Tribal territories: Of values and value- part 1

Times continue to be tough for the industry and this author has been doing some more reflection that has manifested in three linked articles. In this first piece, we’ll briefly explore the industry’s interface with its new customer groups

With the background of global economic meltdown, one notes that David Brennan, AstraZeneca’s chief executive and incoming chairman of the Pharmaceutical Research and Manufacturers of America, recently called on industry colleagues, policymakers, health advocacy organizations, new non-traditional partners and others to promote policies that expand access to affordable health coverage while fostering continued innovation. A good call! He also notes the need for a new debate that features fresh thinking and open-mindedness - not partisan bickering… An even better call. He adds that ‘only respectful, give-and-take discussions will produce the reforms we need’. This has to be the crunch issue here. But respect and give-and-take can only occur between ‘partners’ that understand each other and the different value sets in play. And given the value that the industry adds to 21st century society, it should perhaps be doing a lot better in terms of corporate reputation than it is compared to other sectors. Being regarded as a trusted, pro-active advisor and as part of the solution must surely be the way forward.

So where are we going with this? Well columns and columns are now being written about the traditional industry model being broken and how it might be fixed. Absolutely key here must be a fresh approach to customer focus. To engage in this new debate requires a detailed understanding of each other’s working environments. But this is probably often not the case. Payers do not have a good grasp of how medicines come to market much as industry managers, for instance, do not have a good understanding of publicly funded healthcare systems. And so, where we often end up is in a clash of values.

Industry mantra at the moment is all about demonstrating the value of its products. But value is rather like beauty; it is in the eye of the beholder. And the industry is not the only beholder! These beholder’s behaviors are often driven by their values. And “values” are not the same thing as “value.” So let’s examine– values, valuing and valuables: the values of your customers, the value of medicines to different stakeholders and the valuable strategic role that appropriate medicines utilization can play within any 21st century healthcare system.

So first to values and value sets. The point is not really about exactly what these values are, but that they need to be accurately determined and appreciated and customer focus programes must so orientated. It’s worth noting that in the UK, a ‘corporate’ value set is now explicitly stated in the new NHS Constitution. And healthcare systems tend to comprise multiple groups, or “tribes,” each with their own values, culture and language. Healthcare tribes are everywhere, represented by various Associations, Colleges, Institutions, Societies, Alliances and Confederations – and all usually referred to by their acronyms! One particularly likes the last one - a nice descriptive tribal noun with echoes of the Iroquois!

Of course, the industry has its own tribes and sub-tribes too. The values of the various tribes of healthcare professionals - doctors, nurses and pharmacists - tend to be well understood but over the past few years, whole new tribes of customers have come to the fore. At the moment, companies have a strong focus on payers, where for years they seem to have invested little effort in trying to understand their perspective on things. This rather generic term would largely encompass a professional management tribe, but 21st century healthcare systems now involve a whole plethora of other new tribes.

For example, people talk about wanting to influence health policy in relevant areas. In the UK, policy makers are largely central government workers - civil servants, bound by their own unique code. And local government workers and particularly those in social care are again a wholly different cultural tribe. Push too hard while not understanding their core value sets, and conflict can result.

And with rapid healthcare change and redesign of clinical work processes around the world, intra-sectarian tribal hostilities and tribal warfare also are not uncommon, particularly between clinicians and managers/politicians, as significant cost-containment policies come into play - all driven by a clash of values. In addition, governments around the world are grappling with overspent healthcare systems and talk about the need for healthcare systems to be ‘fit for purpose’ for the 21st century. But these systems tend to have huge systematic problems, not the least of which are old-fashioned demarcations between the various tribes and essentially unchanged working practices of generations.

With more moves to integrated care, professional demarcations within healthcare systems will need to be broken down, particularly between health and social care. And that could mean dismantling the current tribal set ups. So all of this will be important to empathetically understand and warrants effort expended in detailing out what the various value sets comprise of. All customer focus programmes aimed at excellence must understand these differing value sets.

But if one is not familiar with the new territories within healthcare systems, mapping out the new landscape is an absolute pre-requisite, as is discovering the various languages of these indigenous tribes and becoming fluent in them. And all of this must be tackled before any respectful, give-and-take discussions are possible….

A LITTLE PARABLE
Some Main Tribes
To try and come to grips with all of this, let's consider a light-hearted story about aliens visiting from outer space who are spending time looking at and recording the characteristics of some of the different “tribes” found working in healthcare systems on Earth. This galactic observer’s story chronicles some of the significant gaps between the various tribes, particularly related to the use of language, which has been found to significantly distance the tribes from each other. The following main tribes were found:

The Manpols
This tribe was largely made up of managers and politicians. The Manpols’ language was called SOS, a language made up of Systems, Organizations and Structures. This tribe used a currency called CAB which had two denominations: costs and benefits. The visitors found the Manpols’ thought processes interesting, because unlike the rest of the tribes they seemed to think in terms of analysis, decisions and visions (these visions often seemed like hallucinations to the other tribes!). And the Manpols tended to dress in a particular way. The leading Pol frequently wore shirts and carried a baby in his arms. He worried a lot about the Youmes tribe. The Mans appeared to be grey-suited most of the time. Although this tribe seemed to have become increasingly powerful over the past 10-15 years, the visitors found that their life expectancy was reducing. The Pols generally survived for little more than five years and the senior Mans tended to survive for much shorter periods of time with many disappearing every year or moving on to things called ‘Academia’ or ‘Consultancy.’ The Manpols were not very popular among the other tribes, but that didn’t seem to worry them too much as they knew what was necessary for others. And the Manpols tried to work very closely with the Three Ps tribe to help convince the Youmes that what they said was right, because the Three Ps were trusted more by the Youmes than the Manpols were. And the tribe formed into groups for self-protection, which they called ‘Political Parties or Institutes.’

The Three Ps
This was found to be a tribe of Professionals who work for Providers and Payers and were sometimes known by the other tribes as the ‘white coats.’ Their language was called ‘DAP’ and was made up of Diseases and Populations. Their currency was called ITO, which had three denominations: Investigations, Treatments and Outcomes. The Three Ps think in terms of scientific inquiry, logic and controlled trials. Until recently, this tribe seems to have been very influential with the Youmes, but this now appears to be changing as the Youmes attend more things called ‘assertiveness training courses.’ Many of the Three Ps don’t like the Manpols, who keep on asking what the Three Ps are really doing and what difference it makes. Something new called ‘healthcare reform’ they hate very much. The Three Ps are the most educated of all the tribes and go to the best schools and obtain a lot of things called ‘qualifications,’ which allows them to know that what they do is always right. This tribe is the best networker of all the tribes and spends a lot of time traveling from one country to another to learn from their cousins and see nice places. The Three Ps have long lifespans and can survive for 20 years or more. They too form into groups for self-protection, which they call ‘Colleges and Associations.’ The Three Ps also have things called ‘Medical Schools’ that enable them to reproduce other Three Ps in exactly the same form, time after time. This Tribe is driven by wanting to make individual Youmes and whole populations of Youmes better. Many of the Three Ps work in places called ‘Institutions,’ which allows them to protect themselves from where the Youmes live, although some would now like to work in a place called the ‘Community,’ where the Youmes do live.

The ROTS
This is the tribe made up by the Rest Of The Staff and they are sometimes called the ‘non-core tribe.’ Their language is PASS and it is made up of Practical and Supporting Services. Their currency is JAS, which has two denominations:Jobs and Security. They are the most numerous of all the tribes, with the exception of the Youmes, although their numbers are constantly falling as a result of being affected by a rampant disease called ‘Contracting Out.’ They are often called the ‘invisible people’ because the Manpols and the Three Ps seem not to recognize them. The tribe is also subject to something called ‘Monitoring’ by the Manpols, because it is assumed that they are naturally weaker and more subject to suffering from sickness and disease.

The Youmes
This is an interesting tribe and is the tribe of you, me, and our friends and families. It is sometimes called the tribe of the ‘Done Tos.’ They are the most numerous of all the tribes. The other tribes owe their allegiance to the Youmes who pay all their bills, but somehow it doesn’t seem like that to the Youmes. Their language is ‘WAN,’ which is ‘Wants and Needs.’ Their currency is ‘CAS’, which is made up of denominations of ‘Care and Support.’ They think in terms of emotions and feelings. The Youmes are a very hospitable tribe and socialise a great deal at their own expense, while the other tribes network at the Youmes expense. The Youmes are very frustrating to the other tribes because they don’t always do what they are told or what is good for them. They often like ‘drinking’ and ‘smoking’ and eating food with lots of salt. The Youmes have some difficulty communicating with other tribes. This causes particular concern to the Three Ps at times called ‘consultations.’ The Youmes are often told by the Manpols that it would be good for them not to use the services of the other tribes as they are very expensive and it would be better for them to stay healthy and look after themselves, as long as they still pay the same level of something called ‘Taxes.’ The Youmes particularly worry about entering the Three Ps’ institutions as they might then be counted as ‘Finished Episodes’…..

Fatima Moncrieff is a UK-based independent healthcare policy analyst and adviser. Her consultancy specialises in healthcare policy issues for both the Pharmaceutical Industry and the National Health Services and aims to support organizations in steering the right strategic course through a rapidly changing and turbulent healthcare environment.

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