ISSUE 23 Lancaster University Management School | the place to be FIFTYFOUR DEGREES Shaping a better tomorrow for health and healthcare Fit for the future Solving the problem of drug shortages 26Helping workers with MS 6 Bringing compassionate care to the NHS 18
Check out the podcast from the Pentland Centre for Sustainability in Business New episodes out weekly (ish) Available on most major podcast platforms – search ‘Transforming Tomorrow’ or visit: pod.co/transforming-tomorrow trAnsfoRming toMorrow
FIFTY FOUR DEGREES | 3 When did we all become risk-takers? Irina Obeada explains how perceptions of risk vary from person to person, and how living on the edge has become more commonplace. 18 In this issue... 22 Artful Accessibility Dr Killian O’Leary and Dr Leighanne Higgins show how The Marketplace and I project provides a way for businesses to better understand how the commercial world can be made more accessible. 10 Waiting Too Long Dr Roger Prudon shows the significant negative labour market impacts of mental healthcare waiting times for patients. 38 Playing Toxic Chicken Ziyi Yang explains how older K-Pop followers are ridiculed and shamed online for showing a caring and compassionate side. 6 Show a Little Compassion Professor Michael West explains the problems of inequity across the UK healthcare system and the importance of staff engagement. Working life post-menopause Professor Clare Rigg outlines her research with working women post-menopause. 50 The Little-known Brain Infection Professor Carlos Alós-Ferrer explains the many surprising effects of toxoplasmosis. 34 42 Sustainable, responsible business schools Dr Marian Iszatt-White details the B-School to ESG-School project and how business and management schools like Lancaster can change to better reflect the needs of the 21st century. 46 An Uneven Playing Field for Self-Employment Dr Cara Molyneux reveals the extra obstacles disabled entrepreneurs face on the road to success – and how we might remove them. 14 30 Tackling Essential Medicines Shortages Professor Kostas Selviaridis and Dr Nonhlanhla Dube outline work to help mitigate and even prevent medicine shortages within the UK National Health Service. The Not-So-Green Family Firms Professor Alfredo De Massis reveals research indicating family firms are often left behind when it comes to environmental practices. 26 Supporting people with MS in and out of work The Work Foundation’s Aman Navani outlines a report showing how better employer and Government support can enable people with MS to thrive at work and fulfil their potential.
FIFTY FOUR DEGREES | 5 Foreword Subscribe online at lancaster.ac.uk/fiftyfour SUBSCRIBE I hope you’re feeling well. After all, none of us like being less than 100 per cent, and we know how hard it can be to cope with any illness or impediment. The future of health and healthcare is an important pillar of the work we carry out here in Lancaster University Management School and within our think tank, The Work Foundation. We have experts working on topics as wide-ranging as medical supply chains, hospital leadership styles, and the effects of waiting times on broader patient outcomes. Beyond this, we work with people with a disability and businesses to improve their access to the commercial realm, and address key issues around disabled entrepreneurs. And this is only scratching the surface. In these pages, you can read about some of the work being done within key institutions such as the National Health Service (NHS) in the UK. Michael West has been involved with the NHS for many years. His work on compassionate leadership impacts not just the staff working across hospitals in England, Wales, Ireland and even Denmark, but also patients under their care. He shows that if we are to deliver the highest quality of care possible, it is essential that there is compassion throughout the workforce delivering it – from the top down. It is at the very top that decisions are often made that affect the availability of medicines on hospital wards. Kostas Selviaridis and Nonhlanhla Dube have been part of an international project looking to improve supply chain systems and prevent medicine shortages. They have worked with the NHS and the UK Government Department of Health and Social Care, and their practical insights and advice have the potential to make real-world impact. The same is true of work being carried out by our economist Roger Prudon, who has been studying the effects of increased waiting times for mental health treatment on patients. His work uncovers impacts beyond recovery times, and with effects on both personal economic outcomes and expenditure by care providers. There is much to be gained for all concerned in Clare Rigg’s work on working women post-menopause as well. Too many women can feel forced out of the workforce due to menopause symptoms, and Clare’s project shows just how much they still have to offer – to their own benefit and to that of the companies they work for. The Work Foundation’s Aman Navani outlines work they are doing with the MS Society to likewise improve the working lives of people with multiple sclerosis. MS is a condition that can cause many health issues, but it does not have to mean the end of a working life. Problems of workplace access are also to be found among entrepreneurs with a disability. Cara Molyneux and colleagues from Lancaster’s Faculty of Health and Medicine highlight how disabled people wanting to start their own companies are not well supported, and how better backing could improve their working and personal lives. Likewise, Leighanne Higgins and Killian O’Leary have been working with organisations to help them improve accessibility for people with a disability. The marketplace can be far more accessible than it currently is, and it has been fabulous to see the impact Leighanne and Killian have had on improving that through their innovative artwork project. I am please to see two of our up and coming PhD researchers also featured in this edition. Ziyi Yang and Irina Obeada work on what could be considered the fringes of the health and healthcare sphere, but their respective pieces on stigmatisation in K-Pop fandom and on our sense of risk both provide fascinating insights. You will find much else to consider as well, and I hope this edition provides you with some positive mental stimulation – and we can consider that another small way in which LUMS is helping with improving the health of all those we come into contact with! Welcome to Issue 23 of Fifty Four Degrees. Professor Claire Leitch Executive Dean Lancaster University Management School
6 | SHOW A LITTLE COMPASSION Compassionate care is crucial for the wellbeing of staff and patients across the UK’s National Health Service. Drawing on more than 40 years’ experience working in the healthcare sector, Professor Michael West explains the problems of inequity across the system, the importance of staff engagement, the need to move on from a command and control structure – and why the NHS is in the worst state he has seen it.
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The current healthcare context is challenging. There are high levels of staff shortages in areas like maternity and A&E, and there is worldwide competition for staff. The World Health Organisation estimates that by 2030 there will be a shortage of 11,000,000 healthcare workers globally. In the UK, there are high stress levels, with around one in three staff reporting feeling burned out at work. This has real health consequences for staff, and so we are losing those who are finding work too stressful. Burnout also affects the quality of patient care. There are shocking inequalities in healthcare outcomes and in how staff are treated. This is in the context of increasing demands on health services from an ageing population. We have to transform how we manage and lead our health service organisations. The healthcare system is facing the biggest crisis I have seen in my lifetime. A MAJOR PROBLEM At the same time, there is a growing recognition of and commitment to developing compassionate, high- quality care cultures by embedding compassionate leadership at every level. So, although there is much darkness, there are also light spots, such as places that are putting our research into practice. Compassionate leadership must be at the heart of the changes we make. Why? Firstly, we know from randomised controlled trials and meta-analyses that compassion is the most important intervention we have available in healthcare. This is demonstrated in the effects of compassion in the treatment of longterm disorders like diabetes and HIV, of therapists’ compassion in mental health treatment, and compassionate care related to the longevity of patients with cancer. Secondly, when staff can deliver compassionate care, it has beneficial effects for their health and well-being. In trials with GPs and nurses, who are asked to be extra compassionate in their interactions with patients over a twoweek period, this has a significant impact on their own mental health, with lower levels of anxiety, stress and depression. When you ask patients what they want from healthcare professionals, they want compassion. They want professionals who will listen to them, who are present when they are having a consultation, not lost on their computers, who empathise with them, who care for them, and who are motivated to help them. We also know that there is an almost universal commitment among healthcare staff to high-quality compassionate care. When they see that the values of their organisation reflect that, then their engagement is much higher. When they hear leaders 8 |
talking more about productivity and financial performance than high quality, compassionate care, their engagement declines. Yet our research shows that the single most important lead indicator of the performance of NHS organisations is staff engagement, particularly involvement in decision-making. Compassionate leadership is the key lead indicator of staff engagement, which in turn is the key predictor of NHS performance, care quality, patient satisfaction, staff retention, avoidable patient mortality, fewer errors, fewer infections, etc. CHANGE ON THE GROUND Organisations increasingly recognise the need for changes in their cultures. I have been privileged to help promote initiatives on compassionate leadership at organisational and national levels across the UK and more widely. A good example is Berkshire Health, who have been retraining all their staff in compassionate leadership for the last six years. They now have the lowest levels of stress and the highest levels of engagement of any NHS trust in the country, and they are rated outstanding in terms of care quality by the Care Quality Commission. In Wales, I am working with all the NHS organisations as part of a 10-year strategy, supported by the Welsh Government to create compassionate leadership and cultures across all of health and social care by 2030. They have invested and continue to invest courageously in transforming all parts of health and social care to ensure compassionate high-quality care cultures – not only care for patients but also for staff. All the NHS trusts and boards in Wales have now signed a compassionate leadership pledge, developed by Health Education and Improvement Wales to facilitate organisational commitments over the long term to developing compassionate leadership and cultures. We have created compassionate leadership training courses, which are being rolled out across the entire system of healthcare and social care. These inspiring changes give hope in dark times. MORE IS NEEDED We need broad and sustained changes at every level of our health and care systems in the coming years. Firstly, we must make workforce the priority, with compassionate leadership at its core. If leadership is not inclusive, it is not compassionate. We must address issues of equity and inclusion. We must better meet the core needs of staff, because problems of stress are not solved by simply giving people access to mindfulness apps and advice on diet and yoga. It is much more fundamental. It is to do with the working conditions people face – not having voice and influence, having chronic excessive workloads, poor team working, poor supervision, and so on. We must move away from the hierarchical command and control cultures which characterise healthcare. The announcement earlier this year of the abolition of NHS England seems radical, but unless that change is accompanied by devolution of responsibility to local organisations, it will just be another disruptive structural change. At a deeper level, we need to make sure organisations are not box ticking in relation to developing compassionate and inclusive cultures. We have to embed it in the DNA of organisations. We must collaborate internationally to learn, to develop and to share ideas about how to develop and sustain compassionate and inclusive cultures in our health and care systems. I am involved in a coalition of nations for compassionate healthcare, where we are seeking to share good practice and support each other in our various countries to influence policy and practice at national level. The changes must be in partnership with communities and patients, because none of this is going to happen unless they are involved in the co-design and co-ownership of health and care services. IT TAKES A VILLAGE The only way to care for the well-being and happiness of the people of our communities is if all the agencies, such as local government, education, criminal justice systems, health and social care, work together more effectively and in an integrated way. To do that, they need common cultural values. Compassion must be the glue that binds these organisations together, because that is what they are there to do – to help people lead the happiest lives they possibly can. I would include universities as central to this. We play a key role in advancing understanding about the factors that promote the happiness and well-being of people, and indeed of the of the wider environment and of the planet. We must model the compassionate and inclusive cultures which aid human flourishing and work together with agencies, policy makers and politicians to pursue a vision of sharing a commitment to creating a far more compassionate and inclusive society, and with an NHS that is far better able to serve both staff and patients. FIFTY FOUR DEGREES | 9 Michael West CBE is a Professor in the Department of Organisation, Work and Technology. His research explores organisational innovation and effectiveness, and the cultures of quality and safety in healthcare. He has worked with organisations including NHS England, the UK General Medical Council, the Royal College of Surgeons of Ireland, and Health Education and Improvement Wales (HEIW) to implement compassionate healthcare and leadership. He is Senior Visiting Fellow at The King’s Fund, London. m.a.west@lancaster.ac.uk
10 | Waiting Too Long As approximately one-in-eight people worldwide struggle with mental health issues, waitlists for mental healthcare are increasingly common. While no-one likes waiting for care, little is known about the impact of these delays on patients. Dr Roger Prudon shows the significant negative labour market impacts of waiting times on patients, resulting in substantial costs to society.
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Mental health problems impose a significant burden on people. They experience lower levels of wellbeing, reach lower levels in their education and are more likely to become unemployed. This personal burden translates into a substantial and growing economic cost to society. In 2010, the worldwide cost associated with mental health problems was estimated at US$2.5 trillion (5% of world GDP), and this is predicted to grow to US$6 trillion by 2030. Given the substantial cost, adequate treatment could greatly benefit society. Unfortunately, many countries struggle with providing sufficient mental healthcare, resulting in long waitlists. In England, almost four million people received mental healthcare through the National Health Service (NHS) in 2024. However, approximately one million are currently on the waitlist due to limited treatment capacity. The UK government has made it one of its priorities to reduce these waitlists. Prime Minister Keir Starmer announced in May 2024 that “the first steps of my Labour government will be to cut NHS waiting lists”. Despite this high prioritisation, evidence on the actual impact of waiting for mental healthcare on individuals is lacking. Insight into this is crucial in determining where, for whom, and how to effectively reduce the burden of waitlists given that NHS funds for interventions are limited. My study sheds light on these impacts, showing strong deteriorations in patient labour market outcomes as a result of waiting times, especially among those with a lower educational attainment and/or a migration background. MEASURING WAITING TIMES The first step in determining the impact of waitlists is measuring how long people actually wait for mental healthcare. Data in the UK is scarce, however. The NHS publishes average waitlist for the NHS Talking therapies, Children and Young People with Eating Disorders, and Early Intervention in Psychosis programmes, but information on all other mental healthcare is not available. Given this lack of data, I turned to mental healthcare in the Netherlands. The UK and the Netherlands share many similarities in terms of their healthcare and social assistance systems, and both struggle with mental health provision waitlists. The Dutch context is therefore ideal for studying the impact of waiting times, as detailed individual level data is available on all mental healthcare treatments. This data can be linked with a wide range of labour market measures, making it possible to examine the impacts of waiting times on both healthcare utilisation and employment outcomes. Before turning to waiting times, it is important to have an idea of what happens to people around the moment they seek care. Mental health is a broad concept and ranges from mild depressive symptoms to severe personality disorders. To illustrate the severity of mental health problems of individuals on the waiting list, Figure 1 shows the percentage of patients with a job relative to the moment they first seek care. In the years prior to seeking care, approximately six-in-10 are employed, and this drops to five-in-10 in the years after seeking care. One-in-10 thus lose their job around the moment they enter the waitlist. The drop in employment illustrates that there is 12 | 66 64 62 60 58 56 54 -72-48-24 0 24 48 72 96 PERCENTAGE EMPLOYED MONTHS BEFORE AND AFTER SEEKING CARE Figure 1
scope for labour market improvements through treatment and thus also for negative labour market impacts due to waiting times. THE IMPACT OF WAITING The actual duration people must wait for care is not random. A key driver is the severity of their mental health problems. If they are severe, individuals are likely to be given urgency, and treatment will commence as soon as possible. This means that to estimate the impact of waiting times, we cannot simply compare people with short and long delays, as such a comparison would not take severity into account. In my study, I therefore exploit differences in average local waiting times. The intuition behind this is that individuals can be ‘lucky’ and seek care when the mental healthcare system in their municipality is not congested, resulting in a relatively short waiting time. I can compare these individuals to others who are ‘unlucky’ and seek care when the system is very congested. These lucky and unlucky individuals are similar in the severity of their condition but face a different waiting time. I computed average monthly waiting times across the Netherlands between 2012 and 2019 and compared the healthcare utilisation and employment outcomes for patients. I found that a one-month increase in waiting time increases the total amount of care patients receive by approximately 10 percent in the first five years. This increased utilisation of care could indicate that the mental health of patients deteriorates while they are waiting, or that care becomes less effective as patients wait longer. This implies that if we could reduce waiting times for mental healthcare, the total amount of care needed would reduce as well, and treatment capacity could be shifted to other individuals seeking care – further reducing the waitlist. Alongside this healthcare impact, the labour market status of patients also deteriorates as they wait for care. For every one-month increase in waiting time, approximately two percentage points of all patients lose their job. Most flow into the disability insurance system or into social assistance. These negative consequences are very persistent, as the vast majority of those who have lost their job due to the waiting times are still unemployed eight years after the start of treatment. AN UNEQUAL BURDEN The negative impact of waiting times is not equal for all subgroups of the population. Firstly, there are differences in how long people wait before receiving care. Prior research has shown that disadvantaged groups such as those with a migration background are less likely to use mental healthcare. However, my study shows that even among those who do seek care, individuals with a migration background or lower educational attainment must wait one more week on average. This is even true when comparing them to individuals seeking care at the same healthcare provider and with the same diagnosis. Secondly, there are also differences in the impact of having to wait an additional month. Perhaps unsurprisingly, the negative consequences are largest for those with more severe mental healthcare problems seeking care from psychiatrists, and smallest for those with mild problems seeking care from psychologists. More surprisingly, individuals with a migration background or lower educational attainment also experience larger negative impacts of having to wait one additional month. This implies that the burden of waitlists is particularly large for already disadvantaged groups. CONCERTED EFFORTS The most straightforward way of reducing the negative impact of waitlists for mental healthcare is to reduce the average waiting times by providing more care. While providing more care can be costly, I used a back-of-the-envelope calculation to show that in the Netherlands a one-month reduction in the average waiting time would save more than €300 million in unemployment-related costs each year. This saving strongly outweighs the labour cost of training and hiring the healthcare workers required to achieve the reduction in waiting times. Alongside work to reduce the average waitlist, additional efforts should be undertaken to support those most affected: individuals with a migration background or lower educational attainment, and those suffering from the most severe mental health issues. FIFTY FOUR DEGREES | 13 Dr Roger Prudon is a Lecturer in the Department of Economics. His research focuses on the interplay between mental health, disability and employment. The paper Is delayed mental health treatment detrimental for employment? by Dr Roger Prudon, is forthcoming in The Review of Economics and Statistics. r.prudon@lancaster.ac.uk
14 | Life for working women does not end with the menopause. Yet many can be made to feel their careers are over when they still have years left to give. Professor Clare Rigg outlines her work to explore their experiences. WORKING LIFE POSTMENOPAUSE
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Menopause symptoms can be extremely disruptive to women’s working lives. Typically, menopause is experienced between the ages of 50-55 (though this can vary widely), as women gradually (yet often unevenly) cease menstruating. Currently, around a quarter of women aged over 50 are considering leaving their job due to experiencing menopausal symptoms. Only in very recent years have some organisations begun to recognise that offering wellbeing support and flexibility during menopause can be a means to ensure women do not leave employment. The risk of losing any employees before retirement age matters for several reasons. Firstly, it is important for people themselves to be able to keep working and earning. Secondly, the UK workforce is facing serious labour shortages, which cannot be filled purely by the numbers of young people entering the workforce. Thirdly, for employers, it is an expensive waste of talent to lose experienced employees and costly to recruit new ones. Women currently make up almost half the UK workforce (47%), and until 2010 they could retire with a pension at age 60. Now they must wait until 66 and this will rise further in 2026 to age 67. This means that, unlike in the past, women could easily be working 10-15 years post-menopause. That is a third to a quarter of their working lives. However, very little is known about the work-life experiences of women in this age bracket. Consequently, there is little known about how women might be supported, and their skills and talents retained at work, postmenopause. RENEWED DRIVE This knowledge gap is what prompted me to research women’s experience of working post-menopause. I was interested in how they made the transition from working whilst being menopausal and in how they viewed their working life now, their aspirations and ambitions for this stage. I had a personal motivation. My experience of finding myself postmenopausal with renewed drive and further career ambitions seemed so contrary to the rather pessimistic images circulating in society about my sex and age group which suggested that working life and productivity were more or less over alongside the cessation of your reproductivity with menopause. I wanted to find out what other women’s experiences were and the potential implications for employment practices. We are speaking to women aged 55 and over about their career experiences post-menopause. So far, we have interviewed and held a focus group with dozens of women and received eightweek diaries of experiences from some of them. We have also interviewed employers about their perspective. This is an ongoing study, which so far has not included many women in manual jobs. We do not pretend that what we have found is necessarily true for all. But here are some of our early findings. MORE AMBITION All the women in our study said that, compared to working during their menopause, they now have more energy, enthusiasm for working, and a new-found confidence. As one woman put it: ‘Oh, my God, it’s back. I’m back’. Several described life as levelling out: ‘I think one of the great things about it is that you can trust that every day your mood is going to be stable, right? You know, once you get through it all… Also, I have loads of energy.’ Some described having enhanced ambition and had gone on to take ‘bigger’ roles with more responsibility in their late 50s and early 60s, including setting up their own business. Several said they had felt forced to leave their jobs or change their roles during their menopause, due to symptoms that are widely reported, such as extreme tiredness, anxiety and/or brain fog. One woman who quit her job, who had previously worked long hours as a London solicitor, illustrated this, saying: ‘Back then I thought I was burnt out, but I was experiencing the menopause. I couldn’t concentrate. I was bursting into tears in front of clients, and I lost all confidence in my own ability to be a competent solicitor.’ Another described a situation that made her reevaluate her job: ‘I could feel the blood leaking into my shoe under my trousers, right, and going, “How the feck am I going to get out of here?”, right? And it was just one of those awful moments when you’re thinking your body is utterly betraying you. … I didn’t really know that those kinds of things could happen.’ All the women we spoke to who left jobs returned to work once their menopausal symptoms cleared, though not necessarily in the same careers. Some retrained into something completely different and were happy with their choice. Others, however, felt they were never able to retrieve their career trajectory. 16 | ‘I have gone through that hell in my life and now I feel like a new woman… I am about to live again’
Many participants reported feeling their later career development was hindered by negative assumptions that combined ageism with gender stereotyping. Even if they had ten or more years to work before retirement: ‘there is an assumption that you might retire soon, that you’re not interested, but we are … I am. I love what I do.’ ‘I … want to excel and progress further’. WHAT HELPED? All the women in our study mentioned flexible working arrangements that could help manage highs and lows of energy. Examples included being able to work from home at least some of the time; being able to work variable hours; and being able to have some control over scheduling of tasks. One woman said: ‘I know if … I’ve got some phone calls to make with new clients, I won’t do that if I’m feeling particularly tired.’ Some suggested absence policies should provide for menopause leave in a similar way to the availability of maternity leave. One employer described what they have put in place informally for a specific employee: ‘There’s a woman at the moment she’s going through it, and my God, she’s like an unexploded bomb a lot of the time. But, you know, we’re able to give her some extra time; she can work from home Mondays and Fridays, so that we’re trying to take it into account.’ However, the women we spoke to had mixed opinions on whether specific policies for post-menopausal career stages are necessary. Most preferred to see a broader shift to workplace inclusivity and culture. Some highlighted how difficult it could be to contemplate a conversation with a line manager about specific needs to accommodate menopause, particularly if the manager themselves had no personal experience: ‘do you really want your boss to know that you’re not functioning very well, or to see you a bit differently?’ Better training for managers and supervisors on supporting employee health and wellbeing in general was viewed as a means to foster a more empathetic and collaborative workplace culture, and through this a means to enable women to continue working through and post menopause. MORE TO GIVE Our study is at an early stage. However, it shows so far that women have much to give to their careers postmenopause. Most want to continue working, (as much as they need to), though not necessarily full-time; some want to accelerate their careers; some want to retrain into a new area. The work reinforces the idea that the years of menopausal symptoms can often derail careers. But we found two key messages. One, if employers do not take steps to prevent that derailment, they risk losing years of both past experience and future potential. Secondly, there are steps employers can take to support women into and through their post-menopausal working lives. FIFTY FOUR DEGREES | 17 Clare Rigg is Professor of Post-Experience Management Education in the Department of Professional and Executive Management Learning. Professor Rigg is working with Dr Laura Reeves, from the University of Suffolk on the study Post Menopausal Careers. c.rigg2@lancaster.ac.uk
18 | Tackling Essential Medicine Shortages Making sure enough medications are available is a key goal for governments and healthcare providers. But with global pandemics, political upheaval and the complexities of contemporary pharmaceutical supply chains getting in the way, it is not as easy as it might sound. Professor Kostas Selviaridis and Dr Nonhlanhla Dube outline their work on the MIA project to help mitigate and even prevent medicine shortages within the UK National Health Service.
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ADuring the height of Covid-19, many countries found themselves short of essential medicines. As well as for Covid-related medical complications – such as patient admissions for respiratory and related symptoms – hospitals did not always have the required stocks of critical drugs for a range of illnesses. Factories producing drugs were closed; international shipping was disrupted; hospitals were coping with unprecedented circumstances; and it all added up to a dilemma that received widespread attention. But the problem was not a new one. While Covid amplified the exposure, medicine shortages have been with us for some time. And with events like Brexit and the pandemic, alongside major geopolitical shifts, scarcities are more evident. Every year there are reported drug shortages, from oncology drugs to antibiotics, chemotherapy agents to even intravenous (IV) fluids, basics used in public hospitals every day. On the Measures for Improved Availability of Medicines and Vaccines (MIA) project, we have been part of an international team looking at what can be done to solve this problem. We have identified cost-effective supply chain interventions, such as stockpiling medicines, changing the way you buy them or, thinking about the capabilities of the medicine supply system as a whole. The UK part of the project has had three aspects, each bringing valuable insights and opportunities for change within the UK medicine supply system. EXISTING CAPABILITIES We looked at the situation from preBrexit to post-Covid to see how the UK medicine supply system dealt with overlapping crisis events, and how it developed capabilities to respond. There are different types of uncertainty. Brexit was foreseeable, we knew it was coming. Covid, we did not see coming. These two things also overlapped. Based on cross-country research, it emerged that the UK had done better on medicine supply than many other European countries during Covid. Looking at how this happened and what lessons were learned was an important aspect, and some of the measures organisations were taking during Brexit helped in the initial pandemic response. For example, the UK Government asked manufacturers to stockpile medicines to be able to respond to a possible no-deal scenario. This meant during the first wave of the pandemic, they had some of these medicines in stock. We could also see the evolution from the UK Government and the National Health Service (NHS) constantly firefighting as a reactive approach to dealing with the crisis, to having firefighting as one of several measures for dealing with disruptions. Organisations became more proactive and strategic. There are lessons here for supply in many areas. What happens with the housing crisis in different parts of Europe, for instance. There are the same fundamentals in terms of learning and building capabilities leading to something that is going to be much more sustainable and viable in the long-term. BUILDING RESILIENCE The second area we have looked at is what we call “contracting for resilience” – how to change the way the NHS buys medicines in the hospital care sector in the UK. Presently, if you look at the tenders and the contracts used to buy medicines in public hospitals, it is all about price and cost efficiency and not resilience in the supply chain. There is a desire to change that to give more weight to supply chain resilience. We have engaged with stakeholders within NHS England, the UK Government Department of Health and Social Care (DHSC), and industry associations to see how this can become a reality. For example, so far the NHS makes contract award decisions without thinking of things like how robust the supply chain is, whether there is a dual source for supplies including for active pharmaceutical ingredients (APIs). There is a tension between making supply chains more resilient and working with tight budgets. One of our key findings has been what the NHS and medicine suppliers are trying to do to reconcile these competing priorities – investments in resilience and affordability. One good 20 |
example is the introduction of agile contracting practices that increase supply flexibility. The idea is to lure back dormant suppliers, who have dropped out of the UK market because the prices are too low. By doing that, the NHS also diversifies its supply sources. Other established practices, such as varying tendering frequencies and awarding contracts regionally to different suppliers, are also helping to keep suppliers interested. ESTABLISHED LESSONS We are trying to facilitate evidencebased decision-making in the UK medicine supply system by sharing supply chain management knowledge and best practice from other sectors, or from other procurement contexts. Some of the things we have proposed would be transformational, but it takes time and resources to implement changes. We propose, for example, that supplier resilience must be rewarded appropriately by increasing prices for products (especially generics) with extremely tight margins or by giving some sort of minimum volume commitments to suppliers. The added costs of doing so would most likely be offset by a reduction in the substantial costs of dealing with drug shortages. We are also drawing on insights from other countries, like Norway, the Netherlands, France, Belgium and Sweden. Good supply chain management practices there can be potentially transferred to the UK, and the other way round. A lot of medicine supply contracts seem to focus more on “sticks”, the penalties for failing to do something. There are not enough “carrots”, positive incentives for suppliers achieving certain things. This is where we can learn from countries like Norway, and how they build in more incentives to get desired outcomes. BE THE BEST Last summer, DHSC and NHS England wanted to understand best practice in getting manufacturers and wholesalers to share their supply chain data – stock levels, sales, production capacities etc. They want this data to increase visibility of what is happening in different medicine supply chains, to model the flow of stock and see where they are likely moving towards a shortage. They asked us to look at what is happening in other countries and see what the best practice is in terms of either incentivising suppliers to share their data or alternatively mandating them to do so. Under Covid, stakeholders were willing to share information given the urgency of the situation. They shared more information than they had ever done in history, but they lost that interest when the crisis was over. We examined what is happening in Australia, New Zealand, Canada, Norway, the Netherlands, France and Denmark, and put everything into a report with several recommendations. Overall, we found the DHSC are not behind. Some of it was a question of showing them what they already do well, so they could formalise things they did during Brexit or Covid, or even before. But there is still room for improvement. One issue is that a lot of stakeholders talk about information sharing in real time, but this is extremely difficult to achieve in practice. There is always a time lag between collecting, analysing, and sharing date to enable informed decisions. Data sharing governance is also problematic. We only found one good example in Australia of a clear governance framework to communicate with suppliers what type of data they need to share, when, in which cases, and so on. The question also arises of whether it always pays off and makes sense for suppliers to share data. Policymakers and regulators need to think about the cost effectiveness of asking suppliers all the time to share their data. Should this be done only in particular situations? For example, when you have a medicine with a vulnerable supply chain. MOVING FORWARD We are continuing to study many of these areas and are interested to see what happens in the future. There are further actions that can improve supply chain resilience and ensure that the medicine shortages that make the news – and that often do not – become rarer, and healthcare provision becomes more robust as a result. FIFTY FOUR DEGREES | 21 Professor Kostas Selviaridis is Chair in Operations and Supply Chain Management in the Department of Management Science. Dr Nonhlanhla Dube is Lecturer in Operations Management in the Department of Management Science. Both were investigators on the Measures for Improved Availability of Medicines and Vaccines (MIA) international project, funded by the Research Council of Norway. The paper Riding the waves of uncertainty: Towards strategic agility in medicine supply systems by Dr Nonhlanhla Dube and Professor Kostas Selviaridis, of Lancaster University Management School; Professor Kim E. van Oorschot, of BI Norwegian Business School, Oslo; and Professor Marianne Jahre, of Kühne Logistics University, Hamburg, is published in the Journal of Operations Management. k.selviaridis@lancaster.ac.uk; n.dube@lancaster.ac.uk
22 | For hundreds of millions of people with a disability, navigating the everyday is far from straightforward. Dr Leighanne Higgins and Dr Killian O’Leary’s The Marketplace and I project provides a way for businesses and the public to better understand how exclusionary the commercial world can be, and how it can be made more accessible. Artful Accessibility: Reality over Regulation
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24 | In April 2025, 80-year-old Barry Dobner embarked on an EasyJet flight to Athens for a two-week holiday. Or so he thought. Just moments before take-off, Barry – a wheelchair user – was asked to disembark. What had Barry done that was so irregular, disruptive or heinous? Well Barry has limited mobility and therefore cannot walk to the onboard toilet. This does not stop Barry flying, he just plans for these trips like most other people do. However, Barry’s urinal bottle, which he only brings for emergencies, had caused consternation among service staff. Stewards quickly asked Barry to disembark. Barry and his family left the flight, gave up more than £2,000 they had spent on their holiday and felt utterly dejected. Unfortunately, Barry’s experiences are a lot more common for those with disabilities than you might expect. With an estimated 1.6 billion people worldwide said to have a disability, and with them holding disposable income of approximately $13 trillion, consumers with disabilities (CwDs) make up the largest emerging market in our world. Yet, despite the mid-1990s witnessing the instantiation of accessibility regulations and laws, such as the UK Disability Discrimination Act (DDA) and the Americas with Disabilities Act (ADA) in the USA, 30 years on accessibility barriers continue to exclude CwDs like Barry from full enjoyment and inclusion in commercial experiences. LACKING PERSPECTIVE Issues to accessibility are numerous and complicated but in the interests of brevity, two major issues hold sway. Firstly, legal regulations continue to be informed by able-bodied persons. They often ignore the lived realities of disability. Shelves and service points are not designed for wheelchair users, doors and entrance points do not always consider those with visual impairment, and service offerings on the high street do not account for how lighting and sound levels can disinhibit those with neurodivergent conditions. Secondly, the level of detail, understanding and guidance on how to implement accessible adjustment(s) to cater for CwDs is ambiguous. Organisations simply do not know what to do, beyond the minimum, and they most often prioritise accessibility in terms of physical and infrastructural changes. Further to this, as in the case of Barry and many others, there remains a stigma around CwDs. Anything that deviates from the norm, that may disrupt others, or any special adjustments and requirements are viewed by many organisations as beyond their well-defined rules or organisational practice. These frustrations prompted us to explore the barriers to access for CwDs. Rather than conduct the standard interviews, focus groups and surveys, we undertook an alternative approach. We turned to art! ACCESSIBILITY AND ART Our project started in 2015, when Leighanne began voluntarily caring on holiday trips for people with a range of different disabilities and care levels, including many unable to walk, talk, feed, bathe or toilet without assistance. It quickly became apparent how many of the patrons had creative ways of sharing their sense of self. Many painted, others wrote poetry or were avid photographers. An idea formed that it would be wonderful to learn about their commercial experiences through the creation of art. The Marketplace and I was born. THE MARKETPLACE AND I The Marketplace and I began in early 2019 by asking CwDs from across the UK to make any creative artwork or expression. It could be painting, song, dance, poetry – any medium creative in nature was accepted. The only remit was that the artwork should speak to commercial experiences. This resulted in the submission of 36 pieces exploring experiences in retail, hospitality, tourism, care and a plethora of other commercial sectors. The artworks comprise poems, song, dance, paintings, sculptures and installations and represent mobility (i.e. wheelchair users), sensorial (i.e.
visual impairment) and neurodivergent (i.e. autism) disability experiences. Devising this project was about developing an accessible methodology to allow the at times non-vocal voice and experiences of CwDs to be unearthed. Our goal was to display these artworks in a museum. Since the first exhibition in 2019, the project has toured both Ireland and the UK, been shown in universities, regional art spaces and most prominently at the 2022 Edinburgh Fringe. To date, we have engaged publicly with more than 3,000 people. The exhibitions have been powerful tools of public education, enlightening those unfamiliar with disability and marketplace accessibility on how disenfranchising and exclusionary the marketplace can be to CwDs. Visitors have been moved in extremely powerful and emotive ways by the artworks, as recalled by one male visitor: ‘[The exhibition] made me think how often do I look down, how often do I see a person in a wheelchair … how often do I acknowledge people in wheelchairs and people who differ from the “norm” – whatever that is? The truth is rarely, you have opened my eyes to something here ... I came in for a browse and to get out of the rain (laughs), yet I feel I have had something of an epiphany or an awakening – so thank you.’ Given such experiences, of which there were many, we knew that the artworks were special. They held a power that no textbook, academic article, presentation or educational video might translate. This was affirmed during the Marketplace and I exhibition at the Fringe, as several visitors all shared the same idea: ‘We would love for you to come and talk to my workplace and my colleagues, they’d learn so much.’ And we thought why not? Why not use the artworks to engage organisations in accessibility training? Since 2022, we have been using the artworks to offer organisations across the UK innovative, art-based accessibility training. At the core of this training are the artworks and the narratives of the artists – their lived experiences in commercial settings. We use the artworks to begin dialogue on accessibility and work actively with the organisations to develop tailormade short- medium- and long-term accessibility strategies. The importance of our research, our expertise and time spent studying accessibility is moot unless we activate change in the marketplace and to do that we need organisations to act. REALITY OVER REGULATION To date, we are working with more than 30 organisations including: The National Trust, Age Scotland, the Royal Society for Protection of Birds, WWT Martin Mere, The Grand Theatre, Lancaster City Council, Marketing Lancashire and Blackpool Transport. We are witnessing companies moving away from a mentality of regulation – wherein they think a ramp or lift, or a hearing loop system is sufficient – to genuinely reconsider the lived experience of disability and what that means in terms of accessibility. The training, to blow our own trumpet, is good. It is unique, built from lived experience, and it has helped organisations consider more prominently accessibility-related needs. We never advocate for thousands of pounds to be spent, instead we ground recommendations in simple but effective changes. For example, after our training companies are: • Improving their signage to be clearer and more accessible • Including alt text on the images on their communications • Offering quieter spaces, times, and events to allow not only neurodivergent, but aged, sensory disabled, and people suffering with mental health conditions time, space and commercially inclusive experiences These are just some examples. The last 30 years have shown that regulation alone is unable to instantiate appropriate levels of accessibility. The marketplace still has much work to do to adequately cater to those with disabilities. Barry’s is only one story among thousands of everyday exclusion. We know that in prioritising lived reality over regulations and minimum requirements, organisations are better able to ensure that future accessibility practices can meet the real needs of CwDs. FIFTY FOUR DEGREES | 25 Dr Leighanne Higgins is a Senior Lecturer in the Department of Marketing. Dr Killian O’Leary is a Lecturer in the Department of Marketing. They lead the Marketplace and I project, which was initially funded by the Marketing Trust. The Marketplace and I offers free accessibility training workshops for organisations. Contact the authors for more information. l.higgins@lancaster.ac.uk; k.oleary1 @lancaster.ac.uk
26 | Multiple sclerosis impacts people’s ability to work but it does not have to be the case. The Work Foundation’s Aman Navani outlines a new report showing how better employer and Government support can enable people with MS who can work to thrive at work and fulfil their potential. SUPPORTING PEOPLE WITH MS TO THRIVE IN AND OUT OF WORK
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There are approximately 150,000 people living with multiple sclerosis (MS) in the UK. MS is a legally recognised disability under the Equality Act 2010 and affects the central nervous system by damaging the protective coating around the nerves. It is an unpredictable and fluctuating condition with wide-ranging symptoms including fatigue, severe pain and challenges with movement, thinking and feeling. MS can impact people’s ability to stay in work. The MS Society estimated that in 2022 the employment rate for people living with MS was 47%. This is lower than both the UK disability employment rate (54%) and the non-disabled employment rate (82%). While leaving work may be the right choice for some people with MS if their symptoms make it difficult to continue working, people with MS who are in work should have the workplace protection and support to thrive and flourish at work. The Work Foundation’s new report, No Compromises: Supporting people with MS to thrive in and out of work, highlights the barriers and enablers to staying and progressing in work for people with MS and identifies how government and employers can help them thrive at work. The report was based on the findings from an online survey of 1,125 people with MS, undertaken in partnership with and funded by the MS Society. WORKPLACE CHALLENGES The majority of people with MS (96%) who responded to our survey indicated that MS had an impact on their ability to work. For some, the symptoms of MS make it too difficult to stay in employment. A quarter of survey respondents said that the severity of their MS meant that they were unable to work at all. A third of respondents (35%) who had left a job because of their MS highlighted that no additional support would have helped them stay in work. These figures suggest that leaving a job can be the right choice for some people with MS and they should be able to do so without having to worry about their financial security. However, people with MS who can work often leave employment earlier than they would like to, or miss out on the opportunity to progress in their careers due to a lack of workplace support. Survey respondents reported experiencing several challenges at work from unmanageable workloads, a lack of flexible work options, and inaccessible workplaces. More than a quarter (26%) had to contend with unmanageable workloads, while 19% stated that inadequate wages made it hard to cover living costs. A lack of flexibility was a key workplace challenge too. One fifth of respondents (21%) cited a lack of flexible working hours as a workplace challenge, while 34% of those whose health had been compromised by staying in work said that the lack of flexibility over working hours was particularly challenging. A further 22% said they have a flexible arrangement that does not meet their needs. While flexible working arrangements are not a panacea and can create their own sets of problems, having them is a key priority for job seekers with MS. 53% of 28 |
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