How refreshing to see a national report talk about emotions.
Crucial to future policy making, independent and commissioned by the government, Lord Darzi’s Independent Investigation on the NHS in England made for stark reading recently and covered a great deal of ground. Notably, alongside the graphs and quantitative data, it gave voice to the feelings of clinicians who report working harder in a system that isn’t functioning well. It describes what this means in practise, the wasted time and resulting feelings of disempowerment and disconnection from a shared purpose. It also made clear that patient voice is not loud enough in the system, evidenced strongly through lack of sufficient response and respect, as detailed in a number of safety inquiries.
Although tough, the inclusion of how people feel about the last few years is important. In my 15 years working in national policy, people, with their myriad vulnerabilities, defences, reactions and needs, are not always central to the conversations at this level. I was inspired in 2018 by Julie Unwin’s work on kindness, emotions and human relationships as a blind spot in public policy, but this hasn’t become the norm.
Yet seeing this laid bare also came with sadness for me personally, not just reflecting on where we are but also how this narrative could mask some of the great work happening all over the NHS (whilst also importantly clarifying how the system is not getting the result it aims for - hence 'broken'). But mainly because I spent five years working on the national patient safety campaign, Sign up to Safety. We ended that with a simple message that summarised all that we had heard and learned from talking continuously to those doing the work providing healthcare services: safer care is only possible if you care for those who care for others.
Despite our efforts to make this case and communicate it clearly then, work has become even harder and people feel less cared for then ever in the system due to numerous pressures, not least shown through months of strikes. I know first-hand how hard senior leaders at a local level have been working and how concerned they have been for their staff. This report then also comes with a sense of responsibility and mix of feelings for me, that despite the effort, we are where we are.
The truth is people and their emotions isn’t a constant consideration in how the whole system is designed. This is despite credit due to the NHS England Patient Safety team whose NHS Patient Safety Strategy in 2019 reflected the same shifts in understanding and learning about safety that we experienced at the campaign, baking this into policy, and in spite of other advances such as the People Plan - as well as concern from many trust leaders who would agree with Sir Jim Mackey who wrote in 2020 that “Our people are at the heart of what we do and without keeping them well, happy and motivated, we cannot continue to provide high-quality, compassionate care for our patients”.
Now could be the chance to change that. Despite its challenge, this report also comes with hope for positive change. The team focused on developing the upcoming Ten-year Plan can take this opportunity to systemise what we learned during Sign up to Safety, and what human factors and ergonomics experts have known for many years. That systems need to be designed with human needs in mind or the lack of meeting those needs creates risk and undermines the outcomes we all want to see.
What could this look like?
The post-Messenger work on leadership and management could operationalise the form of leadership at a national level acknowledged and evidenced as providing wide ranging benefits to staff and patients, by experts such as Michael West. Valuing staff and supporting them to work in ways that not only protect their personal well-being but their ability to nurture positive team dynamics, and make unimpaired judgements when faced with pressure and complexity, are important to safe outcomes. It is not something that can be tokenistic, nor programmatic like Sign up to Safety, but is instead a way of functioning for the whole. It not only needs to be systemised but needs leadership and management development and support to maintain it so it isn't sidelined amongst the anxiety-inducing realities of a highly scrutinised, high risk, safety critical industry. How do other, similar, systems do this?
We could all better capitalise on the expertise in human factors and ergonomics, and large-scale change expertise in the NHS such as the Clinical Human Factors Group (disclaimer – I’m a trustee) and Q Community. The potential to learn from their expertise in designing systems that support human performance and improve the interaction between people and tech is huge. This is needed. As noted in response to the investigation by Pritesh Mistry, Fellow in Digital Technologies at the King’s Fund “…technology seems to add to clinician workload. Exacerbated by staff not having the skills, capability or agency to solve technologically generated problems instead they are distracted by them when trying to provide care. [The] Theme of staff engagement should have a focus here.” How can those with this knowledge help in the coming months?
The report also calls for a move towards prevention, rightly. Couldn’t we also include here a systematic approach to the prevention of burn out, errors from exhaustion, lack of access to food and rest, too much fear and blame, and even suicide, for NHS staff at all levels? With over 1.3 million staff, preventing ill-health and protecting physical and mental health and wellbeing is a win win, as well as a moral imperative. We know what helps people perform well - see decades of research, and at the least Maslow's Hierarchy of Needs - and people will tell you what they need if you listen and take action as a result. What could we borrow from audience research approaches in other industries (like advertising and marketing) when it comes to listening at scale to identify patterns and trends, and to build and sustain trust?
Before we even get to implementation of policy recommendations, I would argue we need to restore relationships. There is much to be learned from the concepts of restorative justice – Who is hurt? What do they need? Whose responsibility is it to meet that need? (cite Dekker) – to help draw a line under the pandemic and difficult years and enable those working in such a challenged system to move on with motivation and hope. Let’s find out the answers to these questions and use these to create a system designed for what we hope to see – motivated, valued, innovative people who can work to the top of their skill set and collaborate towards change.
Really though, this is a mindset or even just a 'simple rule'. “Systems” don’t actually exist. It’s just how we make sense of a group of people relating to each other and the world around them. Systems are only judged as effective or not by people making that judgement. Simply think about those people, the impact of changes on them, and where they are right now in their motivation, energy, emotions.
Looking ahead, we need to be aware that the emotional component in all this isn’t going to go away as we seek to support the system to recover from being ‘broken’. Emotive language is being used and emotions being triggered. Even with the best of intentions, those designing the work to come from Darzi’s Investigation into the NHS should heed the realities of the last few years. Let’s not repeat what we saw when the national system moved with speed from responding to a dynamic pandemic at full pelt, to setting expectations for providers to tackle the backlog, with not a moment to draw breath.
Experience (and a year studying psychodynamics) shows me that it is at times of pressure when our defences and anxieties really show. The reality is that a complex system like healthcare is fraught with the unpredictable and unintended consequences. Let’s recognise the human frailties we all share, restore relationships and bake in sufficient, systemised and evidence-based support for those working regularly with that pressure to help us all achieve the outcomes we want.
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