I retired from the NHS on Friday the 1st of March. I had worked initially as a sessional Psychotherapist for an individual GP Practice and following the formation of the Primary Care Trusts in 1984 joined a managed Counselling Service. I retired not simply because I had reached retirement age but because the levels of stress being placed on clinicians was becoming intolerable.
I had been encouraged to write about my experience of the new NHS by friends as soon as I had decided to retire and had thought it might be of some interest but events in the media have changed my feelings about this. First of all there was the publication of the Francis Report and then the trial and conviction of Nicola Edgington. You may remember Ms Edginton was a diagnosed schizophrenic who had previously murdered her mother. She had contacted mental health services because she was experiencing a return of her symptoms. She was not admitted and a few days later semi-decapitated a woman in a car park. Marjorie Wallace of Sane when referring to the latter pointed out that if a woman who had a diagnosis of schizophrenia that resulted in her murdering her mother could not be contained in a safe and secure environment then what hope for all the more common patients who present no risk to others. However, they may pose a considerable risk to themselves. This immediately links these two separate events to a failure of care within the NHS.
Does this mean that clinical staff within the NHS too often don’t care about their patients? Do we have a new breed of staff who just want to do the minimum and take home their inflated salaries and wait for their over generous pensions? In my experience neither of these statements are true. Of course there will be clinical staff who fall below standards of what we should rightly expect but from what I have observed these are few and far between. The vast majority are deeply committed to their patients and try to do their best for them. I can only speak from direct experience about Mental Health Services but the culture in which they are run can be applied to aspects of the NHS.
So what has happened to care? Before I offer my thoughts on this perhaps it is important to think about the NHS as an institution. I was born in 1948 and have never known a world without it. I take it for granted, quite rightly I believe, that it will take care of me and the nation from cradle to grave. It is a monolith and considering that of all public services it is the one that the vast majority of citizens will have experience of. Even those with private health insurance mainly use an NHS GP service. Yet it lacks the accountability that local authority services have by being run by elected members. It is only accountable nationally. However, many attempts to devolve to a more local level have made the situation worse.
This stems from the philosophy of the internal market that was introduced in the Thatcher era and taken up and advanced, sadly, by the Blair Government. This has led to money washing around and creating credits and deficits all over the place. What is much worse, however, is how it pits Trust against Trust with individual organisations vying with each other for contracts. The language is of commerce not health. In corporate speak we now hear mainly about customers and not patients. Patients are lumped in with anyone that has dealings with the NHS. I worked for Central London Community Healthcare Trust which provides clinical services in Primary Care to the London Boroughs of Hammersmith, Kensington and Chelsea, Westminster and Barnet. On their launch they trumpeted in a staff wide email that they wished to be like CocaCola and Disney. Not what I wanted to hear about an organisation that was going to be providing fundamental and vital services to people who could often be very vulnerable and not empowered.
There has subsequently been a drive to obtain Foundation Trust status which is the so called gold standard. This partly involves showing the organisation being financially viable ie having a healthy bank balance. This is achieved by making year on year cuts so saying there are no NHS cuts is just not true. This in itself can have an impact on clinicians’ ability to care as their patient load increases but the added factor which is making a significant impact on clinicians ability to care is data! Data is needed to obtain and I presume retain Foundation Trust status. I remember at one team meeting we were told, “You are not producing enough data!”.
The collection of data is inextricably linked to targets and outcomes and much is misleading to the point of being clinically fraudulent. The Labour Government were obsessed by targets. My belief is that they were determined to show that they were not Old Labour who just spent willy nilly and couldn’t be trusted with the economy which has reared its ugly head again following world financial collapse. The Conservatives promised before the election that they would do away with this culture. On the contrary, since they have been in power the amount of data required to be collected appears to be increasing on a monthly basis.
The philosophy now is that if it hasn’t been recorded it never happened! Much of this stems from that awful phrase of John Reid’s, “Fit for purpose”. The need to ‘prove’ that you are doing the work of course means that it takes away from time to actually do the work. However, in many instances this leads to a pile up of admin and little or no time to actually think or reflect on the work. This reduces everything down to a task. I would propose that caring is beyond a task it is a state of being with patients. Staff and patients in the NHS come well below the requirement to provide data. You can record that you have done a task but how do you record meaningfully that you have done it in a caring fashion? Patients are also asked to fill satisfaction questionnaires for most services they receive. I cannot speak for Secondary Care but this is becoming the norm for Primary Care.
If you transpose this to staff on a ward they may have to record that they have delivered food to a patient and at what time but how can we tell how that food was delivered? If staff are under pressure to fill in forms they will have to log in to their computers . The computer most likely will have logged them off because they have been away for twenty minutes doing clinical work. Therefore what becomes uppermost in the mind of the staff is the admin and not the patient because this is what will get them grief from their managers.
At the last staff meeting I attended we were handed a sheet of paper that was merely a series of numbers and could have been about anything. These numbers contained nothing about the highly skilled and dedicated work of the clinicians but represented response times, length of treatment (too long is bad) and recovery rates. Mental Health is highly complex and it is increasingly being reduced to simplistic diagnoses which are always highly subjective anyway.
Whilst I am all for accountability and high professional standards the monitoring and evaluation takes precedence over all. Treatment within the NHS is becoming increasingly burdened by clinical governance and manualised treatments. Staff are reprimanded for stepping outside these protocols. By its very nature care involves stepping outside these boundaries and is what used to be called,”Going the extra mile”. No one is going to do that if they fear that they will be disciplined for it. It is my belief that it isn’t that clinicians don’t care but the systems and structure make it extremely difficult.