The Three Professors: Science and the Ideology of World Views

I mentioned it in one of my previous blogs and didn’t really tackle the issue, but a little while ago I got into a twitter debate with Ann Pettifor on the ideology of world views. I stated that “all world views are ideological” and Ann, an eminent economist, disagreed and understandably felt able to very politely “dis” my arguments. Which is not that surprising given that I am not an eminent anything. Anyway after a fairly fruitless attempt at explaining my position on the epistemological status of world views in bursts of 140 characters I decided that I would blog about it.  Knowing full well that not even the people who love me would be likely to read it. But it matters to me so here goes. And just to compound the folly – this is the first of three blogs that I’m going to write on science and the social sciences.

I guess that in unpicking and trying to justify my statement that “all world views are ideological” there two things that have to be tackled:  the first is the concept of a world view; the second unsurprisingly that of ideology. I guess I should start with the idea of a world view but I’m not going to, I’m going to start with love and science you’ll get why in a minute.

In my distant youth, long before I became an occasional social scientist and the parent of a disabled child/ young man – I fell in love with a visiting Austrian student called Katharina. It was my first great love and at the time it was definitely the most important thing that had ever happened to the entire human race. And when her visit ended rather than dealing with a temporarily broken heart, as most sensible people would have done, I decided that it would be a good idea for me to go to Vienna to study Geology despite the fact that I couldn’t speak German. So at the tender age of 19 after a year spent learning German, I followed my heart to study Geology under the guidance of Professor’s Exner, Tollman and Frank at Vienna University.

They were remarkable people as Professors sometimes are. Professor Exner was a man of enormous stature within the department. I remember him being very dignified and kind, but also very confident of his field of expertise – he seemed to me to personify the knowledgeable professor scientist. He had earnt his PhD in 1939 and after a brief spell in a Mountain Jager Artillery Regiment he had spent the rest of his career as an academic geologist or working for the Austrian Geological Society. Becoming University Professor at the Universitat Wien in 1967.

Fairly early on in my studies I remember doing a field trip and it was on this field trip that I learnt a lesson about science that has stayed with me ever since. The trip was an introduction to geological field methods and we were in a small group in the Alps, I think it was around Fieberbrunn and on this particular day our group was being led by Professor Exner. Anyway we students had been wandering about looking at rock outcrops and then we met up with the Professor, who was standing in-front of a small outcrop describing a particular formation as consisting of certain types of rock.  From memory I think that they were mainly lightly metamorphosed slates and quartzite’s of one form or another and I added that the formation also included conglomerates because I had seen conglomerate in a nearby outcrop. The Professor was however quite adamant that the formation did not include conglomerate and that I must be mistaken. After a brief attempt at arguing with an eminent Professor in a foreign language I gave up, probably sulked and we all moved on. However, not much further along the track we came to another rock outcrop – this time a conglomerate and the eminent Professor apologised to the argumentative English student.

For me there were three lessons to be learned from this incident; the first was that Professor Exner was a true scientist- confident and yet ready to accept that he might be wrong about something; the second was that smugness is a very unappealing character trait in a student and the third was the difference between knowledge and empirical observation in scientific enquiry. Professor’s Exner’s knowledge of Alpine Geology was by then based on decades of research and observation and nine hundred and ninety nine times out of a thousand it would have been utter folly for me to disagree with him. But knowledge has to be continuously tested and re-tested and even in the sciences, the belief that a statement is true is simply that – a belief – because what may have been true for one particular part of a rock formation or moment in time isn’t necessarily true for another.  The core of scientific enquiry is the presumption that the conditions that cause a particular effect cannot be presumed to exist unless they have been proven to exist.

Fine  – but how does this relate to world views? Well put simply a world view is a theory or set of theories about the true nature of something that applies to all or part of the social/economic and political world.  They might be Neo-Liberal, Marxist, Liberal, Pluralist, Realist, Systemic, Religious, Discursive world views – to be honest there are hundreds. Every discipline within the social sciences has its own theories and models that it uses to interpret the world and (with the odd exception) each aspires to present itself as a uniquely valid interpretation of the world or of part of it and each attempts to assert their validity by describing other interpretations as false.

The difficulty for the social sciences is the challenge that it faces in developing knowledge about the world that is uncompromised by competing theories and interpretations. So whilst Professor Exner and I, and pretty much every other geologist on the planet could agree about what a conglomerate looks like, most social phenomena are likely to be subject to at least a dozen different interpretations and therefore definitions. Knowledge within the social world is often based on theories about theories, whereas knowledge within the natural sciences is more readily based on observations of phenomena that have been defined and are now ‘relatively’ uncontested.

Ok so world views are big, theoretical and contested, what about ideology?

Well apparently  the term was first used by the Enlightenment thinker Destutt de Tracy who used it to describe the “Science of Ideas”. Now we take it for granted that “Science “ is the best way of trying to make sense of the world but in the late eighteenth century, thought and philosophy was dominated by faith and the new ideas of the Enlightenment were seen as the vehicle of rationality and progress and “ideology” was to be the science of those ideas. However, as we all know the meaning of words shifts, as much as most things in the social sciences and the meaning of the term “Ideology” has probably done so as much as any other. I won’t go into all of its different -meanings  nor the will I bother with the argument of some that the concept has become irrelevant. But my preferred use of the term ideology was that used by James Donald and Stuart Hall who stated:

Ideology is used to indicate the frameworks of thought which are used in society to explain, figure out, make sense of or give meaning to the social and political world.  

Kind of like a world view.

So if you use the interpretation offered by Donald and Hall then my statement “all world views are ideological” would seem perfectly reasonable.

However, there are a great many people who use the term differently and I accept that its current dominant use is more pejorative and its application to a framework of thought or world view implies that the world view is in some way false or at best misguided. Ideological world views are therefore driven by political bias and false consciousness rather than objectivity. If applied in this way, and if correct my statement “all world views are ideological” would have to mean that all world views are in some way false and that no world view can claim or even aspire to the truth. Which would probably be why Ann Pettifor implied that I was being cynical.

Alternatively it could be that I am wrong and that some world views are ideological and others are not – which I believe reflects the principal position that Ann Pettifor adopted during our Twitter discussion. But if some world views aren’t ideological then it must follow that they are true.

Maybe but probably not – The difficulty is the complexity of the social world and the problem that the social sciences have in developing scientific or “true” interpretations of the world. This doesn’t mean that social phenomena aren’t ultimately subject to the same laws of science as every other phenomena within the universe. As far as I am aware nobody has ever yet seen any evidence that would indicate otherwise. It is rather a reflection of the epistemological status of our sciences. We are not only trying to study the most complex system’s known to us – we are also studying them from the inside and every time we act on them, observe them or even think about them we change them.

At our best, we might at certain times be able to develop models of aspects of the world. Models and theories that at a given moment in time offer an accurate representation of the conditions that brought about a specific event or phenomena and that we can test and re-test through modelling, experiment and empirical observation. However that does not mean that the occurrence of similar conditions will necessarily bring about the same effect. For the simple reason that similar doesn’t mean the same and if it is sometimes unwise to presume that conditions have remained the same across a rock formation it is profoundly unwise to do so across a view of the world.

So even using a pejorative definition of the term ideology, in my opinion the statement “all world views are ideological” remains valid because the complexity of the social, political and economic world prevents us from developing views of the world that are at this moment in time sufficiently uncontested and sufficiently scientifically robust for us to be able to describe them as “true”. Does this mean that we shouldn’t try? No it doesn’t – it just means that the first tool of a social scientist isn’t certainty, theory, nor even observation, it’s the question.

As for Katharina – well she dumped me and married a bank manager.

Advertisement

Champions of Patient Safety: The people part of Human Factors

Jeremy Hunt wants a seven day NHS. Well for the record the last time that I needed the NHS at the weekend it was definitely there and the service I got was as good as it always is. But I’m willing to accept the theory that it would be better if all of the things that it does, are available every day of the week. Jeremy Hunt’s argument is that doing this would make the NHS better and safer for patients. As we all know – in pursuit of this objective the Secretary of State has negotiated (sort of) and then imposed a new contract on junior doctors and as we all also know – the junior doctors aren’t very pleased about this.

At the same time as this, Jeremy Hunt has also become a Champion of Safety. Last week he launched his Global Patient Safety Summit at which he announced the creation of The Healthcare Safety Investigation Branch (HSIB). Which apparently will be a safe investigatory space that can investigate a limited number serious patient safety incidents and will begin by focusing on maternity services.  In addition to this, yesterday there was a question in Prime Ministers Questions praising the work that the Secretary of State was doing in the field and Scott Morrish the parent of a child who died from medical error, wrote an article for the Times in which he outlined his own personal experience and then praised the establishment of HSIB. Which is not altogether surprising because he was part of the group tasked with its formation. His article, like that published by James Titcombe on his blog yesterday was profoundly moving.

Patients’ experiences are extremely important. Our stories can and often are used as a lever with which to change and transform established practices and power relationships. The stories of James Titcombe and Scott Morrish are examples of the kind of patient/parent narrative that can and should change the way in which things are done. But the way in which families stories are used is rarely politically neutral. Often we will be brought into conflicts where senior managers and politicians want change and staff and trade unions don’t, and the current government initiative is such an instance. The patient safety stories of people who have been the subject of medical error have become a weapon in Jeremy Hunt’s dispute with junior doctors and his broader drive to create a seven day NHS.

Now you might well argue that having a 7 day NHS would be safer and that the pay rise offered to junior doctors might be reasonable and I’m not going to argue with you either way. What I will say is that any kind of systemic or cultural approach to patient safety is going to be dependent upon the wholehearted commitment and support of junior doctors for it to work. The struggle for a safer NHS cannot achieve progress in the context of the kind of relationship that the government currently has with its junior doctors. And the learning that might arise from considering Scott and James’ stories in a more constructive environment is likely to be lost in the white heat of the current conflict.

A safer NHS is one that will be built on collaboration, consensual leadership and a collective drive to make the NHS safer for its patients. And as families and patients we need to be wary of becoming embroiled in politicians’ battles, because in the end the Champions of Patient Safety that count aren’t going to be the Secretary of State and probably not anybody else that was at the recent Global Summit – it will be junior doctors, consultants, nurses, support staff and families working together – the people part of Human Factors.

Parents, Unwise Decisions and the 5 Principles

I’m not sure how many parents of young adults with learning difficulties like the Mental Capacity Act and I suspect that I’m one of the few that do. I also suspect that may change one day because I don’t like many of the things that are done to families in its name.  But right at this moment I like its principles. I like them, because I believe that if they are applied in the spirit in which they are written and if the social and health care provision provided in support of those decisions is sufficiently funded, then they can go a long way toward reducing the breakdown of care for people with learning difficulties in their community.

And when its used in this way it’s not about risk or wisdom it’s about control.

I remember reading something that Mark Neary wrote about the changes that young adults with learning difficulties and ASD go through between the ages of 16 -18. And there is a change and it may not always be exactly at that age but it happens and it’s important. It’s the age at which all young adults want to take control of their lives and it doesn’t matter if they are disabled or what their disability is. It’s the age at which their existing relationships will be challenged, when long established boundaries will no longer seem relevant and a new assertiveness takes hold.

It’s in this context that I think that the principles of the Mental Capacity Act are relevant for families and not just social workers (I’ve amended the text a bit  a lot to make it sound a bit less formal):

1. We should assume that our young adults have the ability to make their own decisions (even if every ounce of our previous experience with them is screaming that they can’t ) because often they can  ;
2. We should do everything we can to help them to make their own decisions and only if we’ve done that should we consider the idea that they may not be able to make that decision for themselves (otherwise it will be really easy for somebody to come along and challenge what you as a family are doing) ;
3. Young adults make decisions that people in authority like parents and social workers think are unwise – and we need to get over it;
4. If people do have to make decisions on a young adult’s behalf then those decisions have to be made in the person’s best interests and not because its convenient for everybody [family][service providers] [social workers][politicians] else;
5. If people are making a decision on somebody else’s behalf its probably best to do it in a way that is least likely to piss them off.

To be honest and sort of joking aside,  I think the essence of the 5 principles of the MCA are what we try and do anyway. Its what most of us try and do with our other teenage children. When they are ready to make their own decisions we let them. In the process of helping them mature we do everything we can to help them to make their own decisions. They often make decisions we think are unwise, and despite all of that we sometimes make the judgement that they are not ready to make a decision. And if we do have to do that, we do our best to mitigate the impact of the decision that we have had to make on their behalf.

Of course many of the decisions are different. The choices that a twenty year old man with ASD and severe learning difficulties will make are not the same as those that another twenty year old might make. His ability to act independently is different, as is his ability to assess and manage risks to his own well-being. But it doesn’t mean that tomorrow he won’t be able or willing to do, what he couldn’t or wouldn’t do yesterday. What is the same is his need to take increasing control of his life and his choices and the 5 principles of the MCA can help him to do that.

However, there is another problem because it’s not just families that stop young adults from exercising more control over their everyday lives. Choices and opportunity do not exist in a vacuum and often choices are denied to a young adult with learning difficulties because a particular choice doesn’t fit into an existing pattern of service provision or doesn’t reflect best value for a local authority.

The risk then is the risk of no choices and no funding to support those that there are. The unwise decision maker is not the young person, the parent or even the social worker it’s the politician that thinks that you can save money on local social care provision without it having a knock on impact on emergency healthcare placements for young people with challenging behaviour.

And when that happens I’m not such a fan of the Mental Capacity Act because then it can be used for a whole different agenda that has nothing to do with its principles.

Families and the Politics of Patient Safety

 

It’s been one of those weeks where I could have blogged about a dozen things. I got into a twitter argument with Ann Pettifor about what I believe is the intrinsically ideological nature of world views. Then there was the statement by the Archbishop of Canterbury that it’s not racist to be worried about immigrants and indeed that saying its racist is outrageous. Well I guess that would be his world view and there are undoubtedly people who worry about the impact of mass movements of people in a way that isn’t racist – Peter Sutherland the UN Special Representative for Migration would be a good example – but most us aren’t concerned about migration because we care, we are concerned about immigration because we fear and the thing we fear most of all, is difference. 

But those are blogs for another day – today I think I’m going to write about patient safety.

Now you might think that patient safety isn’t a particularly interesting or important subject and you’d be in good company if you did. The government launched a major patient safety initiative this week at a Patient Safety Global Summit and it got precious little media coverage. Understandable? Perhaps, patient safety doesn’t seem very exciting but this year more people will die from medical error in the United States than will be killed in the war in Syria. Almost as many people will die in the UK from adverse incidents as will die from gunshot wounds in the United States and in the UK alone the current clinical negligence liability of the NHS is estimated at £26.1 Billion. So it may not seem exciting but in reality its impact upon our everyday lives is likely to be far greater than terrorism or immigration.

Anyway in response to a problem of this scale the government is launching an organisation called the Healthcare Safety Investigations Branch (HSIB). Its remit will be to create a safe space in which patient safety incidents can be investigated and which will disseminate safe practice to NHS Organisations. It will draw on the principle of “Intelligent Transparency” which Jeremy Hunt defined in a speech at Lancaster House as…  …well actually he didn’t define exactly what he meant by Intelligent Transparency beyond stating that the government would publish data on numbers of avoidable deaths by Trust as well as data on the openness and honesty of reporting cultures.

Beyond these new performance measures we have also been informed that the HSIB will be resourced in its first year to investigate 30 incidents and that most of the investigations that the organisation will carry out in its first year will be into deaths in maternity services. So just so we are clear, the government believes that a proportionate response to the 12,000 avoidable deaths that will likely occur in the NHS this year is to resource the investigation of 30.

I guess going back to my argument with Ann Pettifor about the ideology of world views – I could argue that the discrepancy between the government’s language about patient safety and the reality of its commitment as expressed by the resources allocated to HSIB, is an indicator of the profoundly ideological or even rhetorical nature of that commitment. If the government was serious about preventing avoidable deaths it would go way beyond the scope of its current measures and invest in learning and transparency in a way that would genuinely transform the relationship between patients, their families, practitioners and the managerial infrastructure of the NHS.

The problem for the government is that in order to prevent its mistakes – it has to learn from them – in order to learn from them it has to admit them and in admitting them it potentially becomes liable for them. Hence the focus upon Intelligent Transparency. The intelligent bit comes in being transparent enough to be able to create more performance data so that politicians and senior managers can use it to manage the behaviour of NHS staff, without being so transparent that it increases the NHS’s vulnerability to litigation. Unfortunately for families and patients the addition of yet more performance criteria and the establishment of a significantly under-resourced investigation unit, is unlikely to make a difference to the number of people dying from preventable causes.  

So where does that leave us – the patients and the families of people in the care of the NHS.

Should we back it or should we be cynical about the government’s plans for trying to make the NHS a safer place for its patients and its practitioners?  I think that the answer to this can be found in the perspectives of two parents both of whom have personal experience of the tragic consequences of medical error. James Titcombe, whose son Joshua died from an unidentified infection nine days after he was born and Sara Ryan whose son Connor died whilst in the care of Southern NHS Trust. Each of their children died for different reasons, but what they have in common is that both Connor and Joshua died from preventable causes.

I think it is fair to say that both Sara and James have chosen different ways of fighting for their own sense of justice. The focus of James’ struggle has been a relentless drive to uncover the truth of what happened at Morecombe Bay, whilst retaining a commitment to work with practitioners and politicians to improve the system.  For Sara the struggle to uncover the truth of the failings that led to Connor’s death and the implications that this has for the wider community of people with learning difficulties has remained outside the system.

For me each of their struggles is in their own way heroic. James’ reason in the face of unreason and incompetence; perhaps expressed most clearly at the recent court case, where his recollections were described by a practitioner’s council as unreliable, on the very same day that he was introduced by Secretary of State for Health as a champion of the government’s patient safety initiative or in the unreason of the  letter from a local doctor who accused James of failing to let his son’s soul rest in peace. But the brutality of the current system is shown equally clearly in the struggles that Sara Ryan has had to endure in her efforts to inch incrementally closer to the truth of her son’s death and nothing deserves our respect more than the tenacity and humanity she has displayed in the course of that struggle.  

What is less heroic is the way in which elements of the system have come to represent and appropriate the actions of these two parent’s. James has engaged with the system, struggled with it and to a great extent has become an exemplar of “the good parent”, the family member who has seemingly adjusted to his personal tragedy and who is working for the benefit of others to improve the system.  Whilst Sara “the angry or frustrated parent” is implicitly being used as the unspoken example of a parent who has failed to adjust to her son’s death and is looking to “ blame” practitioners for their mistakes.  It’s not been publicly stated, these things never are, but in my opinion it is reflected in the Secretary of States failure to take significant action against Southern Health and in the tone of his speech:

Time and time again when I responded on behalf of the government to tragedies at Mid Staffs, Morecambe Bay, Winterbourne View, Southern Health and other places I heard relatives who had suffered cry out in frustration that no one had been ‘held accountable.’

But to blame failures in care on doctors and nurses trying to do their best is to miss the point that bad mistakes can be made by good people. What is often overlooked is proper study of the environment and systems in which mistakes happen and to understand what went wrong and encouragement to spread any lessons learned. Accountability to future patients as well as to the person sitting in front of you.

The rush to blame may look decisive. It may seem like professionals are being held accountable. In fact, the opposite can happen. By pinning the blame on individuals, we sometimes duck the bigger challenge of identifying the problems that often lurk in complex systems and which are often the true cause of avoidable harm.

The reality is that neither representation accurately reflects James or Sara or any other parent in their situation. James is now undoubtedly working to focus on the role that systems can play in improving patient safety culture and to a great extent he has become a part of the improvements that have taken place over recent years – yet in my opinion his best intentions are in danger of being hijacked by a politician who whilst well meaning has no intention of making that system genuinely more accountable for its mistakes – if that accountability has the potential to lead to financial litigation.

Equally Sara may well be looking to “blame” or hold to account an organisation for the death of her son but that search for justice is not a reflection of her lack of adjustment or of her being misguided, it is a measure of the lack of transparency and obfuscation with which she is confronted and her rejection of the presumption that staff are always doing their best and that systemic failure is the only cause of avoidable death.

To be honest the more I look at the detail of each of their stories, the greater the parallels and the more that I see that they have in common. In fact the major difference is probably that when James started his struggle to uncover the truth social media didn’t exist – whereas it has been an essential part of the #justiceforlb campaign. There may also be differences in responses to James and Sara because of the fact that James is the bereaved parent of an infant and Sara is the bereaved parent of an adult with learning difficulties. The former is something that every parent fears – whereas the death of an adult child with learning difficulties happens to parents who are “different”.  Another thought for another day. 

However to return to the question I asked earlier: Should we back the government’s plans for trying to make the NHS a safer place for its patients and its practitioners?

Despite my cynicism about Jeremy Hunt’s underlying motivations, I believe that the experiences of families across the country indicates that we probably should.  But in doing so, we should probably remember that for a while yet the reality of the struggle for the truth about why people die in NHS care is more likely to reflect the experiences of James Titcombe at Morecombe Bay and Sara Ryan at Southern Health than the ideals espoused by the participants of the Global Patient Safety Summit and that any government that is genuinely serious about tackling the 12000 avoidable deaths per year will have to invest an awful lot more in patient safety than this one is doing.