Keith Barnard
We cannot know what particular controversies will be generated in this meeting, but any good futures study will generate controversy. So, let it be said now that the Nuffield Trust/Judge Institute (NT/JI) futures study is an impressive achievement and we are indebted to the writers and synthesisers.
We need synthesisers to help us address the future. The consequence of specialisation in science is a compartmentalising of knowledge that does not mirror daily life or the decisions we have to make as individuals and institutions. We can only make use of this knowledge if it is synthesised to identify factors that will shape the quality of our lives.
The study has a particular value for WHO. This is (to my knowledge) the first attempt in the European Region to carry out a study that is a comprehensive attempt to look ahead and around in the health field.
Earlier efforts, such as the Swedish study on the elderly (“Time to care”) and the various studies of the Netherlands Foundation for Future Health Scenarios, have focused on possible and expected trends in specific sub-areas of policy and service development, rather than offering an integrated perspective on the whole health field.
The NT/JI study is a pioneering example of how one can use futures studies for health for all policy-making and for crafting HEALTH21 strategies. The detail given makes it especially useful for stimulating mutual learning between countries, which is a principal task of WHO.
Comparisons between the approaches of countries and communities to a given health challenge expand our awareness of the range of possibilities. For this purpose, the documentation this study provides is invaluable.
Issues for reflection
I am not going to attempt a critique of the NT/JI study. I want to offer some thoughts prompted by what I have understood. The result is a mix of comments, questions and reference to what we have tried to do in the WHO Secretariat.
The issues that I think should be reflected on are the following:
●the market for futures studies– who are we selling to and what they want to buy;
●the world of futures– determining the frame of reference and the mind set of script writers;
●the future of order – how we organise ourselves as a society;
●the mistakes of futures – including seeing the future as a continuation of the present; and
●the future of intelligence– and how we might do it all better.
I said I wanted reflectionon these issues. If I use that word excessively in its various forms, it is because that is my understanding of futures. It is not to rush confidently to judgement, but to reflect on where we came from and where we might and could be going.80
80. The World Future Society, an independent non-profit body, puts it this way: “No one knows exactly what will happen in the future. But by considering what might happen, people can more rationally decide on the sort of future that would be most desirable and then work to achieve it”.
The market for futures studies
Reflecting on and reacting to the NT/JI study, two questions come to mind:
●What is the intention behind the product?
●How will people understand and react to that product?
The object of the exercise
A key decision in conceiving a product such as this is whether to offer one scenario, i.e. one set of assumptions describing a possible or a desired future, or alternative (two or more) scenarios. This depends on the intention, which could be:
●to unfold a path to be followed into the future, an explicitly or implicitly “desired future”, and therefore to influence the way people will expect the NHS to evolve (this is the
“scenario with a message”, another approach to marketing);
●to identify a set of health and health care policy issues that the scenario writers judge need attention (“pedagogical scenarios” guiding recipients to what they need to do); and
●to “nudge” government policy in a particular direction by describing an expected future with implications, i.e. an intended input into present rather than more distant policy-making (“the seductive scenario” promising success to those who follow it).
Thus a related pertinent question is, “who is the primary target audience?” It could be:
●the wider community or some sets within it: the politically active, top managers and professionals in the health sector, those in leadership positions in different sectors and civil society generally (this means presenting an attention-commanding, plausible story or stories of the future;
●policy analysts and advisers within government who would (or should) expect to see the detail laid down transparently, so that they could recover for themselves the sequence from the selection of evidence, to the argument, to the conclusions (assumptions about the future) to the recommendations; or
●ministers who, given their limited attention span and absorption capacity (because of the pressures on them), will want simple succinct statements with a hard content and with clear relevance to decisions they will face in the short term.
Pitfalls and constraints
If the intention is to influence present policy-making, there is also a negative side. Since the story must be simplified, there is a self-imposed constraint not to open up too many issues.
There is a temptation to be highly (not to say unduly) conscious of what message is likely to receive the most favourable reception. In WHO we are faced with a similar problem.
One of WHO’s objectives is to influence the ways people in the Member States see the future developing, focusing on desirable developments that should be encouraged. This is the visible end-point of the internal process that started with deciding what assumptions to make (which is when we start to apply futures thinking). We try to couch the message in terms that
maximise its acceptability to all Member States.
The diversity of the Region lands us with a built-in dilemma that is perhaps not always
recognised. The expectations and needs of our Member States can be quite different. This leads
us into choosing between approaches that should generate quite different products. Simply put, the choices are (a)stimulating imagination or vision-building by scanning the time horizon for possible futures (a range of scenarios); (b)giving a lead by proposing a policy direction; and (c)offering detailed guidance on policy implementation through what we believe are highly desirable strategies.81
We have not so far followed through on option (a)with a policy document that builds on
“scanning the future”. (The dissemination of reports of futures consultations is more the sharing of information and ideas than policy development.) This is partly because we had signals from Member States that they did not want a policy document of that type. But it was also because the Secretariat felt it had a responsibility to deliver on (c), especially for the NIS and others without policy-making experience, while western European countries made it clear they preferred (b).
The world of futures
Having settled the questions of object and target audience, we can consider the frame of reference, the scope and emphasis in our field of concern.
The functional frame of reference and the point of emphasis
In WHO we have adopted what is in effect a standing agenda based on experience and scanning the future. This strikes a balance betweenhealth care, the health sector agenda of health services development, and“sustainable health”, an agenda of multisectoral and
intersectoral action on health protection and promotion. In our presentation in HEALTH21, we put “sustainable health” first to emphasise the concept of health as everybody’s business.
This is a symbolic attempt to correct for the tendency in Member States, among politicians and public alike, to be concerned with medical services: how much they will cost in the future, how well will they perform, and how well will they meet the expectations of patients and voters.
An apparent difference between NT/JI and WHO can be found in the point of emphasis. In essence, a futures study can take as its principal focus the environment for health (prospects for the health for all agenda) or the environment for health care (e.g. prospects for the NHS).
The point of emphasis in the presentation follows from the choice made between them. The crafters of the NT/JI synthesis and of HEALTH21 are clearly aware of this distinction, but seem to have made different choices in the point of emphasis.
The geopolitical frame of reference
In WHO we have been concerned with the effects both on the European Region as a whole and on sub-regions such as CCEE and NIS. We need to look for trends and influences (“determinants”) and potentially significant new developments at different levels:
supranational, national and subnational, and local. What are the effects of factors external to the health sector and to the remit of health ministries and administrations? How do they affect what would or would not be possible at each level?
81. In 1980, for the initial framework health for all strategy, we chose in effect option (b). For our target documents In 1984 and in 1991, and with the concurrence of the Regional Committee, we chose option (c).In 1998, in HEALTH21, we combined (b)and(c)by producing two volumes: in the first we have a policy called an
“Introduction”, which lays out the desired future and the issues to be addressed but does not proceed to the objectives and strategies.
We have recognised that we need to consider how the futures of other bodies and movements might affect the societies and economy of WHO’s Member States, in terms of opportunities and constraints on social and other policy that could promote wellbeing. We have to reflect on alternative assumptions we could make about European regional organisations, especially the direction the European Union will take in the scope of its policy-making competence and the way decisions will be taken.
We should similarly look at possible futures for the United Nations family, both the specialised agencies such as WHO itself82and the Bretton Woods institutions (the International Monetary Fund and the World Bank), and for the multinationals and such institutions as the Soros Foundation for their impact on global society. These concerns, and assumptions related to them, find their way into the HEALTH21 targets, even if there is no sustained discussion of alternative futures in the text.
If WHO acknowledges its interdependence, and even dependence, Member States are
presumably making calculations about how far the ship of state can and will sail on in cheerful disregard of weather conditions. The image of the ship of state that normally comes to mind is the Atlantic liner; but perhaps it is more plausibly a yacht in a flotilla, which demands a different kind of seamanship.
To change metaphors, in terms of John Donne’s much quoted line, “No man is an island”, we can also say that no country is an island. Politically and – with the advent of the Channel Tunnel – literally, this is as true for the United Kingdom as for any other member of the European Union.
What balance should be struck betweentaking the weather and the neighbours into account andfocusing on internal political and other factors?
The future of order
We should now move from a frame of reference to the ways and means of ordering our affairs as a society that we might adopt in future. These will have implications for the viability or sustainability of any desired future we attempt to create. We might call these the issues of governance, but there is a family of terms to reflect on; some might be synonyms and others might catch important nuances.
Notions of stewardship, stakeholding, mutualism, navigation, self-adaptation and other such terms could be explored in this context. Here, for convenience, governance is used as a general term to embrace a family of concepts.
The importance of governance
There are a number of issues of governance, including the idea of public health infrastructure, to which we attach considerable importance in HEALTH21. Governance means how decisions are made and the overseeing of action, and who is involved and how. Whatever we can achieve in the future will depend on the form of governance that is in place, its efficiency and its responsiveness.
82. One possible “weak” signal, which we might track, is the changing international stance of WHO since Dr Brundtland became Director-General. There is much more conscious, overt effort to do business with other IGOs, to court global economy players, and to be much more pro-active in WHO’s constitutional international directing and coordinating role (e.g. the envisaged “tobacco treaty”).
When we come to forms of governance, we all seem to be particularly challenged by the constraints of our perception of the present. Most of us take virtually for granted the constraints on the United Nations to fulfil the mandates of its Charter, the inevitability of sovereign nation states, and the preference for passive representative over active direct democracy, even at local level. Maybe we shall soon be rethinking the “who does what and how” questions.
Levels and responsibility for action
We have the Vatican to thank for the concept of “subsidiarity”, but it is the European Union that has given it political, and perhaps soon constitutional, significance. It seems accepted that there will be no further expansion of the European Union without changes in governance.
Among other changes, there could be further elaboration of the concept of subsidiarity and new forms of its application. This could mean consequences within countries as well as within the machinery of the Community.
The word “subsidiarity” may not be much in evidence in WHO documents, but it has been in our minds: the most appropriate level for a given decision to be made. Although
decentralisation is a fashionable philosophy, it may not necessarily be that it is always best;
and despite the experience of the Soviet Union, centralisation may not always be wrong.
As one example, after the recent food safety crises it is reasonable to argue that aspects of food safety that are interrelated with the European Union single market should be handled at the supranational level. This in turn will have knock-on consequences for the scope and direction of national and local action.
What are the implications of subsidiarity for governance within countries? We can take as read that the governance of the health sector largely mirrors governance in public service
institutions as a whole. What do we think will happen in the United Kingdom, or in Europe as a whole, if we continue with present “thinking inside the box”?
To the outside observer, the organisational characteristics of the United Kingdom health sector reflect the need for corporate control, supervision and regulation through a variety of devices, and close performance monitoring – all necessary features of a politically accountable national service. Such approaches might be expected to create tensions between the controllers and the controlled, who desire operating freedom.
Order and the health sector
The observer then asks: will this and similar corporate systems survive till 2015? And will its managers at all levels still be concerned with achieving ministers’ performance targets, with living within available resources and with meeting public expectations?
To answer the point in other terms: opinion poll ratings, falling unemployment rates or a rising stock market index may not be good indicators of confidence in our governors or the system of governance. A transformation of our present concept of democracy would lead us into completely uncharted waters. The Open University’s futures project,83with confidence in
83. The Millennium Project of the Futures Observatory was run by the Open University with the Strategic Planning Society and the think tank Demos. According to its Web site, its “predictions are the most accurate (sic)ever made.
They come from a four-year study involving over a thousand of the world’s largest organisations. It describes in graphic detail the future you will soon encounter”. Available as a book, Future revolutionsby David Mercer, published by Orion Business.
its predictions, foresees the end of political parties.84
When in the former Soviet Union the old certainties started to give way in glasnostand perestroika, people in the Baltic states started to challenge central power. They no longer felt bound by the old rules and assumptions. I find something of a parallel when I hear young people in a Swedish television documentary, saying on camera in a country that prides itself on its political participation: “we do not have democracy in Sweden, voting is not
democracy”.85
They are also not prepared to play the old political game by the old rules. Some see the future in information technology, as the new way in which people connect to one another, exchanging information and building consensus on a mass scale that will generate the drive for action.
How might the system adapt? If we are serious about subsidiarity, we might look at the thinking being applied to the science of complexity and borrow from biological systems the notion of “organising simply for complexity”.86If this track is followed, it is likely that the importance of values87and notions of coordination, reciprocity and trust will be dominant.
Of course, that may be possible only if there is a fundamental change in political culture, which currently expects power to emanate from a strong centre in a context of confrontational politics and the assumption of an available alternative, the Opposition, as a “government in waiting”. We must not underestimate the strength and resilience of an existing culture, but
“government by negotiated agreement” could be an alternative. We have long seen something similar in the Netherlands and other countries. We may be seeing the first weak signals of a new political culture in the United Kingdom, in devolution to Scotland and Northern Ireland.
Governance and primary health care
There is also a specific link with primary health care, going back to the Alma-Ata concept with its emphasis on individual and collective involvement and on finding means for intersectoral action. How much can be conventional “top down” and formal inter-organisational
negotiation, and how much should it be by direct participatory forms of local democracy?
This challenge was brought out even more clearly in the Ottawa Charter with its concepts of enabling and empowerment, whereby people have a sense of the “locus of control” being within them; and with its identification of strengthened community action as an imperative.
None of this fits easily with conventional party-dominated democracy.
84. Richard Clutterbuck, in Britain in agony: the growth of political violence,asserts: “We can no longer afford the party game in which nearly 50% of our elected MPs have no better aim than to ensure that the government of the day fails to solve our problems – a game which causes increasing public exasperation and contempt for parliament”.
The essential point is still valid. The engagement of the general population with the political process continues to
The essential point is still valid. The engagement of the general population with the political process continues to