Physician, heal thyself?
Ian McDowell asks what the NHS is doing to recover from the Mid Staffordshire scandal
Leadership, training and development feature strongly in a truly serpentine tally of 290 recommendations made by Robert Francis QC, the brains behind the Francis Report into the shocking events at Mid Staffordshire NHS Foundation Trust. Here, patients lay for days unfed or in their own excrement. The snake is a traditional symbol of medicine: are these 290 ideas a totem of healing for the NHS, or just a tangled distraction?
This snake is of variegated hue. One of its colours, a soothing green, is all leadership, culture, integrity. The second is hotter, redder, all blood and stop-lights: inspection, regulation, standards, zero tolerance. One is all heart; the other all head. One is about each NHS organisation nurturing and valuing the contribution of each individual; the other is about each individual conforming absolutely to organisational norms.
Francis talks about a top-down culture of bullying in which the collective was free to prosecute its will against the troublesome individual. Inconvenient people - and the facts they dared to highlight - were systematically massaged out of the way so that a pre-written story of organisational success - designed in this case to win for the Trust coveted 'foundation' status - could be trumpeted.
This was a management culture big on value and short on values, a culture that measured care out of existence.
A nurse interviewed anonymously on Radio 4's Today programme, on the morning the Francis Report was published, told how a national regulator had sent inspectors into one of the hospitals and the nurses told them that the 14 audits they were currently running, along with the associated paperwork, was taking their eyes off the basics of patient care. The inspectors said: "Oh dear, we'd better have an audit about that."
Individual staff members' hearts were manifestly not in their work. This led to the evident absence of compassion in the delivery of the care itself, but also to all the familiar forms of buck-passing, to an emphasis on professional demarcation rather than personal responsibility. The first nurse to be interviewed on the Today programme instantly blamed healthcare assistants, a lower-paid staff group, for the problems.
Understanding this failure to integrate individual emotion and motivation appropriately into collective work is partly about understanding the nature of the work. A doctor in a busy accident and emergency department, or a nurse delivering chemotherapy, face challenges in terms of their own continuing mental health. In response to this, the professions have sometimes encouraged - either explicitly or implicitly - a culture of collective emotional detachment, a merging of the individual into the collective, and justified this via a doctrine of self-preservation.
Where a culture of more 'reflective' practice has been introduced in pockets around the country (via support and supervision groups for nurses, for example), significant benefits have been demonstrated, including improved staff retention and attendant reduction in the use of expensive agency staff. But this has been sporadic, and so have the gains.
The foundations of the NHS were also about individuals and collectives. When we imagine our most vulnerable relatives in these unpardonable situations, many of us will automatically visualise the Great Individuals (mostly men in this case) of post-war Britain - the tweedy and pipe-smoking Bevans and Reiths - spinning like tops in their unquiet graves. The NHS was founded in a post-War crucible of social and intellectual innovation, driven by charismatic individuals, but affecting huge swathes of the general population.
For this reason it is not surprising that the 1940s was also an important time in the history of philosophy, especially of the relationship between the individual mind and the actions it triggered in a society that was all about turning airy thought into concrete social betterment. The new public services were the practical out-workings of a new set of collective national feelings, feelings that were markedly egalitarian and universalising. This was a remarkably different idea from the concept of charity: it was the whole country that had fought against the common enemy, and the whole country should reap the rewards.
In this heady atmosphere of new national feelings turned into new national actions, the post-War Oxford philosopher Gilbert Ryle managed to get himself into a very public tussle about the relationship between thought and action with a philosopher who was not capable of answering back, because he had been dead for three hundred years. Rene Descartes had been around at the very birth of medicine and, in the tradition of Plato, he emphasised the difference between the mind and the body, rather than their connection. Descartes spent most of his career wrestling with the problem of how something immaterial (the mind) could trigger things to happen in something material (the body). In the end, he tried to suggest that a gland was responsible but this didn't really cut the mustard.
So Ryle was pushing at an open door when he made fun of Descartes' attitude to mind and body as "the myth of the ghost in the machine": in Descartes' idea of the mind, claimed Ryle, it was as if our finest thoughts were just a bit of vapour circulating in the apparatus. Ryle proposed that this dualism was a "category error": mind and body were really the same kinds of things, definitely not two different substances. Beliefs and actions, according to Ryle, were yoked inextricably together and, for this reason, he became known as a behaviourist.
Much of classical management theory is underpinned by behaviourist thinkers like Ryle, and on these beliefs rests the case for investment in the values and beliefs that trigger and inspire action, not just in the actions themselves. People whose hearts are with the company, or so the orthodoxy goes, will work harder and more reliably than those who drag themselves unwillingly through a set of mandatory routines.
On this classical management orthodoxy also hangs Francis's most basic criticism of the NHS: the wrong set of values is leading to the wrong kinds of behaviour. According to Francis, this is a national problem: "echoes" of the "negative aspects of culturally-driven behaviours" found in Mid Staffordshire are to be "found throughout the NHS".
According to Francis, these include:
- target-driven priorities
- disengagement from management
- low staff morale
- lack of candour
- acceptance of poor behaviours
- reliance on external assessments
Recent NHS attempts at creating more edifying and positive lists of organisational values and beliefs, and holding staff to account for adhering to them, have been notoriously top-down and clunky. This is because the 'values' are typically written on a flip chart in a board seminar and then announced with an absurd fanfare by corporate communications.
Is it any wonder, then, that these 'values' are perceived by many frontline staff as an additional un-owned burden, a new stick with which to be beaten rather than a reason to turn up for work bright-eyed and bushy-tailed?
There are signs that all this may be changing. The December 2012 nursing document Compassion in Practice proposes the regular use of a cultural barometer and mandatory culture reviews in NHS organisations to test whether values are really understood, owned and put into practice. Its very title, Compassion in Practice, proposes a Rylean world view of mind and matter in dynamic relation.
In April 2012, the NHS announced a £1m fund aimed at "creating wholly patient-focused organisations". I proposed a series of pan-organisational interventions based on storytelling, where an agreed theme - such a caring for patients with learning disabilities - was explored from the perspective of both individual patients and individual staff. Their stories would then be compared and analysed using a method developed in the 1960s by two US sociologists called Glaser and Strauss, overcoming language differences and identifying shared themes.
In response to findings from the work, one of the hospital trusts introduced a training course for nurses and a volunteering scheme to help local disabled people get more involved in the hospital, building new networks of peer support. During the course of the work, in one hospital there was a 60 per cent reduction in complaints, an eight-fold increase in formal compliments received by staff, and a significant leap in performance in the government's new Friends and Family Test, which asks patients whether they would commend the service to their friends and family (see p28).
When the NHS was founded, it was undoubtedly a little easier to line people up behind a single set of beliefs. This was a world in which most people wore the same clothes and listened to the same radio stations. How much harder is it in today's super-connected, super-diverse world, where people pick and choose their identities in ways our ancestors could only dream of? We live in a world in which the same team might well include a couple of married, gay, pigeon-fancying trainspotters who don't get on because they follow different football teams. But in this case, the use of patient and staff stories, and the analysis of the qualitative data contained in them to reveal what were often shared preoccupations, seemed to do the trick.
The paradox of a system that needs consistent values and standards, and in order to bring these about needs to engage with an unprecedentedly diverse set of individuals, is as much a challenge for the private as the public sector. Compassion in Practice proposes "six Cs" for nurses: Care, Compassion, Competence, Communication, Courage and Commitment. Courage is the one that stands out as the freshest of the Cs. This is the most individual of the words: the closest to what marketers would term a call to action. It was also the word that caused the most heated debate and the word that was included last.
The NHS has its own Leadership Academy, launched in 2012, nine months before the Francis Report was published. Its chief executive Jan Sobieraj was quick to state his view that the Leadership Academy is the same thing as the "Leadership College to provide common professional training" Francis demands. But where was the leadership in Stafford? The Leadership Academy's website is packed with opportunities for nurses, doctors and managers to "become better leaders"; but the NHS logo is ever-present, and the question that floats alongside it in the minds of most people is very much of the 'physician, heal thyself' variety.
Perhaps this is the most important lesson of all, because a culture in which individual - and organisational - identity is always merged into the Great Collective will always have trouble challenging itself. The new NHS "duty of candour", originally talked about as a matter for individuals, has settled down in policy terms as a duty for organisations. The language the NHS talks is still collectivising, universalising.
Next time a thousand people die who should not have done, next time people's loved ones are physically or mentally abused, or left in their own urine, which individual will actually say 'stop!'? It would appear that Florence Nightingale managed a tighter ship in the Crimean War than the peacetime NHS in Stafford. Just like medicine itself, it has to start with someone.
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