Back in December, I told the Guardian Health Network that we were looking at publishing information for nurses and midwives about positive uses of the internet and social media. Well, issue 4 of NMC Review is just out, with a lead article written by me (reproduced below), comment from health bloggers and lots more. And an awesome eBoy-style illustration.
Caught in the web
The internet is having a profound impact on how healthcare is delivered, managed and discussed – and there’s no turning back. We explore some implications for the public and the professions
Digital technologies have changed our lives. We feel the impact of the 'digital decade' in the way we use the media, entertain ourselves and connect with our friends and families. Being online has become an unremarkable, mainstream element of many people's daily experience. Whether you check Facebook on your smartphone as you wake up, or you are a Twitter refusenik confused by David Dimbleby mentioning hashtags during the BBC television programme Question Time, we all find ourselves caught up in the world wide web.
Being online is transforming our social lives - and changing the world. The Arab Spring of 2011 highlighted the power of blogs and social networks to mobilise real-world communities and transform societies, with digitally connected citizens playing a central role from Libya to Bahrain. Closer to home, Twitter and BlackBerry Messenger might have played some part in fanning the flames of last summer's riots in England, but the Big Society response that followed could only have been facilitated through a social network. Organising themselves around the Twitter hashtag #riotcleanup, hundreds of people armed with brooms took to the streets of London.
The online world can seem bewilderingly complex, especially for nurses, midwives and patients who are reluctant to be swept along by the digital revolution. Though websites and services may be daunting for a first-time visitor, scratch the surface and you will find the same information, news and gossip that people share with each other in everyday conversation. Beyond the jargon (see our glossary), so much is familiar.
New technology creates opportunities for patients and service users to access healthcare information online, and to connect with others with similar conditions, but this is close to the familiar world of glossy leaflets and support groups. In the arena of health promotion, social marketing and public health practitioners have harnessed online tools to help transform health outcomes, but the principles, messages and methods remain much the same. Furthermore, as we explore later, although social networking sites like Facebook present new challenges for nurses, midwives and students, as well as the institutions where they work and learn, those challenges centre on a perennial concern - appropriate professional and personal behaviour.
Empowerment and reliability
Beyond the challenges for people trying to understand and use these technologies, the world wide web also presents new opportunities to empower people to improve and maintain their health - by placing the tools to discover and share information directly in their hands. Empowerment may be a relatively straightforward idea in the context of online behaviours, but it is considerably more complex in the world of healthcare. It can underpin both the role of professionals in guiding patients' choices, and the concept of patients as consumers who make decisions independently of professional advice. It does, however, provide a useful prism through which to view the development of a wide range of technologies and their impact on patients (Lemire 2010).
Patients and service users are becoming more empowered as they use the tools of the world wide web to learn and apply expert knowledge, and play a more active role in the prevention, treatment and monitoring of their own illnesses and conditions. Empowerment has a role to play collectively too, as groups of patients and carers participate in solidarity networks and advocacy groups centred on specific conditions and experiences.
Ready access to health information online can give empowered patients access to a range of materials that may help them manage their own conditions. If access to a real-world healthcare professional is needed, patients may find it useful to 'triage their conditions with the easiest or most appropriate information source first ... the convenience of accessing online self-care information rather than visiting a health professional is oft en cited as a motivation for using the internet' (Eysenbach 2008). This can speed up diagnosis, and lead to more informed discussions between patients and professionals.
It can also lead patients to develop a firm self-diagnosis that may make it harder to explore the problem when they do eventually meet a health professional. Yet dealing with patients who are attached to inaccurate but seemingly credible information that supports their view of the world is not a new phenomenon. More positively, the world wide web opens up many possibilities for patients who want deeper knowledge of their health problems, and find information that leads to more sophisticated questions.
Credible information
Conversations about the credibility of online information are particularly important with patients whose approach to searching the web can be characterised, perhaps unfairly, as diagnosing with Google and treating with Wikipedia. Avoiding low quality and potentially harmful healthcare information online in itself represents a challenge. Initiatives like the Information Standard, designed as an accreditation scheme for online health information and supported by the Department of Health (England), may help address this but their reach will always be limited to mainstream websites willing to enter a certification process.
Information is easily distorted as it is replicated across the web, and both patients and professionals need help to find, evaluate and use high quality peer-reviewed information controlled by experts. What is most important is the credibility of the sources cited by a particular piece of health information, not how frequently it appears in online searches.
Communities and crowds
The internet, as well as being a source of health-related information, also provides mutual support opportunities for patients and service users online. Sometimes these online communities are managed by organisations that provide support in other ways, such as Breast Cancer Care's online community of 17,000 members. Others emerge spontaneously and organically in online spaces that were not designed for the purpose. There is room for healthcare professionals to engage here too. The Terrence Higgins Trust, for example, has an online outreach programme, with sexual health advisers available in chat rooms.
How can we engage with discussions about health in online spaces that deliberately exclude healthcare professionals? Take the continuing controversy around 'pro-ana' websites, which have been criticised for promoting anorexia nervosa among young people. Such sites do express a form of empowerment, but they are extremely worrying because of the potential harm to people who follow their advice. This has led to calls to have them classified as harmful (Royal College of Psychiatrists 2009), and blocked automatically by internet service providers.
Pro-ana websites are of course an extreme example. Many self-organising online communities provide valuable and health-enhancing spaces for those affected by eating disorders. Professionals need to tread carefully, to understand when to step in and when to step back while patients support each other.
Sharing experiences online
Patients and service users are not going online just for information and support. As more people use Facebook, Twitter and other social networks, more are sharing their thoughts and experiences in real time with their friends and the wider world. Talking online about experiences in healthcare environments is becoming more common, though there are competing views about whether the open, public nature of social networking sites increases or diminishes the likelihood of someone disclosing personal information (Bateman et al 2010).
This sharing can include good news, from celebrity mums using Twitter to announce their pregnancies and praise their midwives, to the hundreds of patients who shared their personal experiences of high quality NHS care in 2009, using the hashtag #welovethenhs. Patients also talk about poor experiences, like journalist Mark Sparrow. His experience of hospital food during a long in-patient stay was so poor that he photographed and blogged about every meal. This eventually led to a television documentary (Channel 4 2011).
Sharing personal information online may be a particular problem if people talk not only about their own experiences but also those of others. Just 23 breaches of patient confidentiality by NHS staff [PDF] were found on social networking sites between 2008 and 2011, (Big Brother Watch 2011), but the more widespread breaches of confidentiality by patients usually go unchallenged and unreported. While acknowledging the importance of empowering all service users, open discussions about responsibility and respect may be needed to deal with these situations.
Useful channels for those who wish to share their experiences can be provided by initiatives like Patient Opinion. This online service encourages open sharing of positive and negative stories, with opportunities for healthcare providers to respond. Such channels can be a force for good by bringing problems and solutions into the open, and providing an impetus for change.
Whether you yourself go online or not, you cannot ignore the impact of the world wide web. People in the care of nurses and midwives are increasingly going online to find healthcare information, create communities and share their experiences. It would be foolish to make predictions about the future of healthcare online, but the desire of many patients and service users to empower themselves and take control of their own health and wellbeing is not going away.
In a world transformed by digital technology, nurses and midwives can play a vital role in using the rich resources of the internet to support the health and wellbeing of people and communities, in the real world and online.
References
Bateman, P J, Pike, J C and Butler, B S (2010). To disclose or not: publicness in social networking sites. Information Technology & People, 24(1), pp 78-100.
The Truth about Hospital Food (2011). [Television programme] Channel 4, 21 February 2011, 20:00.
Custers, K, and Van den Bulck, J (2009). Viewership of pro-anorexia websites in seventh, ninth and eleventh graders. European Eating Disorders Review, 17(3), pp 214-219.
Eysenbach, G (2008). Credibility of Health Information and Digital Media: New Perspectives and Implications for Youth. In: Metzger, M J and Flanigan, A J, ed (2008), Digital Media, Youth, and Credibility. Cambridge, MA: The MIT Press, 2008. 123-154.
Lemire, M (2010). What can be expected of information and communication technologies in terms of patient empowerment in health? Journal of Health Organization and Management, 24(2), pp 167-181.
Putting another hat on as a board member of Mosaic Clubhouse - a south London charity that supports people recovering from mental ill health - I was interviewed as part of a piece on the role of charities in the Big Society. With a changing funding landscape in the voluntary sector, there are big challenges ahead, but I think the Big Society is a positive. As I say in the piece, "the big society model ... is about people taking a stake in their own lives."
Does 'big society' spell the end of charity as we know it?
When is a charity not a charity? We are seeing the end of the clear dividing line between what government does and what the voluntary sector does. The government at all levels has made it clear that it is uninterested in directly providing public services, leaving it to charities, social enterprises and ethical companies to battle it out. The Victorian notion of a charity – giving money, goods or time to others – is becoming unfamiliar to the British public in the age of the big society. Are we, therefore, seeing the end of charities as we've known them?
"The public connect charities with poverty and the needy" says Rosie Chapman, who has spent many years formulating what charities should be. "The reality is much wider." Until recently, Chapman was director of policy and effectiveness at the Charity Commission, and despite clearly being an advocate of charities, she holds "quite an old-fashioned view" of the state's role in society. Charities are increasingly threatened as independence decreases, and government-funded dependency increases.
"There's a huge scope for what a charity can do, provided you show there's a public benefit which outweighs private gain. Clearing the rubbish? You could argue that there's an environmental and health aspect to it," says Chapman. "And it doesn't matter if there's a monopoly. Look at Royal National Lifeboat Institute, for example".
A good example of a charity taking advantage of opportunities in this new world of charitable activity is Mosaic Clubhouse, which focuses on recovery for people from mental illness. The Clubhouse "movement" started in New York in the 1950s, and was designed to prevent stigmatisation. Run by and for the benefit of its members, who come and go as they please, Mosaic is principally funded by Lambeth council and other public sector bodies including the NHS.
"Clubhouse is the perfect big society model in lots of ways," says Andy Jaeger, a trustee for the charity. "It's about people taking a stake in their own lives."
According to Jaeger, there is much that the third sector can do in this instance that could never be matched by centrally managed programmes of care. Central government is focused on short-term intervention but Clubhouse membership is always open to those who need it, meaning that a community has developed over the years which can provide longer, more sustained support.
"Lambeth recognises there is a need for a recovery-focused model," says Jaeger. "It has one of the highest rates of mental ill-health for anywhere in the UK." The Clubhouse is crucial in providing a stable, yet innovative service. The charity is welcoming an increase in its funding, somewhat against the trend. "But there's an increased expectation of what we do as a result," says Jaeger.
The charity will move to new premises, from its pleasant Georgian building in Balham to a site in nearby Brixton. An "infohub" service will be provided, catering not just for people with mental ill-health, but potentially anyone in the wider community. There will be a continuation of the activities its community engages in, such as cooking or gardening, but the new centre will also provide psychological therapies in the same building, which explicitly do not fit the ethos of the Clubhouse movement that exists all over the world.
"It's challenging to the Clubhouse model, which makes decisions as a community," says Jaeger. "And there are tensions as a result. We're being asked to do more, doing it better and adding value. But we are not free." Staff still need paying, and rent and bills have to be paid. Jaeger accepts that the Clubhouse is not the kind of charity that necessarily attracts big public donations.
For small charities like Mosaic Clubhouse, negotiating with local authorities and other funders can provide a challenge to their independence as service providers. "We are having to beg and borrow financial and legal services," says Jaeger. It's the sort of resource that multi-national private sector players have much readier access to.
There is no doubt that charities such as Mosaic Clubhouse are doing much-valued work. But is the goodwill of charities maybe valued a little too much by government, to the extent that it ends up being taken for granted? Chapman thinks it might be.
"Charities should have the independence to say no," says Chapman. "Freedom over the board and freedom by the board must count for a lot. But the way levers of power are exercised in charities means that influential people get to become trustees. On the face of it, you could see a charity seeing almost anything. But charities don't have to pay the cost of democracy – and it's cheaper if a local authority hasn't got to pay into a local government pension scheme."
Fundamentally, people in the third sector appear to be optimistic that the big society agenda will work, partly because they know it already exists. But they remain cautious because they know the funding doesn't. There are new models of delivering services, new types of organisations and a charitable sector that is ever more flexible in what it delivers. The dilemmas faced by organisations such as Mosaic – whether an organisation should rescind its independence, coupled with strict conditions of funding – could ultimately undermine the enthusiasm of today's social entrepreneurs; the old charity model doesn't necessarily fit with the new environment.
Healthcare regulation faces a cacophony of criticism. How should it change and what part should the public and professionals play?
‘When people’s lives and wellbeing are at stake, the public doesn’t want to hear about light touch regulation,’ according to Cynthia Bower, Chief Executive of the Care Quality Commission (CQC), the health and social care systems regulator for England (Santry 2011). She was setting out her plans in response to damning criticism, but also adding her voice to a broader debate about regulation and its purpose. Amid a crescendo of concerns about poor care, from Mid Staffordshire to the Vale of Levento Winterbourne View, healthcare regulation is in the spotlight.
There are different types of healthcare regulation and a plethora of regulators. Yet professionals have dominated regulation for much of its 500-year history. Professional self-regulation developed to recognise specialist skills and ensure that only those meeting the standards set by their peers gained professional status. As late as the 1970s the Merrison Committee, examining the role of the General Medical Council (GMC), concluded that a regulatory body must also be a professional body.
As it turned out, the 1975 Merrison report played the final chords of professional self-regulation. Its proposals represented ‘the last moment when so confident astatement of the superiority of the professions, their right to control their own affairs and their ability to act in the public interest could be made’ (Davies and Beach 2000). Significant changes began in the world of nursing and midwifery regulation. The General Nursing Council and Central Midwives Boardwere replaced by the UK Central Council for Nursing, Midwifery Council and Health Visiting (UKCC), which was in turn superseded by the Nursing and Midwifery Council (NMC).
‘Amid a crescendo of concerns about poor care, healthcare regulation is in the spotlight’
There were changing registration requirements, rising fees and growing numbers of fitness to practise cases. Amid this noise the mood music of regulation itself was changing, though almost unheard at the time. Better regulation required a balancing of the interests of the professions with those of employers, service users, educators and others, are view of the UKCC concluded (JM Consulting 1998). In tune with the emergence of patient-centred care in the 1990s, professional self-regulation gave way to a subtle but significant variation and professional regulation in the public interest came to the fore. Systems regulation also began to develop, with the Commissionfor Health Improvement founded in England in 2001.
The review that led to the establishment of the NMC chimed with a new regulatory paradigm that found its expression later in the Hampton principles (2005) and the Legislative and Regulatory Reform Act (2006). Regulators should not set aspirational standards, and should only intervene if there is a threat to public protection. Regulation should be transparent, accountable, proportionate, consistent and targeted. Above all, it should be ‘light touch’.
Politicians like cutting red tape and light touch regulation is an engaging idea, but hard to sustain when faced with care scandals. This is creating tensions in people’s expectations of regulation, as shown in the current debate on whether statutory regulation of healthcare support workers would improve care. Two recent documents highlight some of the complexities.
Enabling excellence (2011) sets out the government’s proposed direction for healthcare regulation. It adheres to the Hampton principles, and is a continuation of the regulatory paradigm of the late 1990s, being a strategy not just for reform but also for simplification. It says statutory regulation should not be extended to healthcare support workers, and instead supports a voluntary arrangement (‘Transforming regulation’, NMC Review, issue 1, p33).
Contrast this with a recent report of the House of Commons Health Committee (2011), whose chair Stephen Dorrell MP introduced it by saying, ‘At a time when there are signi?cant concerns about standards of care… it is important that the professional regulators step up to the plate.’ In a view reminiscent of Merrison, the report encouraged the NMC to ‘embrace more ambitious objectives for professional leadership’. Moreover, directly challenging government policy, it endorsed mandatory statutory regulation of healthcare support workers, as ‘the only approach which maximises public protection’.
Some opponents of extended regulation think professional regulation has failed to change the quality of everyday healthcare. Their concern that its focus on individual responsibility may lead to scapegoating has some justi?cation. And the regulatory system may in itself be inadequate to deal with increasingly complex issues, with the current separation of the potentially punitive power of a professional regulator and the enforcement regimes of a systems regulator. The regulatory paradigm that neatly separates individuals and systems is ?awed.
Take systems regulation. Despite the CQC’s recent promise that its inspections will focus more broadly on quality of care and the views of service users, systems regulation must necessarily focus on processes and policies. When failure is investigated, responsibility heads to the highest possible point in an organisation, and corporate decapitation is called for. Enforcement actions, whether closure of services or financial penalties, are not in themselves transformative. They may reduce the likelihood of terrible incidents, but they cannot alone create better outcomes.
‘We need a new language of regulation that deals with the collective and focuses on the everyday’
Professional regulation, on the other hand, focuses on individual responsibility at the expense of a corporate view. Investigated through the prism of professional misconduct, responsibility for failure tends to gravitate to the front line, and the person furthest down the chain of command is made the scapegoat. The professional regulator can remove a single dangerous person from a healthcare environment, but the removal alone does not necessarily improve the situation.
These are descriptions of extremes, and the reality is significantly more nuanced. Nevertheless, there is a gap between professional and systems regulation in dealing with the everyday reality of complex healthcare delivery. Even in the simplest of healthcare interactions, the planning, delivery and assessment of care is neither an individual act, nor the working out of a system, but a collective effort. Neither end of the regulatory spectrum adequately deals with collective action or collective responsibility.
Individual healthcare professionals create collective norms as they work together, and those norms in turn shape them. Those collective norms are codified into systems, which in turn influence collective activity. Without an acknowledgement of the power of the collective as a bridge between the individual and system, our understanding of healthcare delivery is incomplete, and our regulatory paradigm cannot be effective. In its current form, systems regulation cannot support collective responsibility, while professional regulation is too focused on punishing individuals to deal with collective failure.
Regulation is under great pressure, and perhaps even failing. We need a new language of regulation that deals with the collective: an effective regulatory regime that focuses on the everyday, not the extremes. New thinking is needed to help regulators safeguard public health and wellbeing, and drive up standards. This thinking needs to focus not just on patient safety, but also on public trust in the professions. It must avoid over-regulation, especially when it damps down positive innovation. Balancing these issues and concerns, three simple principles are central to the new regulatory paradigm: being proactive, rethinking standards and reaching out.
Being proactive
In the new paradigm, regulators have a responsibility to be proactive. For the NMC, this means responding decisively when concerns are raised. For example, the request that universities remove their nursing and midwifery students from Pilgrim Hospital in Boston, Lincolnshire, in response to serious concerns raised by the CQC, shows the power of collective action to improve healthcare education. Being proactive also means that the NMC has started initiating its own investigations, using powers under section 22(6) of the Nursing and Midwifery Order 2001. Over 200investigations have already been launched this year in response to media reports. Standing on the sidelines waiting to be invited in is no longer adequate. As Cynthia Bower says, regulators have to ‘cross the threshold’ and work collaboratively with organisations under pressure to support andenable change.
Rethinking standards
Reimagining regulation also means a fundamental rethink of the purpose and nature of standards. Standards for education and practice are NMC core business, but have too often described the bare minimum of expected quality. Used as a blunt regulatory tool, they allowed the removal from the professions of people who signi?cantly underperformed, but they have never been aspirational. Too many professionals upholding NMC standards found they simply supported existing good practice, and no more.
The NMC is now committed to setting what it describes as ‘standards with stretch’ in the current reviews of the code (NMC 2008) and record keeping guidance (NMC 2009). It recognises the need for collective effort to implement, change and improve practice at every level and in every setting. It will also set standards that focus on improving health outcomes. Looking for measurability and impact in the setting of standards is challenging, especially when the relationship between the regulator, the standards and the multifactorial delivery context is so complex. Setting standards with stretch requires regulators to become professional leaders.
Reaching out
Finally, the new regulatory paradigm requires regulators to reach out to the public by setting out clearly the standards of care they can expect, and providing an open door for expressions of concern when those standards are not met. Professional regulation, even if it is exercising professional leadership, cannot be the sole domain of professionals. Healthcare regulators are required by law to regulate in the interests of public health and wellbeing, but in reality can be far removed from the everyday concerns of patients and service users. The NMC is now listening closely to those concerns, and ensuring their voice is heard at every level of regulatory decision-making. Regulators must also reach out to each other and act collaboratively with employers for the collective good. The NMC memorandums of understanding with systems regulators across the UK help ensure information is shared, and concerns that otherwise would fall into the regulatory gap are acted on. It is also engaging more positively with employers.
Whatever happens in these uncertain times, the healthcare environment will continue to change. Can regulation also change fast enough to safeguard public health and wellbeing, and drive up professional standards? There may be trouble ahead, but it’s time for regulation to face the music.
References
Davies, C and Beach, A (2000). Interpreting Professional Self-Regulation. London: Routledge.
Department of Health (2011). Enabling Excellence: Autonomy and Accountability for Health and Social Care Staff. Command paper Cm 8008. London: TSOL
Hampton, P (2005). Reducing administrative burdens: effective inspection and enforcement. London: HMSO
House of Commons Health Committee (2011). Annual accountability hearing with the Nursing and Midwifery Council (2011). HC 1428, London: TSOL. Available at [http://www.publications.parliament.uk/pa/cm201012/cmselect/cmhealth/1428/1428.pdf]
JM Consulting (1998). The Regulation of Nurses, Midwives and Health Visitors: Report of a review of the Nurses, Midwives and Health Visitors Act 1997. Bristol: JM Consulting
Nursing and Midwifery Council (2008). The code: Standards of conduct, performance and ethics for nurses and midwives.
Nursing and Midwifery Council (2009). Record keeping: Guidance for nurses and midwives.
Nursing and Midwifery Council (2010). Raising and escalating concerns: Guidance for nurses and midwives.
Nursing and Midwifery Council (2011). Transforming regulation. NMC Review, issue 1, p33.
Santry, C (2011) In charge of the not-so-light any more brigade. Health Service Journal, 28 July 2011, pp16-17.
Legislative and Regulatory Reform Act (2006). London: HMSO
Report of the Committee of Inquiry into the Regulation of the Medical Profession (1975). Command paper Cm 6108, London: HMSO [Merrison Committee Report]
...if you are true to them even in the most extreme circumstances. In the face of the horror that has unfolded in Norway over the past 24 hours, this is powerful stuff.
As a graduate of Stonewall's Leadership Programme, it's a real pleasure to help out in promoting the course to future participants, and sharing my experiences in the workplace. A little while ago, I was interviewed by the lovely Hashi Syedain for a piece in People Management magazine. The complete article is below, and also on the People Management website. The interview with me is towards the end.
Diversity - the pink ceiling
Being openly gay shouldn’t be a big deal any more, yet many people still face enough prejudice to make them wary of revealing their sexuality. But the effects of not coming out can also harm career prospects.
"Organisations generally have become more diverse, but you don’t often see gay people in senior teams, just like you don’t see gender or ethnic diversity at top levels,” says David Shields, Stonewall’s director of workplace programmes.
Telling your workmates that you are gay can be tough: witness the brouhaha that surrounded rugby player Gareth Thomas, cricketer Steven Davies and Swedish footballer Anton Hysén when they each declared their sexuality. Sport may be an extreme case – Hysén is still the only openly gay professional footballer in the world – but that doesn’t mean it’s easy everywhere else.
Even if open homophobia in workplaces is less common than it used to be, gay rights group Stonewall argues that many organisations still operate with a “pink ceiling” – a more subtle barrier of prejudice that stops gay people getting to the top of their profession or causes them to hide their sexuality.
“Organisations generally have become more diverse, but you don’t often see gay people in senior teams, just like you don’t see gender or ethnic diversity at top levels,” says David Shields, Stonewall’s director of workplace programmes. Women or ethnic minority men may fear a double dose of prejudice, he adds, which means that lesbians or black men are more inhibited about coming out than white, gay men.
In other cases, people may be out to their colleagues but not their clients. ”Coming out isn’t a one-off event. It’s something that comes up every time you build a new relationship,” says Shields.
One of Stonewall’s initiatives for smashing the pink ceiling is a leadership course for mid-career gay professionals at Ashridge Business School. Among other things, the programme looks at authenticity and leadership.
“Good leaders have a strong sense of self-awareness,” says Albert Zandvoort, a management professor who teaches on the Stonewall course. Exploring authenticity can help gay people become more comfortable with their orientation and more open and honest. It’s not impossible to be a good leader if you are gay and not out, but it’s harder, says Zandvoort. “The personal stress will get in the way of being fully authentic. Honesty is a great thing and people respond well to it.”
The principle of a separate training course can be controversial, however, even among gay people. “I wouldn’t want any special courses for gay people. You treat them as an integral part of your workforce and if you think someone has been ill-treated because they are gay, you deal with it,” says Bernard Buckley, an ex-HR director and now an executive coach, who is also gay.
Even those who sign up to the course sometimes go with mixed feelings – although our case studies also show that gay people, even in broadly enlightened workplaces, face issues that most of the rest of the workforce don’t.
Case study: Lucy Bryans, EMEA operations manager, American Express Business Travel
“I wasn’t out until I was about 22. I took a gap year after university and went to New Zealand and Australia, where I met my first long-term partner. Getting a visa to work in Australia was my first big challenge as a gay person – we had to jump through all sorts of hoops to prove our relationship and could not get the same visa as a straight couple. That’s when I realised that there are barriers in life when you are gay.
“My first experience of coming out at work was at Trailfinders in Australia. I took a deep breath and told everyone on the training course, ‘I have a partner and her name is Cat.’ Trailfinders was a great place to work. It was no big deal, a non-issue. I made a decision then that I’d never be closed at work ever again.
“It’s very hard to come into work every day and not refer to your partner, to keep having non-gender specific conversations. I can’t imagine doing that – although I know people who have. My current partner did it for three months at one place, because some of the people she worked with were very homophobic. Then one day she said “my partner” and “she”. They sneezed, coughed and spluttered – and never mentioned it again.
“When I came back to the UK in 2006, I started working at Hogg Robinson. It was a more formal environment. In the main the experience was positive, but it was the first time I experienced anxiety. Certain people were a bit suspicious or said inappropriate things. The standard ones are assuming that you’ll never have children or asking, ‘Which one of you is the man?’. I deal with that sort of thing with humour and honesty because the minute you get defensive, people don’t understand.
“I’ve been more out with each job I’ve had. At AmEx, I found out about the Pride network when I joined and emailed them: ‘I’m new and I’m gay.’
“Last year we set up a mentoring scheme with the network and I have a mentor from that. She’s very senior and she’s not gay but she’s a strong ally of the Pride network. She was the first person to challenge me about whether being gay has an impact on how I am at work. I’d never considered before how I am always making split-second decisions about coming out many times each day. You want to be authentic, to be 100 per cent yourself with regular contacts – but it mustn’t become overwhelming to yourself or others.
“In some roles I’ve worked with people who had never come across a gay person. I thought, ‘I’m not going to hide it, but I’m not going to throw it in their face.’ You just hope that if you are genuinely hitting a barrier, you’ve got someone else to turn to. Not everyone does.
“When I first heard about the Stonewall leadership course I wasn’t sure about it. ‘Are we asking for separate courses now?’ I thought. ‘Really?’ But I had a very positive experience. The connection with the others on the course was an immediate peer connection – there was a lot of rubbish we didn’t have to go through. You quickly felt free to deal with the hard stuff, such as why you behave in a particular way and what impact your sexuality may have on that behaviour. I’d not experienced that freedom on a course before.
“I manage people from all sorts of minorities – hearing other people’s negative experiences makes you realise how others are feeling. There were people on the course who’ve had real challenges to overcome. I was amazed at how many people weren’t out with their clients. Some must have to listen to homophobic comments all day – so it’s really important to keep up the pressure. If you don’t, things can go backwards. That’s the point of networks. There are people in 2011 who are not progressing in their careers because they are gay. And that is not OK.”
Case study: Andy Jaeger, assistant director, communications, Nursing and Midwifery Council
"I came out in my early thirties, having spent most of my twenties living an outwardly straight life. At the time I was on the leadership team of a children’s charity with a Christian ethos. Overwhelmingly, the colleagues that I was closest to were incredibly supportive. So was the head of HR. No one was deliberately antagonistic, but long-term it was never going to be a comfortable fit. It was difficult. The charity ran 80 projects, 40 of which were church based. Having an openly gay head of fundraising… well, it was a bold decision.
“I now see a real difference in the kind of person I used to be at work. I was much more guarded about everything. I used to describe it as living an inch below the surface of my skin. It coloured everything. I wasn’t being true to myself. Living life as a whole person is important to my motivation now and my ability to do my job. You can’t connect with other people, or manage effectively, if you can’t be yourself.
“I stayed at the Christian charity for a year after I came out and then came to London to do a masters in marketing and communications. I was looking for a complete change and going to university was incredibly liberating. Of 20 people on the course, I was the only UK national. Being gay there was a total non-issue.
“After my masters I worked briefly for a housing association and then came here. This organisation has gone through a period of fairly rapid change and growth. There’s been high staff turnover. There are now 300 people in the organisation, compared with 220 when I joined five years ago. One of my challenges, when I was promoted to assistant director, was to make sure that across the organisation people are treated with respect and dignity – because as we’ve got bigger, we’ve realised that you can’t just rely on everybody knowing each other.
“I was quite skeptical about the Stonewall leadership programme – and I think many of the others there were too. We shared a sense as a group of having arrived, having made something of our careers. I had moved beyond thinking of being gay at work as a challenge. It’s a non-issue now, partly from a personal determination on my part to make it so. There are people who try to hide aspects of themselves, and on the flipside there are people who everybody instantly knows are gay. I make it a non-issue by making sure it’s not the only thing about me. People are much more interested in the fact that I sing in a choir or love sci-fi films.
“The Stonewall course wasn’t about being gay at work, it was about understanding yourself as a person and how your experiences have an impact on the way you do your job. There’s something very powerful in that, for anyone. Being gay, you are constantly making decisions about coming out. That gives you life experience of managing risk and perception. It makes you good at judging situations.
“As a result of my going on the course, we joined Stonewall’s Diversity Champions programme and I set up an LGBT network. This organisation is already incredibly diverse in terms of race, disability and sexual orientation, so the network is a way of enhancing something that’s already good. The course also challenged my own expectations of gay people. I met bankers, accountants, people working for utilities – people I don’t come across in my social circle. It’s amazing the stereotypes we walk around with – and coming out doesn’t rid you of those, or of discriminating against people.”
At work recently, we've been thinking a lot about why people don't complain about the care they receive, in hospitals and elsewhere, when something goes wrong. Working for an organisation that exists to make sure people are safe when nurses and midwives care for them, it's important to us to understand the barriers that prevent people getting the care they deserve. In truth, it's important to me.
I've been surprised in thinking about this subject how little academic research has been carried out in this area. There are some interesting studies, but they tend to have been sited in mental health services - where the subject of service user advocacy is well established - but if you are interested in the experience of older people, and why they might not complain if they are receiving poor care, there is a big gap. In reality, we don't know why older people don't complain, whether they're complaining as much as they should, or too much, or even really what about.
As a result, we're left with a lot of anecdotal information, much of it aired in local newspapers. There are two interesting and contrasting articles this week which focus on the role that newspapers can play in the process of airing complaints. They take significantly contrasting views.
The first that caught my eye was an editorial in the South Wales Evening Post. It appears that one of the Community Health Councils in Wales drew attention to an "epidemic of bedsores" among patients in Swansea, and the Evening Post has been championing their cause. This seems to have drawn a large degree of criticism from readers of the paper, unhappy that the paper has reported on the complaints before they have been investigated, and suggesting that reporting of complaints in this way somehow discredits the NHS. The second is from Monday's Guardian, suggesting that high profile commentary on poor quality care can prompt a flood of letters to newspapers, almost all of which should really be directed at the NHS where they can be dealt with appropriately.
I think we tend to take our health services for granted, precisely because the majority of the time, we are well cared for. It's when we're poorly cared for, or even put in danger by our health services, that the problems start. Having been cared for in an environement that personalised and individual, we come up against an apparently monolithic and bureaucratic complaints system that seems both confused and confusing. In those circumstances, it's hardly surprising that people will want to air their grievance where they think they will be heard. And for many people, particularly of an older generation, that means writing to a newspaper.
So how can the media deal with healthcare complaints effectively? The South Wales Evening Post seems to have got it in the neck for champions patients in its area, while the Guardian suggests they shouldn't be getting the letters at all. Instinctively, I side with the Evening Post. However annoying it is for hospitals to be constantly nagged at by their local paper, the media can play an important role in voicing concerns, and shining a spotlight on poor practice. For as long as they do that, patients with complaints will go to them. Ultimately however, until that constant nagging brings about real change and improvement, those complaints will go unresolved.
This video from feministfrequency.com (via boingboing) asks a question I've never considered before, about the portrayal of women in films.
It also makes me think about the report that Stonewall released today, Unseen On Screen. That came to the not very surprising (if methodologically flawed) conclusion that gay men and lesbians talking about gay and lesbian issues positively were under-represented on the TV programmes most watched by young people.
Hmmm, sure, but I wonder if that is the point. Just as the video above highlights the importance of women in films not only appearing, but being presented as whole people with whole lives, surely it's not a question simply of the appearance or not of gay men and lesbians on TV. And certainly not that they appear to be talking about things which Stonewall thinks concern gay men and lesbians. Surely, a real test of whether gay men and lesbians are represented on TV appropriately, is that they can appear on all sorts of TV shows, and not talk about gay and lesbian issues. There are all sorts of examples of this every day, from the news to sports programmes, from drama to soaps, from reality shows to game shows.
I'm sure the teenagers interviewed were genuine in their belief that gay people on TV need to talk about gay things, but I wonder why Stonewall didn't challenge this perception of what being gay means?
It was LGB hustings night, as organised by Village Drinks, at the King's Fund, in support of Stonewall, so it seemed like a good idea to go along. Except, disaster, there was a cash bar. No party conference warm white wine here. So Paul headed off to find a cash machine. Problem solved. I suppose in the current economic climate you can't expect a freebie!
The hustings were chaired by Ben Summerskill, who did an excellent job, happily bringing each of the elected politicians in to line with jokes about their expenses. I say each of the elected politicians, because there was a late addition from the Green Party, a local candidate from East London on his first foray into national politics. And given the circumstances, I think he did well.
Chris Bryant MP kicked off for the Labour Party. He avoided the usual litany of Labour achievements related to LGB rights, and instead focused on the challenges: tackling homophobic bullying in school, combating hate related violence and persuading EU states to recognise UK civil partnerships. Moving on to say that "the days when people voted according to their sexual preference are gone", he stated that he thought the key issue in election, whether gay or straight, was the economy.
Lynne Featherstone MP came next for the Liberal Democrats. Having been chided by Ben Summerskill for the two pasta ready meals she claimed on expenses back in 2007 (she claims they were dinner for a researcher) she set out a strong case for her party, saying they were "liberal through and through, and not just at elections" and that at the heart of their policies was the idea that "no-one shall be enslaved by conformity". As their lead for equalities issues, she clearly had a strong grasp on her portfolio, tackling a wide range of issues including transphobia, gender identity and the ban on gay men giving blood. She took a little while to get round to talking about the economy, but her description of Vince 'Walk On Water' Cable raised a laugh in the room.
Nick Herbert MP was up next for the Conservatives. His opening gambit was about his own civil partnership, which was held in the register office at Lambeth Town Hall in Brixton, as he said with "plastic flowers in the room and dog shit on the pavement." And he went on to talk at length, and with some passion, about the changes in the Conservative Party. He had some interesting observations, saying that if the Tories win with a majority of just one, they would have more openly gay politicians in Parliament than any other party. He talked about an aspiration that all political parties should be a safe place for a gay vote, and hoped that there would be genuine bi-partisan consensus. And on the subject of homophobic bullying, he made a call for "leadership not law."
And finally, our only unelected politician, Chris Smith who is standing for the Greens in Tower Hamlets. Surprisingly, he touched only briefly on the the Greens' strong LGBT manifesto, and instead focused on broader green concerns, around the environment, consumerism, living standards and housing.
So that was the opening gambits over and done with. Questions at hustings are always more interesting though, as they get the politicians off the script and more off the cuff. The stand out exchange of the evening came between Chris Bryant and Ben Summerskill, in response to an audience question about the role of Rupert Murdoch.
Chris Bryant: Some time I ago, I met Rupert Murdoch, and I have to say he is the most casually violent person I've ever met.
Ben Summerskill: Even more than Gordon Brown?
[laughter from the audience]
Chris Bryant: If you think there's anything casual about Gordon's violence, you really know nothing.
So, what did I learn from the evening. I'd gone in to the event thinking seriously about voting Green, but Chris Smith's comment about Peter Tatchell being on the right wing of the party has made me think twice about their economics. Chris Bryant seemed tetchy and humourless for much of the evening, and seemed genuinely disappointed that his attempts at Tory bashing were falling on largely deaf ears in the room. Lynne Featherstone seemed lovely, and someone you'd definitely want to share a bottle of wine with. But the real surprise of the evening was Nick Herbert. While by no means a heart on his sleeve gay activist, he was engaging, passionate and well informed. And yet, I'm left with a nagging fear that all the talk of the Conservatives having changed might come to nothing.
I'm entering this election as a floating but engaged voter. I want my vote to count for something, but this evening has left me no clearer about where my vote should go. Ben Summerskill closed the evening by saying that he was waiting for the manifestos, which he would read in private, and vote accordingly. I think that might just be a wise move.
It's the morning of day two of the conference, and having missed hearing Alan Milburn speak, I thought I'd take the time for a quick update on yesterday's key speakers. I have some ten pages of notes and all my tweets as a starting point, but given the amount of information yesterday, this is just a summary.
The first half of the morning's plenary was comprehensive in its scene setting for the UK and international health context and the role that social marketing plays. After an introductory video from UK health minister Dawn Primarolo, Angela McNab (director of public health, performance and delivery at the Department of Health England) spoke about how social marketing helps people make the changes they want to make. She talked on the need for good social marketing to be based in good research, and pointed to the launch of a one stop research shop for social marketers next summer. She was followed by Philip Kotler (marketing god... not sure if there's a more appropriate job title) who gave a presentation provocatively titled "Reducing poverty through social marketing". If I was in any doubt that marketing was going to save the world, Philip Kotler was extremely persuasive. He set out a series of principles in social marketing, namely
framing the problem
segmenting the market
targeting segments where the most good can be accomplished
determining desired behaviours
developing strategies using all four tools in the marketing toolbox
and finally monitoring and evaluating results
As a sideline, the four Ps themselves have been under much discussion, particularly on the sidelines of the conference, with lots of talk on whether they provide a robust and comprehensive framework. Anyhow, as much as Kotler's talk was an exposition of the great work done my many social marketers internationally to help people raise themselves out of poverty - the example of MechaiViravaidya, Thailand's "condom king", sticks in my mind - it was also a clear call to action to us as marketers. As he said
Social marketers with compassion with ask "What do you need?" and "What will help?"
Broadening the context even further, SameerDeshpande talked about the history and context of social marketing in Asia, particularly in south Asia, reminding us that marketing is not education, nor is social marketing social networking. SudhaTewari ended the first half of the morning's plenary with a reminder of the real life impact of social marketing in the Indian context. With 5.5 million unwanted children born every year and 6.7 million unsafe abortions, condom marketing has never been more important, and her organisation is leading the way.
The second half of the plenary (after a very well deserved coffee) saw Nancy Lee take the stage with four real life examples of the four Ps in practice, looking at tobacco cessation, littering, HIV testing and... using flags to cross the road. I can't begin to imagine that British people would even begin to think about carrying a flag across the road, but the benefits in road safety were clear. What was most striking from Nancy's presentation was the enormous cultural difference between the UK and US - and it certainly is a reminder to challenge my assumptions that I understand the context in which I'm working. Driven by real consumer understanding and deep research, Nancy's examples showed how powerful the four Ps could be in shaping meaningful social marketing programmes.
The afternoon's highlight for me was Katherine Lyon Daniel (from the US's national centre for health marketing at CDC). I heard her speak twice, once on the context of health marketing in the US and the other on her centre's work on autism. She was inspiring. In her first talk, she challenged us to take a long view, and talked about a native American saying that
In every deliberation we must consider the impact on the seventh generation.
She talked too about how consumers were overwhelmed with information, how we needed to ensure that health information, like Coca Cola, was "within an arms reach of desire" and she set out four principles for social marketing, drawn from her centre's mission statement. She said that it should be
Accessible - ensuring we address issues of the digital divide and health literacy
Accurate - stressing the need for us to document research and outcomes and build our body of knowledge as a profession
Relevant - needing to understand audiences and undertake appropriate research, and finally
Timely - again, going back to the concept of information being within "arms reach of desire"
That's it for now. About to start day two in earnest!
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It was LGB hustings night, as organised by Village Drinks, at the King's Fund, in support of Stonewall, so it seemed like a good idea to go along. Except, disaster, there was a cash bar. No party conference warm white wine here. So Paul headed off to find a cash machine. Problem solved. I suppose in the current economic climate you can't expect a freebie!