The Francis report, time to care, and ethical passivity

Scarcely a day seems to go by without the news featuring some new horror story about the NHS. If you formed your opinions of the NHS by what you read in the news, you’d be surprised that anyone survived contact with it at all. If the dirt doesn’t kill you, the staff will (either on purpose, by incompetence, or by accident)…

If you look at the numbers, though, a different picture emerges. In 2011, the Commonwealth Fund produced a report on the health services of fourteen developed countries. The UK NHS ranked consistently highly for access to care and fewest errors – yet the UK was amongst the lower spenders on healthcare, as a percentage of GDP and on a per capita basis.

The numbers say that we have an effective, efficient healthcare service – yet that isn’t what the news reports say, and as a person who has worked in the NHS for more than a decade, continual negative news coverage destroys morale. No-one comments when the NHS does a good job – even when staff go above and beyond their duty to do their best for patients. No: that is taken for granted. As a healthcare professional, you are expected to devote not only the time you are paid for, but a lot of extra time (unpaid), to patient care. And you are expected to be happy about it.

Then, there are the ever increasing numbers of targets, coupled with funding cuts. Healthcare is inherently expensive. And the better we get at keeping people alive, the more expensive it gets. We have an increasingly elderly population – because people aren’t dying early, the way they used to. Cancer isn’t an automatic death sentence, the way it used to be. We can treat it – with expensive drugs. For instance, sunitinib, used to treat various tumours, costs over £3000 per pack of 28 x 50mg tablets. Without VAT.

Keeping people alive is expensive. Skilled healthcare professionals are expensive. If you want good staff, you have to pay them – or they’ll go and work elsewhere.

So you get to the point where reducing costs in order to hit targets means that you can only do it by reducing quality. This was brought out in the Francis Report which found that one of the major causes of the events at Mid-Staffordshire Hospital was the drive to hit politically imposed targets and cut costs. Staffing was cut to below the level at which safe care could be given; hitting targets was prioritised above providing effective care.

A simple example of concentrating on targets at the expense of care is that of the four-hour waiting time target in A&E. There are three ways you can ensure that you hit this target without doing anything about what the target is really meant to prevent (i.e., excessive waiting for healthcare):

1. See those patients who are about to ‘breach’ the target, even if someone else who arrived later is more seriously unwell.

2. Move the patients who have been waiting for nearly 4 hours out of A&E by admitting them to an ultra-short-stay ward, which you call something like ‘Clinical Decision Unit’ – created by partitioning off part of A&E. They’re still waiting, but since they’re not doing it in A&E, they don’t count.

3. Don’t let patients into A&E in the first place. The clock doesn’t start ticking until they come through the doors, so keep them out. Make them wait in ambulances until you’re good and ready.

In all three cases, you can meet your target, but patient care is not improved – in fact, it may be made worse, especially in cases (1) and (3). This type of target is the classic ‘easy’ target designed by people who don’t really know much about how healthcare really works. It only works at a superficial level – and it’s very easy to meet the target without dealing with the problem it is meant to solve. The problem is that because healthcare is a system, how some parts work depend on how other parts are working. A hospital only has a finite number of beds – so if an outbreak of diarrhoea and vomiting occurs, closing wards so that patients can’t be admitted, this has an impact on A&E, because the whole system clogs up. If you don’t have enough staff (and many A&E departments don’t) then you can’t see all the patients fast enough if you do the job properly – so you have to find workarounds and shortcuts instead.

If you are simply concentrating on targets, therefore, it’s sometimes actually easier to fudge the problem to achieve the target without doing anything about the more fundamental issues the target was supposed to track.

The thing is, fudging doesn’t make healthcare professionals happy. Nursing, for example, is not a job you do because of the mega status and the fantastic pay and benefits. At some level, you do actually have to like looking after people, because if you didn’t, it would probably be easier to get the same amount of pay doing something less messy – and in the case of A&E staff particularly, less likely to get you assaulted.

So how do we reach the Stafford situation, where the hospital was apparently staffed by uncaring, incompetent nurses?

Like A&E waiting time targets, it’s a more complicated problem than it looks. A large part of it – as the Francis Report recognised – is that without adequate staffing levels, you cannot expect to get good care. The University of Birmingham produced a report entitled Time to Care in 2011, pointing out exactly the same thing. Looking after people takes time. Nurses only get issued with the same 24 hours in every day (or 8-12 hours in every shift) as the rest of the human race. The fewer nurses you have, the less time there is for looking after people.

But that is only half of the problem. What about the accusations of nurses being hard, uncaring, and cold?

This, too, is a result of too many targets, and not enough time.

Firstly, and most simply, the more the system encourages you to think of your patient as the locus of a number of boxes to tick, targets to meet, and reports to write, the less likely you are to think of that patient as a person. Bureaucracy requires an inflexible mindset: fill in the forms, tick the boxes, follow the flow-chart. If you’ve done all the paperwork, then you’ve done your job – and you can’t be blamed for anything. Actual care, however, requires a completely different mindset. You have to think of the patient as an individual, with specific needs and views, and this requires flexible thinking.

Bureaucracy encourages you to think “If it isn’t documented then it hasn’t been done” – but the logical extension to this is “If it can’t be documented it’s not worth doing.” This is totally against the principles of actual care – smiling and making eye contact with a patient as you pass the bed takes hardly any time at all, but makes the patient feel like a person. However, if you are concentrated on meeting targets, then you avoid eye contact – firstly, because since there isn’t a box to tick about eye contact, there doesn’t seem to be a reason to do it, and secondly because making eye contact increases the risk of a conversation starting. And conversations with patients take time away from documentable tasks.

The more complex reason for nurses appearing, or becoming, uncaring, is emotional fatigue. Caring for people is stressful. It’s messy, sometimes frightening, often nauseating. But nurses have to deal with it, all shift, every working day. And they have to look happy about it. For nurses, just performing the tasks technically well is not enough: they have to make the patient feel looked after, and the only way for a nurse to do that is to put more of herself (or himself) into the job. The natural way to protect oneself from emotionally stressful situations we can’t avoid is to become emotionally distant – but we don’t want nurses to do that. We want nurses to be emotionally involved, so that the patient feels cared for. But what effect does this have on the nurses, who are deprived of one of their sanity-saving safety mechanisms?

Burnout.

If you are put in an emotionally stressful situation, day after day, with no way of letting off steam, no way to relax, and no way to just be yourself – you always have to pretend to be the one who’s in control, the one who’s happy to help, no matter how exhausted, frustrated, or just plain sick you are – then something breaks. If you keep giving yourself, day after day after day, sooner or later you run out of self to give.

And then you start to think – what is the point? You run yourself into the ground, for what? Nothing ever changes, nobody says “Thank you, you did a great job.” With too much to do, and too little time, it’s just so much easier to save a little of yourself for yourself. Don’t stay so long after shift; stop chatting to patients; do only what you have to do. Then maybe you’ll survive. Follow the rules – there are enough of them, enough to bury you. Above all, don’t look for problems. If you find a problem, you’ll have to deal with it – and you have too much to do anyway. So don’t talk to patients, don’t make eye contact, don’t see problems. Because if you have to do just one more extra thing this shift, you’ll break down and cry right there in the middle of the ward.

Then you reach a sort of cool calm. Do what you’re told. Do only what you’re told. Meet the targets. Fill in the paperwork. Leave your emotions and your initiative at home. It’s so much less stressful that way.

It’s a risk with any job that requires a high level of emotional investment, but people burn out faster if they also have to deal with a high workload through lack of staff, and unsympathetic managers who insist on meeting targets at the expense of ‘doing a good job’. After you’ve butted heads with someone who gets paid more than you a few times, you give up. It’s not worth it. You’ve done your best, and who could do more? If you can’t make changes, then just accept things the way they are and try not to see the bad parts.

Ethical passivity is another angle; healthcare professionals who are expected to follow lots of rules, and to hit lots of targets, tend to concentrate on the rules and targets at the expense of the patient. This is most noticeable when what is best for the patient, in the clinical care sense, conflicts with the rules. A work culture that is heavy on rules and targets tends to prioritise following the rules, even if this harms the patient. After all, the thinking goes, if you follow the rules you can’t be blamed. Whereas if you don’t follow the rules (even if what you are doing will avoid harming the patient) heads will roll.

So, what is the solution? Scrap all the targets?

No. Targets are good – but they must be the right target. And if a department, or an organisation, fails to meet the target, just imposing a financial penalty isn’t enough. That just encourages corner-cutting and before we know where we are, we’ll have another Mid-Staffordshire.

More, tougher, inspections?

No. Inspections can either be fudged (just like targets) or, if it’s known that the inspection will simply be about hunting for problems and casting blame, rather than looking at the reason for problems, it only creates further problems – particularly stress amongst employees, which can result in suicide.

It’s easy, when a scandal like Mid-Staffordshire happens, to simply blame the people most closely involved, discipline them or bring criminal charges, and then move on. It’s much harder to acknowledge that a scandal of that proportion is the result of much bigger problems – like an iceberg, 90% of the problem is below the surface. In order to prevent future icebergs, we cannot afford to cast blame then move on. We have to figure out why the iceberg formed in the first place, because if it hadn’t formed, it wouldn’t have drifted into a shipping lane.

We already have an excellent healthcare system; it can be made better. However, that will take attention to the causes of problems, not a sledgehammer approach of simply reducing budgets and expecting Trusts to ‘be more efficient’. We need to develop IT systems that actually work to communicate with each other; we need to employ the right number of staff so that patients get the care they need, and mistakes aren’t made because staff are overworked. We need to integrate better with social care so that people who can’t cope in their own houses aren’t left in acute care beds needed by other patients because they are waiting for a place in a residential home. And we – the patients – need to take more responsibility for our own healthcare. It’s telling that one of the countries with the highest life expectancy and the lowest spend on healthcare is Japan – and they also have one of the lowest rates of obesity.

The NHS belongs to all of us, and we can’t afford to have it damaged or destroyed, either taken apart by people who see the occasional scandals but not the everyday miracles, who pursue cost-cutting at the expense of quality, or destroyed from within as staff lose the will to carry on.

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