Radical reform follows normalised deviance

Any phrase can quickly become a cliché. Within seconds of its conception it can be tweeted around the world, depending on the number and dispersion of your followers. A little later you hear it on radio or television or read it on a website. When you see it again in your daily newspaper the following morning it already looks tired and annoyingly familiar. You've heard it everywhere. From originality to tedium within 24 hours. Hello, 21st century.

When the Mid Staffordshire report was published earlier this year, normalised deviance enjoyed such brief fascination. The problem with clichés is that we see the words but cease to think about their meaning. Normalised deviance deserves a better fate. Paul Barach and Grant Phelps remind us of the damaging impact of normalised deviance at Stafford Hospital and what approaches might be taken to reduce it.¹

Other articles in this issue challenge behaviour that might be described as normalised deviance in different areas of medical practice. Informed consent was once an important advance in delivering better care and protecting patients. Yet Angela Coulter and colleagues believe that informed consent isn't sufficient because of the way clinicians have implemented it, the current process of consent, even if informed, does not place the patient central in the decision-making process.² Consenting, they explain, implies passive acquiescence to the doctor's decision, instead of an active informed choice by the patient. Their argument for a new gold standard of ‘informed request' is a powerful one.

In general practice, a capitation-based payment system that pays per patient rather than per episode, can create perverse incentives whilst being unresponsive to patient complexity and new service demands. Azeem Majeed provides a clear account of how the current funding system works in general practice and why it is time to consider modifying it in favour of methods that link workload more closely to funding.³ Radical reform is required since the funding model is ill-equipped to meet the needs of primary care in the UK in the 21st century.

Perhaps you might struggle to agree that all these examples typify normalised deviance? If you do see something in the concept, you might also appreciate that when we indentify normalised deviance the only response is radical reform. That's why normalised deviance, however often we read or hear about it, should never become a cliché.