Staff surveys, both past and current, have all shown degrees of disengagement between staff and the organisation. Media coverage of the NHS tends to highlight the shortcomings of staff in their care and attentiveness towards patients. Other coverage paints the doom and gloom scenario of the economic climate, with which we are all familiar.
The NHS doesn’t seem a happy place. Yet, it must be the case that the vast majority of staff and patients interact with each other in a way that restores the health of patients.
Now the Mid-Staffs review is about to be published. This review has arisen because of the use of data that highlighted a number of patients who may have died unnecessarily or prematurely. The work of Dr Foster, the organisation issuing information about how the NHS is functioning, has been brilliant. Earlier work by John Yates was also brilliant in highlighting variations in outcomes of care by clinicians. My own work in the 1980′s provided some standards and policy guidelines against which measurement was made; prior to this period there was virtually nothing other than standards issued by voluntary organisations with special interests, and the Colleges.
Now there is an industry built around accreditation, monitoring and validating what people do in the NHS. The NHS seems to have followed the developments in the USA, Canada and Australia where this type of industry pre-dated the developments in the NHS by some years. The question has to be – has any of this industry made any difference to the care and standards that govern the delivery of healthcare?
There are two aspects of the interest in measurement that I find particularly interesting personally. One is the setting of standards themselves – who does it, what are they and do they directly link to improved or positive outcomes for patients? In other words, if the standards, and their related protocols, were followed, would they inevitably result in improved patient care?
The second aspect is related directly to the self interest of staff, particularly clinical staff.
I make the assumption that these staff are highly skilled, motivated to achieve the best for their patients and other clients, and have a self interest that is related to their imperative to do the best for their patients. Obviously there are shades of interest. I remember well discussing how my father could tolerate seeing 50 to 60 patients in outpatients – what kept him going? I discussed the same with my brother. What motivated them? Apart from the overt gratitude and relieved faces at receiving attentiveness to their plight, which is warming, both were on the look out for the harder to diagnose cases. In a batch of patients there was nearly always one that required the use of their clinical intelligence, perception, and reservoir of experience. Both didn’t often refer their patients on to others, unless it was obvious the case was beyond their expertise. Both delivered their services in the context of clinically determined standards. The buck stopped with them.
Things are different now. The massive industry surrounding the setting and monitoring of standards may have the impact of diluting personal responsibility. It is part of the human condition to baulk at having to do something that we feel isn’t helpful. all forms of rules and regulations create an adverse response unless they are viewed by us as being helpful, sensible and worth applying. If the NHS produces better outcomes now than without the introduction of the standards industry then this would be testament to the validity of overtly stated standards. Alas, the NHS appears to have slipped down the international league table of improving outcomes across the board.
We are, no doubt, going to have more rules and regulations as a result of the Mid Staffs Enquiry. Will this improve the outcomes for patients? Probably, but from a low baseline that started to slide since the standards industry was established. In other words, be are piling another set of standards on a previous set that probably had the damning impact of dis-engaging staff from taking responsibility in the first place.
I personally like the approach on ‘comply or explain’ in relation to standards. My own Manager’s Code, developed to introduce a means of changing behaviour of managers to adopt those behaviours that provoke commitment, trust and engagement, was and is an enabling Code. One that requires managers to comply or explain; not one that condemns managers who deviate from the code, but one that seeks to engage managers in explaining why they do not follow the behaviours suggested.
I believe such an approach will produce a shift back to individuals taking personal responsibility for their actions, and be seen as enabling improvement rather than being seen as regulations that provoke a negative and possibly hostile reaction.
But there has to be more to it than a simple shift of emphasis.
The fundamental challenge in the NHS is the conflicting ideologies of the professional and the bureaucrat. The professional is concerned for the individual, whilst the bureaucrat is concerned for all individuals. Efforts over the years to blend the ideologies together within the umbrella of the NHS have had some success, but we know from the Mid Staffs situation that it is three professionals in a bureaucratic role who are selected to be interrogated further by their professional bodies. The initiatives often called clinicians in management have been seen to be a way of engaging clinicians in the management of services. It works elsewhere, notably in the USA where there has been a much longer lasting culture based on the commercial imperatives of the health services, something the NHS hasn’t had. It is time, I believe, to call a halt to this form of blending the ideologies and to think again.
My own belief is that people who are self employed have a very intense focus on personal responsibility, and are passionate about being custodians of professional standards within a professional framework often described as a Code of Conduct. We see this amongst independent social workers, independent psychologists, general practitioners and many others outside the healthcare industry. It’s not the answer to everything, of course, as there are thousands of employed staff who, also, keep their heads down and focus on delivering extremely high standards. But, there is an imperative that drives professional staff to deliver high standards when they stand on their own, and have to comply or explain their actions in relation to a Code of some kind, as opposed to following standards and protocols that diminish their capacity to exercise discretion.
So the NHS could be staffed in two ways. Staff who are inclined to work within defined protocols, and staff who are inclined to work under a Code or Codes of Conduct. The former group could be employed, as they can easily be held accountable for the delivery of protocols, whilst the latter group could be self employed, in constant danger of losing their income if they do not comply or explain their actions adequately under a Code. Enabling Codes facilitate the use of professional discretion, and provide the space for innovation, development and lateral thinking, so long as actions can be explained. This plays directly to self interest of professionals who are driven to do the very best they can for their patients and clients.
Currently I don’t see the NHS as facilitating professional self interest as part of its mainstream activities. It seems to be facilitating bureaucratic self interest. In this respect the NHS does seem to be letting its staff down.