How many of us feel the culture in the NHS brings out the best in us? Judging from the majority of staff surveys, not many.
I happen to think this matters enormously. Staff really are the greatest asset to any organisation, especially an organisation where caring is a fundamental part of the task. Creating the conditions within which they can thrive and attend to patients is vital. It seems we pay lip service to this obvious truth, but undermine the few positive initiatives around, with a relentless, unthinkingly applied “more for less” philosophy, out of touch top down management, and knee-jerk reactions to risk that result in a level of entangling bureaucracy not so far removed from the Politburo.
Of course, there are islands of good practice where patients’ needs predominate and the anxiety generated by the drivers listed above are minimised. Even in the Mid-Staffordshire hospitals, the Francis Report contrasts the worst examples of inhumanity with the caring culture evident in some other wards. Most of us would agree that a benevolent culture of care is important. Many of us indeed, work hard to show kindness to our patients and encourage compassion in our students and trainees; and some of us are even proud of the caring environment we have been part of creating in our surgeries, on our wards, or in our teams. But very few of us, I suspect, would describe today’s NHS as promoting a kind, thoughtful attitude to the work.
Like many doctors—perhaps particularly those who go in to Cinderella specialties like psychiatry—I went in wanting to make a difference, and not just to individual patients. There were such obvious inhumanities in the system that needed changing. Previous generations of psychiatrists had been inspirational, leading drives to unlock asylum wards, get rid of straight-jackets, and liberalise mental health legislation. I wanted to leave a better service behind me and believed progress was inevitable. Twenty years as a consultant has been a steep learning curve. It’s not easy to organise the delivery of humane care. Caring cultures take years of hard work to build, followed by sustained attention of the right kind. Even then, they can be destroyed overnight.
Anyone not clear what is meant by healthcare culture or doubting its importance should read the original 2010 Francis Report on standards of care in the Mid-Staffordshire Trust. This describes in stark detail a culture that had degenerated to the point where it had indisputable negative effects on patients, including for many untimely death in squalid circumstances. Contrast this to a culture where the commitment, intelligence, and goodwill of front-line staff are recognised and fostered, and where attention and resources are constantly focused on meeting patients’ needs and on solving problems. The way in which tasks, priorities, anxieties, and relationships are viewed and managed makes up the culture of an organisation and this in turn influences our attitudes, emotions, and practice. There is also a sense in which everyone internalises a version of the organisation, building up a kind of internal working model—”the organisation in the mind”—part conscious, part unconscious, which profoundly colours their experience, how they understand their tasks, manage themselves in their roles, and work with others.
As we try to make the best of the massive structural reforms enshrined in the Health and Social Care Act, there seems to be increasing awareness that what really needs to change is the culture of healthcare. This is reflected in a number of campaigns and work streams within the colleges, the Department of Health, and the King’s Fund focused on improving patients’ experience and addressing issues such as compassion, kindness, and dignity—not to mention the recent emergence of websites and single issue campaigning organisations such as Roger Youngson’s Hearts in Healthcare. To quote Chris Ham, chief executive of the King’s Fund: “If the culture does not change in the next 5 years all the fuss around the reforms will not have been worth one iota. The NHS needs to put the patients at the centre of care and clinicians much more in control of how the service runs”
Understanding what promotes and indeed what hinders a compassionate healthcare culture feels increasingly important as we struggle to accept how bad things have got in some areas and respond with intelligence to the Francis Report and other enquiries. Fortunately, there is a whole body of literature and research from disciplines outside medicine that throw light on the issue and I shall be exploring this in future blogs.
Penny Campling is a psychiatrist and psychotherapist and was a clinical director for many years. She has recently co-written a book entitled “Intelligent Kindness: reforming the culture of healthcare.”