, but it has to be minimised when lives are at stake, and community hospitals are public places. Healthcare leaders, with their own stresses and pressures, prone to cynicism and denial, are always on stage. If people screw up in most industry and commerce, earnings per share dip. Get it wrong in yours, and people die. This can lead to a paralysing fear of failure that hobbles all effective leadership; a kind of defensive pact with mediocrity.

Cue the most inspiring leadership day I have spent in a long time — not a course, but a day visit with colleagues from Milton Keynes (where chaplaincy is in need of a reboot) to Wexham Park Hospital, which serves Slough and East Berkshire. Peter Blackshire, co-ordinating chapain, and colleagues gave generously of their time, and involved leaders within the hospital from palliative care and nursing services, along with the chair and CEO of the Trust.

It’s no simple Polyanna-ish story.

Heatherwood and Wexham Park Foundation Trust has had struggles and serious public failures in the not-so-distant past, and has undergone its own sometimes painful reboot.

If you’re trying to lead in a recovering organisation with limited resources, how does hope arise, and the ability to turn things round?

1. The foundation of everything is realism about what’s amiss, but refusal to give in to it, blame others, or collude. It’s values not target driven, and works hard to connect people with the reasons they wanted to be practitioners in the first place, not synthetic goals. Again and again we were struck by openness and lack of management hype. At first this seemed weird, but as it became plain many people were interested in the unvarnished truth, everything came into focus. No boasting, no hype — just workmanlike pragmatism, and a dogged focus on values. We heard about the temptation to be driven by targets to the extent corners are cut. When you stop being target-driven, you actually take a hit — but the hit is an act of faith that if you stick with your values and resist cutting corners, in the end, you will do a better job. That takes real courage and, dare I say it, faith. I wish some churches felt freer to be honest about what’s not working, more rigorous in not cutting corners and tolerating crapada.
   
   
2. Hospital Chaplaincy is not running a Church in a hospital, but delivering siritual care across the board in collaboration with others. Healthcare systems are like water systems — everything affects everything else. If there’s poison in the system, everybody gets poisoned. If different trades take hierarchy or status more seriously than the over-riding point of the exercise, or their part of the action more serously than other practitioners’, attention is distracted, the practitioner community compromised, and patients harmed. Managing chaplaincy isn’t about being nice to chaplains, but everybody respecting everybody else, and honoring everyone’s role in the delivery of the service. Everyone is a practitioner, and the task of everyone else is to maximise their own performance in such a way that all practitioners can function in an integrated, aware and self-aware, way. If you’re angry, use the energy to raise your own game, don’t turn it against someone else. The unity and integration of the whole depends on respect, fuelled by open communication.
   
   
3. The most stressful and wearing place to work is somewhere where you can’t be yourself. In life, in healthcare, in Church, hypocrisy is like Japanese knotweed, or fire at sea. There is a continual drag towards it within the system (what Christians call “the fall”) and open communication with mutual accountability is the only medicine. Communication needs to be as clean as you can make it, remembering at all times that God gave human beings two ears and one mouth.
   

I came away with much to ponder, not only about hospitals, but about leadership and certainly about the ways we do Church. It also sowed real seeds of hope about a new kind of chaplaincy in MK.

Particular thanks to those who led us through the day; squirm and duck for the credits — It’s an unforgivable sin for some British to acknowledge other people’s work, especially in the public sector, without being cynical and/or nasty about them, but this is what I want to thank you for:

• Peter Blackshire (Co-ordinating chaplain) — There’s lots to work out, but you’ve got a real team, and it shows. Many ministers, and healthcare professionals, say they want to work as a team — few acually do. Insecurity and Ego compromises their best efforts. Your clarity of purpose and consistency shone through. May your trolley arrive soon!
  

• Clare Culpin (Director of Nursing) I found your awareness of everyone as a practitioner, courage and realism, refreshing and inspiring. I seldom meet anyone who has come through 20 years plus of leadership in medical care with such a focussed and lively sense of how things actually work together.

• Fiona Lisney (Palliative Care Consultant) showed me how soft and hard skills (to use conventional distinctions) actually can work together to help patients at what could be the most awful time of life, the journey home. You actually demonstrated how to get a system working for patients.

• Julie Burgess (Chief Executive) We were overwhemed by your realism, you will to listen and respond to anyone, your awareness of your context, along with your uncompromiseing commitment to your core values. The heart of your leadership seemed to be willingness to take risks in not cutting corners. I wish there were more of that kind of faith and courage around.
  

• Chris Langley (Trust Chairman) Perhaps it comes from the retail background, but your will to take the people the trust serves seriously came over clearly. Assertive loudmouth leadership like the Apprentice on TV gets organisations so far — but to excel you need something very different — passion and humility, openness and rigorous commitment to making the syetem coherent and effective.

How healthy is your healthcare?

Max the Cat has been to Michelle the vet this week for an eye ulcer — cost £45 (drugs), & £45 for 3 consultations. But why use the same system as a basis for Human healthcare? There’s been all kinds of blogosphere buzz around the US healthcare debate, some of it comparing our own National Health Service.

Like any system it has its ups and downs, its challenges and pitfalls. Amongst its personal ups as I have experienced them over 54 years are Dr MacArthur, our GP when I was 12. He was an old fashioned Scots socialist who refused to take private patients, and got me a hospital bed in 10 minutes at a weekend because I needed it. He saved my life, and would have been insulted to be offered money over and above his pay for doing such a thing.

Stephanie’s birth as an undiagnosed extended breach in a strange hospital (she arrived early and unexpected on Christmas night) was supervised by one of the finest obstetricians in the world, who gave Lucy the choice, then delivered her faultlessly without a C-Section, using an old midwives’ routine called the Burns-Marshall technique. Both these ace bits of effective medical care were delivered with nary a credit card or insurance policy between them, and I would take a lot of persuading that the kind of medical system we use for Max the Cat would have served us any better.

But if you’re comparing healthcare systems across whole populations, the big statistics are the place to begin. Make no mistake, a system which allows people to die earlier and risks more children’s lives, across a whole population is not as effective as one that delivers higher life expectancy and low child mortality. Efficient use of people’s resources is a bonus, given the inherent and spiralling costs of modern healthcare.

So here are the figures, and the comparisons for the UK, France, Singapore and the USA.
No system is free of glitches, failures and compromises, Every system is challenged by spiralling costs, but what works best is surely an empirical, rather than ideological question. It’s unfortunate that the US faces tough basc choices about healthcare at a time politics has been so snarky and partisan. The basic systems of medicaid and medicare was put together at a time there was a higher level of bipartisan respect and public service ethic. All good systems involve public and private elements, but the clever bit is in how they are belnded for the good of all. With any luck something can be done — why should US babies suffer three times the mortality rates of their counterparts in Singapore?

MK NHS Hospitals Trust Good News

Licensing Karen Reeves to Milton Keynes Hospital as colleague to Carole Hough on Friday, felt like a new beginning for the trust, as well as the chaplaincy. Karen brings a strong professional background in hospital and community healthcare, along with a profound commitment to justice, social inclusion and peace. MK is very much the kind of diverse, fast-moving urban environemnt in which she has really flourished.

Milton Keynes has grown continuously and exponentially over 30 years, with a chronic and worsening overhang as money follows people, sometimes several years behind. This makes any social, health, educational planning a nightmare. Hospitals are especially vulnerable, as a burgeoning young population puts an immense load on the whole system. As MK grows into the 10th biggest city in the country, John Prescott's target for 2020, this problem rages on.

The temptation is always to sweat the immediate challenges, whilst ignoring the big unfolding context. MK Hospitals NHS Trust, chaired by Mike Rowlands and, since last summer, Walter Greaves, has worked hard to make the most of the realities, challenges and opportunities of Milton Keynes, short and long term. Where chaplaincy could easily become roadkill, the trust has worked hard to provide proper spiritual care in in very trying circumstances. Karen’s arival is a tanglible sign of that commitment.

After a few years of backs-to-the-wall, through which Carole has, incredibly, managed to cope, Friday’s service was good news. Karen’s arrival, partnership with bereavement services, a good and supportive trust (Thanks to Gill Rodney and, particularly Nicola Lester), means the chaplancy team is now back on track for full out of hours cover, increasing voluntary support, developing its present excellent ecumenical and interfaith character, and a host of other good work. The Creation hanging in the chapel was by sisters from Turvey Abbey — a beautiful piece of work, that looks all the better at a time of great hope, as well as challenge, for the hospital...

Trading control for wholeness...

I’ve just had a spiritually refreshing conversation with Steve Bushell, Chaplain of our local Mental health NHS trust. Steve has studied Desert Spirituality closely, and together with excellent senior colleagues in the trust is working out a fascinating new integrated approach to Spiritual Care. As he talked about his work, I was reminded of Robin Skynner’s Institutes and how to survive them. There Dr Skynner proved the key contribution staff attitude makes to the health of the whole and the healing of patients. This closes the gap between Spirituality and Religion, which has been so disastrous in Western Christianity.

The key to good healthcare, we decided, was the willingness and ability of the hierarchs to give away control, to support and facilitate rather than direct people in what becomes a healing community, not a controlled-and-controlling bureaucracy. What the hierarchy does builds either understanding and respect, or cynicism, depending on its alignment with its professed values. This reminded me of a wise, experienced and perceptive Vicar telling me recently how he had observed that when he stopped forcing his initiatives on people and doing stuff, far more happened, and in a different, more spiritually significant way. More the Coach, less the professional Guardian of the Sacred; more the resourceful friend, less the eccentric drill sergeant. See Mark 10:42.

Steve and I scoped the role of of the Chaplain as someone who learns and listens carefully to the languages people use to express themselves, a spiritual interpreter, someone who can hold the lines and ask key questions of any and all, including themselves. The prime task is to help people identify where God is in their lives so that he can grow their Sacred Centre... Like Vicars?

(National) Healthy Church?

How healthy is the National Health Service? How healthy what some call the National Church? On the Wardman Wire, Simon Sarmiento reports an address to the July NHS Live event by Donald M. Berwick, Professor of Health Policy and Management at the Harvard School of Public Health, President and CEO of the Institute for Healthcare Improvement. He warmly endorsed the vision and principles of the NHS, compared to the fractured, exorbitant and frequently inequitable US equivalent, with its harrowing tales of medical bankruptcy. By way of constructive criticism, Professor Berwick came up with ten points for NHS policymakers, and Simon wondered how they could be cast as discussion starters for the C of E. Some provisional, kneejerk, suggestions:

1. (NHS) Put the patient at the center - at the absolute center of your system of care.
   (C of E) We exist for the common good; the people who don’t come weekly as much as the people who do. 82% of them used a Church in some way last year. How does what we do serve their real needs? How self-serving are we gathered congregations; how realistic and committed about the needs of people out there?
   
   
2. (NHS) Stop restructuring.
   (C of E) There are limits to the benefits of pastoral reorganisation. After forty years of it there are still doubtless anomalies out there, but people need some sense of stability out of which they can work. You can’t solve process problems by structural tinkering.
   
   
3. (NHS) Third (NHS) strengthen the local health care systems - community care systems - as a whole.
   (C of E) Parishes are where most good happens. People used to have a bumper sticker — “This car may not be a Rolls Royce, but its paid for and it’s in front of you.’ After fifty years of being told by clever people that the parish system has no future, it’s still there, and most people value their local church far more than bigger, slicker and more remote specialised units.
   
   
4. (NHS) To help do that, reinvest in general practice and primary care.
   (C of E) Subsidiarity! Bread-and-butter proclamation, celebration, community building, pastoral care, are not distractions, but the core. job. Deaneries, dioceses are enabling systems for what matters on the ground.
   
   
5. (NHS) Please don’t put your faith in market forces.
   (C of E) Money is a good servant and a bad master! We need to be transparent and realistic about resourcing and deployment, applying fair agreed criteria, but not mindlessly Darwinian. Often the parish church is all that’s left, in the country and Urban centres. Beware pure congregationalism and its attendant scourge, suburban captivity!
   
   
6. (NHS) Avoid supply-driven care like the plague.
   (C of E) For whose benefit are we doing this? Ministry is not all about Vicars, but gifted Christians in community, being enabled to do what they are called to do well. Recognise for whose benefit we are really doing this.
   
   
7. (NHS) Develop an integrated approach to the assessment, assurance, and improvement of quality.
   (C of E) Let’s get the act together! We have fine ideals, like the five marks of mission. Changes to clergy discipline and terms and conditions of service, along with other requirements from society (child protection, charity SORPS) are pulling things together pragmatically. We have mission audits and heathy churches, but very quirky and inconsistent means of assessing them across the network.
   
   
8. (NHS) Heal the divide among the professions, the managers, and the government.
   (C of E) Take responsibility for our own feelings and actions. Put the synodical and other stuctures we have to use, rather than being cynical about them. The answer to a crappy meeting is a good meeting, not no meeting.
   
   
9. (NHS) Train your health care workforce for the future, not the past.
   (C of E) We all want training. Do we all want to learn; and if so, for what? How does theological training measure up to real life? The gold standard of theological education is still often sometimes thought to be party biased, Victorian private institutions, in which perfectly sensible people are taught to aspire to ‘have their own church’ one day. They end up having to learn servant ministry on the job, if training institutions let them, and the rest of us, down like that. How sad if conventional colleges spend millions to provide all the potential of community, and then blow it by the kind of behaviour that hits the headlines. The Hind report has begun to restructure learning and training — but what about process and standards?
   
   
10. (NHS) Aim for health.
    (C of E) Aim for personal and corporate spiritual health. Numbers are fine, but what quality of corporate and personal holiness and excellence do people experience? Sometimes very high; and sometimes not. Sometimes both at one. To present everyone mature in Christ is quite a vision, and we need to be focussed and intentional about delivering it.