Anyone disagree about groupthink?
Rich Taunt argues that we all think the same, and that's a problem. To succeed as a health service we need more 'cognitive diversity', seeking different ways of thinking and opening ourselves up to challenge.
Two stories, both true.
- In the early 2000s the CIA had the greatest individual intelligence agents the world had ever known. Thousands of people recruited as the best of the best, taken from the world’s finest universities, and given extensive training.
- In 1967 the CIA employed fewer than 20 African American people in their 12,000 non-clerical workforce. Until 1975 the US intelligence community refused to employ people who were gay. In 1998 the CIA had not one case officer who spoke Pashto, one of the principal languages of Afghanistan.
On 11 September 2001, the US suffered the deadliest terrorist attack in history. As discussed by Matthew Syed in his excellent ‘Rebel Ideas’, the CIA’s surfeit of predominantly white, Protestant men was overwhelmed by its lack of difference in perspective, insights, experiences and thinking styles. Viewing a problem as complex as Al Qaeda from only one viewpoint was vastly, tragically, insufficient.
Does the NHS in 2019 suffer from the same problem as the CIA in 2001?
Let’s take a step back. Diversity of perspective (‘cognitive’ diversity) is linked but different to diversity of background (‘demographic’ diversity). The NHS’s demographic issues are well known: research from the NHS Confederation showed the percentage of NHS chairs and non-executives from a BME background nearly halving in the last decade (15% in 2010 to 8% in 2019). This lack of diversity extends to NHS policymakers, as highlighted by Helen Buckingham and others.
Each lurch sees the proclaiming of today’s idea as infallibly correct, and yesterday’s as inherently flawed
We talk less about the NHS’s lack of cognitive diversity, yet its symptoms lie in plain sight. Take groupthink. In 2010 there was consensus among the NHS commentariat that clinical commissioning groups were the future. There’s just as much consensus now that they’re not. Over the past decade the main driver of improvement has swung dramatically: it’s competition! No, regulation! No, collaboration! No, digital!
It’s not that the NHS orthodoxy doesn’t change, it’s that when it does, it lurches, taking everyone with it. Each lurch sees the proclaiming of today’s idea as infallibly correct, and yesterday’s as inherently flawed. For example, who’s still standing up for competition? Who would have the temerity now to mention Vanguards?
Partly this is the result of a restrictive environment, highly political and unwilling to tolerate ambiguity. Many people can see the climate change benefits of charging for car parking, but good luck looking for it in any major party manifesto.
But far more so, the people who shape, and have shaped, NHS mainstream thought have come through very similar experiences. Since 2006, the top ranked person in HSJ’s ‘Top 100’ most influential people in health list has been a man, aged between 47 and 58, all (bar one) white British, all (bar politicians and a political appointment) having spent their entire careers in healthcare.
Our Super Melting Pot event is one way we’re seeking to break this cycle – visiting prisons and private members’ clubs, hearing from poets and music producers, all in the name of sparking new thoughts that can be brought back to healthcare.
Groupthink matters. Not only do we risk missing different answers to the pressing NHS questions of the day, but we miss realising whether they’re the right questions in the first place.
So where to start? Here’s three suggestions:
- Unexpected conversations. Given the nature of our too-often siloed worlds, without proactively seeking different viewpoints we’re trapping ourselves in having the same conversations with people probably holding very similar views. Our Super Melting Pot event on 16/17 January is one way we’re seeking to break this cycle – visiting prisons and private members clubs, hearing from poets and music producers, all in the name of sparking new thoughts that can be brought back to healthcare.
- Support difference. The NHS isn’t without different viewpoints – from non-executives on boards, to the appointment of Prerana Isser and Hugh McCaughey to national roles. But how often is the difference sought out to deliberately challenge what the rest of us are thinking? On a smaller scale, how could junior doctors be used to share differences in thinking between areas when rotating between trusts?
- Invite challenge. There’s one time the NHS can’t avoid scrutiny by a figure not from within its circles, but sadly only once something has already gone very wrong. Independent inquiries are expensive, and long, yet at present the only institutional way the NHS opens up its thinking in an in-depth way. How could the principle of seeking periodic independent views be used by those shaping policy as a positive way to improve thinking? This may include learning from the Israeli security agencies, which have built challenge and dissent into their structural make-up.
Nuanced debate isn’t always easy in the NHS, let alone at election time. Yet time will come when, like the CIA, lacking cognitive diversity isn’t a choice we can afford to make.