"Reaching every nook and cranny" resonates with the findings of the Council of Rome's "Limits to Growth" 2012 update report and with the recent population report in The Lancet (below). The report analysed the effects of population growth on planetary resources. Equal rights, pay, educational and work opportunities, contraception and maternity care for women seemed to be main pillars for balancing planetary health and human population growth.
It is suitable to point out the lack of electricity, digitization and knowledge in many groups of people around the world and to wonder how imbalances of information and beliefs can be managed if it is desirable to do so.
We commissioned a report on culture change at our medical centre in Manchester, UK in 2001 **. The excellent report produced by Samina Munir and Ruth Boaden reported that culture change was of many types including top down and emergent change. Having become used to a digital world, it is timely to be reminded of peoples who do not for whom "back to basics" - relationship and trust building are necessary through dail business an conversations developing a "trust quotient" - "Credibility, reliability, intimacy and mutual orientation"
** Planned Change: an iterative, cyclical process, involving diagnosis, action and evaluation, and further action and evaluation.
The purpose of this type of change is to improve the organisational effectiveness of the human side of the organisation. Emphasis is on incremental and isolated changes with the assumption that one approach to change is suitable for all organisations at all times.
Emergent Change: The emergent approach to change views change as driven from the bottom-up rather than top-down.
Change is seen as an open ended and continuous process of adaptation to changing conditions and circumstances.
The process of change is regarded as a process of learning for all. This approach accepts that many organisations are faced with changing environments and turbulent circumstances and considers these in its approach to organisational change.
“Many writers point out that managers and employees do not perform their duties in a value free vacuum. Their work and the way it is done are governed, directed and tempered by an organisations culture: the particular set of values, beliefs and customs and systems that are unique to that organisation.” (Burnes, 2000)
It is these values, customs and beliefs that are difficult to understand but are in need of deep understanding for any scale of change to be articulated. The quote illustrates that culture is an embedded facet of an organisation - in order to understand it each layer needs to be removed, until the deepest level is ascertained.
Many different and varied models describing organisational culture are available. Of these, a model was chosen that best reflects the purpose of this report and best describes the organisational culture at the HMC. This model is that of Cummings and Huse (1989), who describe culture as 4 elements existing at different levels of awareness within any organisation. These levels are:
1. Basic assumptions
In this model the deepest, unconscious level of cultural awareness is described as Basic Assumptions (level 1), while the Artefacts (level 4) describe elements visible on the surface of the organisation.
However, this approach has gained many critics over the years, arguing that ‘planned change focuses on top-down [change is led by managers who effectively ignore the needs of the bottom levels of the organisation], autocratic and rigid rule based organisations operating in a somewhat predictable and controlled environment’.
Organisational culture; defined as “the particular set of values, beliefs, customs and systems that are unique to that organisation”. Culture is shown through the basic assumptions that people work in a team, and each person’s skill and knowledge is valued.; people are considered to be very important and valued whatever they can contribute.
 Burnes. B. (2000), Managing Change - A Strategic Approach to Organisational Dynamics (3rd edition), Pearson Education Limited: Essex
"Fertility, mortality, migration, and population scenarios for 195 countries and territories from 2017 bto 2100: a forecasting analysis for the Global Burden of Disease Study by Prof Vollset, Emily Goren, ChunWei Yuan, Amanda E Smith Thmas Hsiao et al https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30677-2/fulltext
The reference projections for the five largest countries in 2100 were India (1·09 billion [0·72-1·71], Nigeria (791 million [594-10-1056]), China (732 million [456-1499]), the USA (336 million [248-456]), and Pakistan an (248 million [151-427]). Findings also suggest a shifting age structure in many parts of the world, with 2·37 billion (1·91-2·87) individuals oldder than 65 years and 1·70 billion (1·11-2·81) individuals younger than 20 years, foorecasted globally in 2100. By 2050, 151 countries were forecasted to have a TFR lower than the replacement level (TFR <2·1), and 183 were forecasted to have a TFR lower than replacement by 2100. 23 countries in the reference scenario, including Japan, Thailand, and Spain, were forecasted to have population declines greater than 50% from 2017 to 2100; China's population was forecasted to decline by 48·0% (−6·1 to 68·4). China was forecasted to become the largest economy by 2035 but in the reference scenario, the USA was forecasted to once again become the largest economy in 2098. Our alternative scenarios suggest that meeting the Sustainable Development Goals targets for education and contraceptive met need would result in a global population of 6·29 billion (4·82–8·73) in 2100 and a population of 6·88 billion (5·27-9·51) when assumingg 99th percentile rates of change in these drivers.
HIFA profile: Richard Fitton is a retired family doctor - GP, British Medical Association. Professional interests: Health literacy, patient partnership of trust and implementation of healthcare with professionals, family and public involvement in the prevention of modern lifestyle diseases, patients using access to professional records to overcome confidentiality barriers to care, patients as part of the policing of the use of their patient data
Email address: richardpeterfitton7 AT gmail.com