What would Mary Seacole
and Florence Nightingale
make of the modern NHS?
Albert Charles Challen
Perhaps a hospital admission will always be nerve-racking. However, the fresh wave of NHS scandal that has hit as a result of the Stafford inquiry may leave patients choosing to take two paracetamol and hope for the best, rather than seek treatment. Media reports combine harrowing descriptions of the patients who suffered, with passionate calls for accountability. Much of the focus has been on the difficulties staff had in reporting incidents and the failure of an effective whistle-blowing system. What is missing from this account is a convincing explanation of how such incidents occur in the first place.
It is undoubtedly true that pressure on the NHS to cut costs can sometimes lead to a drop in standards of care. It’s striking, though, that much of the inquiry describes staff neglecting to attend to things as basic as putting a glass of water within a patient's reach, or responding to cries of pain. Such things are not easily justified by budget cuts. The only explanations given for such incidents are that staff are either bad people, indifferent to the suffering of others, or that they require training in ‘compassion’.
I wonder, though, if this is convincing. What if we assume instead that the vast majority of people who go into caring professions actually have genuine motivations and understand the importance of basic human needs? Can we understand why a good person, with adequate knowledge and skills, might fail to provide a basic level of patient care?
Research into the treatment of inpatients suggests that much can be gained from talking to staff, not just about poor care they have witnessed or their own attempts to report incidents, but about their experiences of the job, and about how they see their role in relation to patients. I’d suggest there is sometimes conflict between the requirements of a ‘medical’ setting and engaging on a more human level with patients. In 1960, Isabel Menzies Lyth's ground-breaking study into the nursing profession identified a number of features of medicalised settings. Primarily, she suggested that caring professionals can depersonalise patients, for fear of coming too closely into contact with the pain of others. She found that some nurses even referred to patients by ailment alone (‘the liver in bed 10’). While staff may have moved on from this, it is likely that the fear remains and that distancing strategies have merely changed shape.
Medical professionals I know clearly value the ability to distance themselves from suffering, arguing that it’s sometimes the only way to protect yourself enough to do the job. And perhaps they have a point. Spending day after day working with people who are ill or dying would make most people cut off a bit. The assumption seems to be that connecting on an emotional level with suffering will be overwhelming, potentially dangerous for the mental health of the practitioner and, by extension, for the physical health of the patient. But if the pay-off from this strategy is a culture in which some staff can become distanced and indifferent, surely a better solution is needed.
The cultural assumption within the NHS - that detaching oneself from one's own experience of the role is the only way to carry it out - may need to be challenged. If staff were supported and encouraged to reflect on the demands of the job, the need for such distancing strategies could be reduced. My experience has been that the anxiety felt by staff is silenced: both within everyday professional roles, as well as in the surrounding whistle-blowing attempts. If anxiety cannot be spoken about, it will continue to grow until staff either leave or begin to compromise standards of care.
There are also extra pressures raised by the current economic context. With increasing emphasis being placed on meeting targets and threats of job losses or service closures in the case of failure, engagement with patients is likely to be relegated even further down the list, as the completion of audited tasks is prioritised. It is no wonder that the response of NHS employees in the wake of scandals such as Stafford is to find someone to blame, be it other staff, management or government policy. Staff may feel increasingly powerless in their jobs, forced as they are to respond to top-down policy changes and decisions about what their roles should involve.
The challenge we face is how to understand what drives scandals and how to stop them. The debate about failures in care seems stuck with either ‘staff don't know enough’, or ‘staff don't care enough’. However, the pressures surrounding the caring professions sometimes mean that problematic cultures and practices will develop, even when people do know enough and care quite a lot. I wonder if it’s possible to work with the psychological and organisational obstacles to fully engaged, compassionate support within today's ward environments. Perhaps this would be a worthy alternative to simply deciding who should get the sack.