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Culture co-creation

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This is my twentieth reorganisation, but most of them have made no difference at all.

My first public health job was in local government – the County Borough of Oxford from 1972 to 1974 – and it was wonderful. I learned a number of things that have never left me: notably, to respect politicians as representatives of the population, and that the official’s job is to advise; the population's, through the representatives, to decide.

Values trump evidence; politicians can accept the evidence but make a different decision; and everyone needs to know their resignation point, the decision that goes against their advice that they would find unacceptable to implement. For example: when I was director of screening I accepted the right of politicians to decide to implement prostate cancer screening, because many men said they had a right to know their PSA even if the evidence, our evidence, the officials’ evidence, showed no benefit. But I would have resigned, without hard feelings. As it was we managed to convince the public, and the urologists, that the there was no strong evidence of benefit  and this reduced the vehemence of the lobbying.

1974 was a dramatic reorganisation because we became one public health family, symbolised and aided by the formation of the Faculty, which was nearly called the Faculty of Population Medicine! 2013 is also a dramatic reorganisation. We are divided again as we were before ’74, and we therefore need to work hard and fast to create a common culture, using Edgar Schein's definition of culture:

the pattern of shared basic assumptions that was learned by a group as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.” (1)

The day to day activity of a public health professional inevitably varies more than the work of a social worker or orthopaedic surgeon. We have to be where the action isn't, which varies from population to population, but we are still far too woolly and variable in describing what we do and too diffident in selling it.

To tackle the first problem we need a common language and set of concepts. If you were to ask a random sample of public health professionals to define terms such as inequity, MDRTB or allocative value, what would be the result? Our language must be based on a shared understanding of our key assumptions and paradigms, and their sources. Not only the classics of Archie Cochrane and Geoffrey Rose, but texts like Creating Public Value by Mark Moore (2). We need to agree our ten key sources and make sure we all understand them and that all our trainees are exposed to them

To tackle the second problem we need to ensure our rhetoric is as effective as our analysis. We need to perform like management consultants, and sell ourselves as Factor Four (3) change agents - twice as effective as the big companies at half the cost, perhaps even a third of the cost!

We now have public health professionals everywhere - Public Health England, Local Government, NHS England, the Department, CCGs, start up companies, universities and, increasingly, provider units - but we have to become one community, always respectful of one another with a strong common corporate culture. The creation of this common culture is an urgent task and it could be our blog is the best way to do it; here is my first proposal for the ten key terms everyone should know. The definitions are drawn from reputable sources, which will be presented soon. There are, of course, many others - perhaps a hundred or so that are essential - but let's start to get a common culture through a common language. It is easier for the orthopaedic surgeon or a social worker: a femur is a femur is a femur.

Disagreements please, and I hope there will be plenty, in the comments below.

Edit: I know that some of you are having trouble with our website; we're looking into it now and will sort it out. In the meantime we can give you the summary list and bottom line definitions below. Please let me know:

  • if you have a term you think more essential and, if so, which term from the top ten you would drop
  • how you would amend the meanings.

You will see the source documents soon.

  • Culture: Culture is the set of important understandings (often unstated) that members of a community share in 
  • Emergence: Much coming from little.
  • Equity: Equity is a subjective judgment of unfairness. 
  • Health Promotion: Health promotion is the process of enabling people to increase control over, and to improve, their health.
  • Health Protection: Health protection comprises legal or fiscal controls, other regulations and policies, and voluntary codes of practice, aimed at the prevention of ill-health.
  • Justice: To ask whether a society is just is to ask how it distributes the things we prize – income and wealth, duties and rights, powers and opportunities, offices and honours.
  • Risk: The chance that something (good or bad) will happen.
  • Sustainability: Protecting resources from one generation to the next.
  • System: A set of activities with a common set of objectives with an annual report.
  • Value: Value is expressed as what we gain relative to what we give up – the benefit relative to the cost.
  1. Schein, E.H.   (2004)   Organizational Culture and Leadership.  John Wiley & Sons Inc. (p.17).
  2. Moore, M.H. (1995) Creating Public Value. Harvard University Press. (p.54).
  3. Factor Four: Doubling Wealth, Halving Resource Use - A Report to the Club of Rome by Ernst U.von Weizsacker (Dec 1, 1998)

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  1. Comment by gary posted on

    Happy to read and agree/disagree/discuss if I could see the ten terms?? One of our often experienced misgivings in Public Health is our IT mishaps when engaging with our audience!!! :-0/

    • Replies to gary>

      Comment by Editor posted on

      Sorry about that Gary – we’ve fixed the link now.

      • Replies to Editor>

        Comment by Ruth posted on

        It still doesn't seem to be working I'm afraid - error says 'Connection to Failed' as at 9:15am on 25th.

        • Replies to Ruth>

          Comment by Editor posted on

          We're looking into the problem and hope to get it sorted out soon. In the meantime we've added the terms to the bottom of the original post.

      • Replies to Editor>

        Comment by Helen posted on

        Sorry have tried the link is not working for me either. Looks to be really interesting.

        • Replies to Helen>

          Comment by Editor posted on

          We're aware of the problems with the website and are trying to get them sorted out. In the meantime, we've added the ten terms at the bottom of the original post. Looking forward to hearing your thoughts.

  2. Comment by Jenny posted on

    I'm afraid I'm still experiencing the same problems with a link that doesn't work. A real shame

    • Replies to Jenny>

      Comment by Editor posted on

      Thanks for letting us know Jenny. We've added the terms to the original post now.

  3. Comment by Albert.Persaud posted on

    The use of the word 'culture' is always interesting to the extent of being 'culture blind' to the public/ patient existence. Organisations that shape their culture on the populations' values, culture, ethnic and racial mix are likely to deliver better services and care. Inequalities, discrimination, racism, poverty and stereotyping are serious public health issues that has got lost or being denied in this cross fire of 'management gooblygock'. Indeed culture and race(ism) has been airbrushed from all Govt Policies. Time for Public Health to step up and be real advocates. Culture predispose and precipitate health behaviours and outcomes.

    • Replies to Albert.Persaud>

      Comment by Dr Cheryll Adams posted on