I think about this complex topic a lot because I frequently hear from, or meet with, staff and public who raise concerns about care quality. Francis links it to culture, but it remains difficult to understand ‘why’ we have a problem. Until we do understand this, solutions will continue to elude us.
We know that most hospital staff are competent and compassionate, and we know that staff who feel valued and supported will deliver good care. We also know from staff surveys that morale is low and that somehow, the system all too often acts to demotivate and disengage the staff who work within it.
Sometimes, the impact of this demoralisation overcomes individual professionalism, and care problems occur. Doctors, nurses, and managers can all reach this ‘tipping point’, and we need to think through why it occurs.
I suggest there are three overlapping, contributory factors…
The rise of managerialism
The introduction of managers into the NHS was never effectively sold to either staff or public. We know that ‘nature abhors a vacuum’ so, without a convincing narrative, front line culture filled the gap with reasons that were not always positive. Consequently, managers have always struggled to establish their legitimacy. Indeed, years later politicians still see the ‘reduce bureaucracy’ line at election time as a vote winner.
Targets and performance culture
Targets were introduced to address failings in access times, trolley waits outside A&E departments, and rising healthcare-acquired infections. All were priorities at the time but a narrative was again lacking which meant that, even today, most front line staff believe the 4hr target to be about politics rather than patient care. This created a ‘values divide’ between staff caring for patients, and managers tasked with delivering the target, that persists to this day.
Matters worsened as central performance management strengthened. The 4hr target in particular came to be seen as a measure of ‘good governance’ and therefore had to be delivered at all costs. Boards were now driven by different priorities than front line staff, with targets dominating however much they talked quality. Downward pressure meant that sometimes measures were implemented that ‘hit the target and missed the point’, further diminishing the authority of local management.
Growing pressure on hospitals
Hospitals have got hugely busier over the years, and the work is more demanding and more relentless. With shorter lengths of stay, a higher proportion of patients are very ill, requiring more intensive care and support. The communal day rooms of my junior doctor days, where most patients ate meals at table together, have gone because few patients are now well enough to use them.
While designed to provide acute care, hospitals have become the default option for the entire system. All other providers close at times, while hospitals remain open, even when full. Consequently, the elderly in particular are admitted because the support needed to allow them to cope at home is not available quickly enough – acute illness is often not the real reason.
Another factor is the continual push to reduce capacity, even though there has so far been no ramping up of alternative means of supporting people elsewhere. Commissioners see hospitals as ‘the problem’, hence the bizarre policy of reducing the acute tariff by 70%, when in fact it is the entire system of care they are responsible for that has not kept pace with changing demography.
The net effect on front line staff is more patients who are more ill and with more complex needs than ever before, staffing levels that haven’t kept pace with this, and frequent crises caused by spikes in activity against a background of nearly 100% bed occupancy.
Of course there are counter-arguments to elements of this analysis, but I believe it will resonate with many who are feeling very criticised this week. Those of us who run the NHS have failed to create alignment with our staff, based on agreed common values and priorities – the crucial ‘shared purpose’ of the excellent NHS Change Model. Until we achieve this, the culture change Francis describes will not happen and we risk pockets of poor care from the few whose professionalism slips in the face of daily pressure and disengagement from the system in which they work.
Some obvious solutions follow logically from the above, and in my next blog I will discuss some practical approaches we might try in order to bring about the cultural change that many of us feel is long overdue.
Courtesy of Mark Newbold