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Feeding the beast


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Friday, 15 February 2013

Feeding the beast

In the introduction to his report Robert Francis urges the NHS to make “a fully effective response and not merely expressions of regret, apology and promises of remedial action”.

A section is dedicated to hindsight: the word occurs 123 times in the transcript of the oral hearings and the phrase “benefit of hindsight” a further 378 times. Francis pointedly observes that hindsight had been an equally conspicuous feature of the Bristol inquiry. The rear-view mirror appears to be the visual aid of choice for witnesses at inquiries.

The Francis report tells us nothing we did not already know about the suffering of patients at Stafford Hospital, but it does deliver his conclusions about what to do to stop it happening again. The first report produced 18 recommendations; there are now 290.

This enormous prescription could easily become a bureaucrat’s charter. Francis blames many of the problems that led to Mid Staffs on the management’s emphasis on process over patients and in particular its obsessions with meeting targets and attaining foundation trust status. It is easy to see how implementing Francis could become the new obsession for the NHS inspiring more plans, forms, checks, reviews and reports than ever.

Changing the culture of the NHS is a constant theme of the report:  management culture – complacent, bullying and inward-looking – and staff culture, particularly in nursing.  No doubt some people are simply in the wrong jobs, but poor recruitment and training does not explain how the problem becomes commonplace, how nurses routinely have the compassion ground out of them, how managers become helpless to act.

Most people become unhappy in their work when they spend most of their time doing the wrong thing and when they no longer feel it is possible to do a good job. We can blame the “culture”, but cultures are notoriously hard to change. The other word for it is bureaucracy and you can fix that.

Bureaucracy is the primary NHS response to anxiety – the fear of getting it wrong makes us cautious, prone to planning, checking and reviewing, keen on controls, fond of sharing accountability and averse to risk and responsibility. As more things go wrong and management feels the need to press down harder to keep the lid on, bureaucracy itself becomes a cause of fear.

Other organisations have lighter management structures, more freedom for individuals to take decisions, more career mobility, less paperwork, better information management, fewer policies, less onerous procedures and – as a result – higher morale, higher productivity, happier customers. 

The traditional NHS management view is that what works for hamburgers or hotels won’t work for healthcare; that without “grip” the system will spin out of control with disastrous consequences. So we try carefully controlled experiments involving devolution of power, introduce policies for the empowerment of staff or try to graft leadership skills onto disenfranchised and demoralised managers instead of devolving power, empowering staff and breeding leaders.

In nursing, there is no shortage of visions and strategies for compassion and care, which generally rely on nurses to become more compassionate and caring by making an extra effort, but little sign of willingness on the part of leaders to address the causes of poor nursing. Only some of these are about resources. Others are about simple things, which could improve working lives and save money, like cutting paperwork and pointless box-ticking tasks.

The Francis report recognises all of these problems as well as its own potential to feed the beast it sets out to slay. It challenges the NHS to stop confusing caution with safety and fearfulness with vigilance.

In the wake of Francis, the secretary of state’s  preoccupations with a five-year strategy for a paperless NHS and measures to cut bureaucracy may be less sterile and peripheral than they seem.

Paul.Johanson@southeastcoast.nhs.uk says:
Feb 15, 2013 11:41 AM
One of the main problems we have in the NHS today is an institutionalised lack of emotional intelligence: a dearth of awareness that the task of delivering healthcare is fraught with anxiety and stress. It’s stressful because we are dealing with patients who are themselves anxious and stressed as a result of being ill in some way. The more seriously ill someone is, the more anxious and stressed they become. So far, so obvious. But because the NHS does not properly acknowledge this (and I think this lack of acknowledgement runs throughout the entire service – it’s a cultural norm in fact) there are no structured ways of dealing with stress and emotional/psychological difficulty for staff. If the emotions associated with the work are not acknowledged it becomes more and more difficult to acknowledge any sort of feeling or emotion. In this way emotional & psychological awareness quickly becomes a luxury, an add-on (if you can afford it at all). Caring for staff – actively supporting the emotional and psychological labour they undertake every day – takes time and resources, something which we are very short of. It is therefore no surprise that compassion and caring attitudes are in short supply.

Compassion gave birth to the NHS: the idea of providing cradle to grave healthcare for every British citizen is highly altruistic and a noble expression of humanitarian values. Compassion is also emotional and psychological in its nature. It is not an additional task which can be carried out and a box ticked. It’s not just another job that can be achieved without regard for our fellow humans, without heart, without feeling. Indeed, everything the NHS does could be seen as an articulation of compassion, rather than compassion being some sort of gloss, or icing on the cake. Compassion is the beating heart of health and social care, but the arteries which feed it are currently atrophied and blocked up through lack of use and neglect.

There’s a great social care researcher in the USA called Brene Brown (there are two brilliant talks by her on www.ted.com). She says that you cannot selectively numb emotion – you cannot just get rid of all the bad stuff you don’t like (anxiety, stress, anger etc) and keep all the good stuff (joy, kindness, compassion). If you try to numb bad emotions you numb EVERYTHING. If we don’t actively address the stresses and strains of the work, staff will find their own, often maladaptive ways of coping – which nearly always involves trying to numb or avoid painful emotions. Compassionate caring is one of the first casualties of this type of situation: if you don’t feel cared for by your organisation and if you don’t have the resources even to care for yourself it becomes very difficult to care for anyone else. Mid Staffs is an example of what happens when such maladaptive ways of coping become entrenched in an organisation. This situation is endemic throughout the NHS and, contrary to popular belief, has been around for a long time - it was observed in 1961 by Isabel Menzies-Lyth in her seminal piece of research on how staff coped with anxiety in a London teaching hospital.

What we desperately need is an acknowledgement of this by senior managers in the NHS. More than that they need to model the compassionate, caring and collaborative attitudes that they expect their staff to have towards patients. At present what many staff get from their management is platitudes, impossible tasks & targets and a shed-load of anxiety which management pass down every time the pressure is on. Modelling positive, emotionally intelligent behaviours needs to start at the very top and run through the NHS like lettering through a stick of rock. We all need protected space for reflection on how we work with each other and with patients. We all need to really try to understand everyone with whom we communicate. We all need to value every contribution to an ongoing dialogue about how we provide services and how we can improve what we do.

This is not just about writing something down and leaving the words on the paper. Compassionate caring is a practice. It’s something you and I and everyone actually does: it’s not just a set of words that you can put down in a leaflet and then leave for someone else to do (usually nurses and front line staff). All good practices, attitudes and well-accomplished tasks in the NHS will stem from compassion. And compassion will only flourish if you nurture, feed and protect it through nurturing emotional intelligence. If we can achieve this in some small measure we will be on our way to being truly patient-centred.

ian.merrick1@ntlworld.com says:
Feb 15, 2013 12:52 PM
The NHS struggles for many reasons but three distinct problems stick in my mind. Firstly wholesale re-structuring of the organisations within the NHS; secondly the drive to improve quality would probably benefit by equal effort being put into eradicating quality failure; and thirdly how about having a fit for purpose number of senior doctors in hospitals 24/7 seven days per week instead of the current 25% of the week.
sharon.levack@nhs.net says:
Feb 15, 2013 01:59 PM
I can see why the recommendations have risen to 290. But the roots of the problems as far as I can see are:
 1. Really bad planning of staff whether doctors or nurses where they are critically needed in numbers that can deliver an excellant service to the patient and not the bureaucracy. After all, who needs the care?
2. There is absolutley NO excuse for treating a patient rudely, ignoring their bell for help, giving the incorrect medication or generally just not caring. It's called service and empathy. No one should be have to be taught basic human kindness!!!

I know this as I worked as Client Relations Manager for a Private Hospital Group where service and excellant care were their main priorities. If people feel they are in the wrong job, then leave or if they can't, change their attitude and treat their patients with the dignity, human kindness and empathy they deserve. They don't WANT to be in hospital.

Have Client Relations Managers on the wards to identify whats going on from a patients and staff point of view. They can write up impartial reports on what is actually going wrong, but better than that, they can also put across recommendations from the staff and patients as well. See the problem and try and resolve it. Oh, and don't take 6 months to write up a revue and then a report and so on and so on. Fix it! And then move on to the next problem to resolve. It can also mean that a ward is getting it right. This then gives the opportunity to learn from that and commend them accordingly. I also think the bureaucrats should be visiting the wards unannounced to see what is happening under their noses.
sharon.levack@nhs.net says:
Feb 15, 2013 02:13 PM
Having read the comments by Paul Johanson on Friday, 15 February 2013 on , I have to totally agree with him on emotional stress and anxiety in patients as well as staff. I am astounded that the NHS does not have emotional support structures in place as the norm for dealing with stress and emotional/psychological difficulty for their staff. This should not be an option. How can staff deal with patients effectively without having their own support?
Michael.vonbertele@pickereurope.ac.uk says:
Feb 15, 2013 03:42 PM
It would take an academic treatise to do justice to the cultural change required but a good starting point is the excellent King’s Fund report written by Angela Coulter on Leadership for Patient Engagement last year. Couple that with some good military principles; selection and maintenance of the aim – Improve Healthcare for patients, plus a dollop of proper delegation of authority to innovate and deliver, with looser controls, and confident guidance and resources.
Then make sure that everyone in every bit of the NHS understands it. CEO, Medical Director, Nursing Director, Finance Director Consultants, GPs, ward staff, practice staff, nurses, cleaners, receptionists, porters, must agree that they are there to do only one thing. It requires investment in defining attitudes, values, behaviours, and skills, based on an understanding of what their patients want and expect. The best way to find out is to ask them, and involve everyone in that conversation. Spend time understanding it. Back it up with some of the resources already provided by the NHS Innovation people on Shared Decision Making and you have the start of a plan. It takes time to roll this out.
It means a commitment from the top and the bottom of every organisation to making it work; it means involving patients and staff in the change; it means that staff must be encouraged to do things differently, taking account of what patients have told them matters; it means measuring what is happening and making continual improvements and measuring again, sharing feedback, reinforcing the positive findings. Targets are too often used to beat up staff for getting it wrong and not often enough to encourage them. Healthcare is about compassion and respect and staff will not show it if they are themselves not treated with respect and compassion. The stick comes out when people fail to live up to the standards and values and behaviours that deliver patient-centred care. They should be the values of the NHS and if you don’t meet them you have no place in it. Then there will be no need for whistleblowers and gagging clauses.
simonarthur@nhs.net says:
Feb 17, 2013 11:24 AM
I agree wholeheartedly
The NHS should simplify not complicate control systems.
To put patient safety at the heart of what we do,we should have simple but effective ways to 'hear' what patients,relatives and staff have to say.
No Gagging !No bullying !
Doctorpfoster@btinternet.com says:
Feb 17, 2013 05:03 PM
Having qualified in 1972 and still in active clinical practice and a clinical director in urgent care for an ambulance service I can agree that we need to be cognizant of what has and hasn't worked through the benefit of hindsight. However with each report into failure comes the inevitable recommendations and tightening of the regulatory screw. With each turn of the screw the level of trust is eroded leading to the erosion of morale and ability of the individual worker to take any meaningful responsibility for their actions. Trust has been effectively squeezed out of the NHS to be replaced by a nightmare of audits, protocols and good practice guidance. It is not co-incidental that the crisis in care has increased with the ever increasing demand for proof of care. So if we are to learn from hindsight it is NOT to have more regulation but to re-energise staff through trust.
A system that rewards high performance with less top down and more self regulation would encourage providers to strive for quality. Anyone who has been on a well run ward does not need to look at MDS or dash boards to know that high quality care is being delivered. The staff have purpose, the ward is organised and the patients are content.

The repeated call for a change in culture is also a red herring. It seems to me that when managers are faced with a problem that is too difficult it becomes a cultural issue and that gets them off the hook. If we are not delivering high quality care and outcomes then the commissioners and providers must accept the responsibility for any lack of effective leadership and the culture that pervades poor care.
Trust has to be the key ingredient for the future of the NHS. However trust is not given but earned and once lost is difficult to get back. We all have much work to do to regain our patients trust.
PeterCooper says:
Feb 17, 2013 09:44 PM
There are a number of interesting contributions to this blog. I would simply like to add the observation that leaders every day contribute to the evolution of culture through the way that people experience their personal behaviour, the systems they put in place and the symbols that they use to signify what is important. It is obvious that whilst the leaders in the NHS are continually creating the curent culture they do not know how to do this deliberately through the appropriate use of these leadership tools(I am assuming the leaders are well intentioned). Practical ways to build positive cultures have been proven to work wherever people come together to work and there is no reason why the NHS would be any differnt expect that it seems impenetrable to having the right conversation. I don't know whether this blog can do any good but it would be wonderful to be able to talk to someone who has some authority and who actually cares enough to explore some alternative approaches that have worked elsewhere.
lanceclarke@sa-vi.org.uk says:
Feb 18, 2013 09:47 AM
What a great piece of writing - a lamentable description of the parlous state of affairs in the health and care sector. It isn't just the MHS its social care as well. Sir Jerry Robinson's expose of the use of theatres in the Rotheram (?) hospital highlighted all there is to know about a lack of respect and leadership that exists when highly paid so called professionals over-ride their staff (and usually get it wrong!) Massive change is usually a symptom of failure - encouraging as it does new systems rather than focussing on the failure of existing ones. There is also a lack of financial accountability when bright ideas are brought into play. Leadership and teamwork are important to success - bureacracy rarely works.
There is not excuse for rudeness whatever and trying vainly to fit reasons to it are doomed to failure. It is simple: get a grip! If managers walked the floor a bit more, listened and communicated better, then this would begin to make a difference; small incredmental changes like this are far more effective than wholesale re-engineering of work practices.

lindleyowen says:
Feb 18, 2013 12:50 PM
In 1892, a typhoid epidemic hit Middlesbrough, and the death rate was such a that 900 bed fever hospital was built in a matter of months. It was noticed that the rate of cases arising from the workhouse was double that of the surrounding town, so a public health doctor was despatched from London to investigate. He found that the workhouse and adjoining infirmary, which had been recently built on a 'lowest tender' basis, had been constructed with no effective drains. It was sitting on top of a cess-pit.
In the 21st century, wide variation in death rates between institutions which have a similar purpose is a prima facie case for public health inquiry.
Bhehir@hotmail.com says:
Feb 20, 2013 05:25 PM
'What happened at Mid-Staffs cannot be disentangled from today’s broader crisis of compassion. After all, it is generally accepted that Mid-Staffs is far from an isolated case – 20 other hospitals have already been named as providing sub-optimal care and having an unusually high death rate. Mid-Staffs was indicative of this widespread crisis of compassion.'
Read my analysis here http://www.spiked-online.com/site/article/13362/