High Stress and Low Productivity in the NHS ("mens sana in corporatione sana")

High stress and low productivity in the NHS: cause and effect, or the same thing?

(“Those who misunderstand the objective task are destined to inefficiency and disappointment” – Otto Fenichel, psychoanalytic writer)

E-mails written well after normal hours at work should really be saved and carefully edited on coming into the office the next morning, such is the effect of one’s circadian rhythm on the internal editor who polices and inhibits what we say.  It was in this twilight zone of impaired self-censorship that a junior member of staff looked up from her keyboard and said “you know, we’re really all on the edge of a collective nervous breakdown”.  Strangely, or perhaps not strangely at all, a senior official in the National Association of Probation Officers had used the very same expression in a piece in the Independent on the very same day.  Whether the fact that one’s tribulations and pressures are shared by colleagues in every corner of the public sector, and often described using the same metaphors, should be a source of consolation or of alarm that we are about to be overwhelmed by a current that even governments can’t stem is a tricky question.  Maybe it’s possible to be consoled and alarmed at the same time. Whatever.

A couple of days later in the cinema I watched in shock as Gabriel Oak (the still but pivotal centre of Hardy’s Far from the Madding Crowd) woke to see his faithful collie, spooked by a canine dream maybe, drive his prized flock of sheep over a sheer Dorset cliff on to the shingle far below.   Allegory can be over-egged, of course, but the public sector is metaphorically in the throes of a comparable disaster: if there is no organising mind which can temper instinct or, let’s say, ideology and self-interest, and understands the wider vista of landscape, the changing but constant seasons and, if you like, the objective task, there is big trouble ahead.

The NHS, perhaps especially in the field of mental health where leaderlessness, defensive anxiety and infinitely elastic demand converge, heads for nameless calamity which only the application of radical, apolitical and truly disinterested common sense will reverse.  Its fatal failings are cognitive, cultural and, no surprise here, capitalistic.

First, treating, managing and minimising the effects of mental ill health are simple and fairly straightforward, though self-evidently not always easy to achieve.  It is, though, important when considering these activities to set to one side the question of what the causes or catalysts of mental ill health may be. If you are the parent of a young adult son with a pernicious and disabling form of paranoid schizophrenia, or the sufferer yourself of a long-standing nightmarish version of depression interleaved with intolerable anxiety, your primary concern is with whatever treatment will bring durable relief and protection from the premature death to which both conditions have a habit of leading.   

There are unavoidable complexities, of course, but these are mainly technical and ethical ones.  Schizophrenia and depression, for example, are clunky, creaking constructs which bracket a wide spectrum of only loosely related conditions which, largely because of key genetic factors, respond very differently to different medications.  Pharmacogenetics, the study of the influence of DNA on individual responses to particular drugs, will eventually indicate precisely which medication should be prescribed to which patient but in the meantime they are subjected to a messy form of trial and error which may last for years.  This, incidentally, is compounded by the promotion of newer and therefore more expensive psychotropic drugs by pharmaceutical companies when, for many patients, older and virtually free versions were much more effective.  The bias in favour of certain forms of psychotherapy, mainly but not exclusively CBT, will in time be corrected so that more toxic, non-reactive forms of depression are properly, pharmacologically treated.

For now, though, the inexact, speculative nature of mental health practice, in which many, perhaps even the majority, of patients remain troubled and often troubling because of the extent and degree of their symptoms, often throws up tricky ethical rather than clinical dilemmas.  Typically, these are about how assertively to intervene, when to use coercion and how broadly and invasively, how to balance the conflicting rights of society and the individual, where the threshold for acceptable risk to the individual or others should be, where self-determination should give way to enforcement, and so on.

Perceptive, clear-thinking, open-minded clinical staff with an exact understanding of the objective task, both for their institution and the world outside it, however, will over time learn to simplify, that is, to distil and discern simple principles and essentials of effective clinical care and treatment. The medium for the transmission of such treatment is still, in mental health at any rate, the therapeutic relationship although the machine which is gradually being constructed from the centre is geared towards eliminating the personal and interactive, leaving staff to be conduits for the official message.  In the meantime, clinical work with patients is, very much like driving a car - truly and essentially a simple matter.  That is to say, the necessary, individual parts of the activity are at first alien and therefore seemingly tricky, require a great deal of practice, often under supervision, but with the right attitude and aptitude eventually turn out to be relatively straightforward and, were the counters and churners interested, measurable.

 

Secondly, this demanding and stretching work which over time can be mastered, though never completely, and which brings real rewards and, most important, a sense of satisfaction, has been colonised by the market – not explicitly so much as by infiltrating the minds of those in positions of influence on the inside.  Privatising some discrete activities or services is neither here nor there – it is the relentless and insidious persuasion of those who determine the culture of the service that there is no other way: that a supervisory superstructure must continue to metastasise until some vague utopia is eventually achieved.  The continuing failure of this position (part cognitive, part economic and part, even, psychological) is then both seen and portrayed as evidence that much more of the same is needed – rather than systematic deconstruction.    It is now sealed by the fantastic excesses of the CQC, a lumbering organisation fatally blinded by one simple logical error – that of mistaking the presence of any number of sine qua non (that is, factors required for a safe and effective service) for actual proof of safety and effectiveness. 

 

An inevitable consequence of an entity’s immune system being impaired or under pressure is that external organisms exploit weaknesses or gaps and begin to establish a foothold and then to colonise territory.  The infiltration of the NHS by the market is a perfect example of this process and the preoccupations of the Health Service Journal (HSJ), for “healthcare leaders” a telling illustration of how it works in practice. Each edition gives over several of its pages (sandwiched by a few token paragraphs of news and a dwindling number of ads for jobs such as “Director of Organisational Development and People”) to private companies promoting their particular product or interest, sometimes in the form of “sponsored comment”.  Recently they have included CSC, “a provider of consulting and outsourcing solutions”, and Incisive Health, “the new force in health policy and communications”.  In the wake of these were articles from BMI Healthcare, GE Healthcare, Gooroo (sic), AbbVie, Managers in Partnership and so on. 

 

Occasionally, the HSJ brings together groups of NHS and private sector “experts” to bear down on the seemingly intractable problems of the state health service.  13 of them recently took a day to consider “how the health service could become more efficient”.  One consultant concluded with a query: “where is the system leadership and management bandwidth going to be to drive this forward?” – a probing question which may well not be among those taxing a band 5 nurse finding herself in charge of twelve disturbed male patients in an inner London lock-up on a Saturday evening. Still, he received a prompt response from a fellow-expert who answered with a plea for “investment in benchmarking and transformation”, activities in which no doubt his company happened to be the leading experts.

 

Thirdly, staff are overwhelmed, if not quite persecuted, by the egregious excesses of investigations into the inevitable failings and mistakes of what largely remains, still, human behaviour, the expansionism of technology still having a way to go.  The Francis Report, sadly, is the locus classicus of such inquiries, with its 290 (sic) recommendations.  Such reports are contaminated by some simple errors of thinking: first, that procedural change necessarily leads to clinical or behavioural change; secondly, that more means better – i.e. that the number and weight of recommendations are an indicator of thoroughness and wisdom; and thirdly, the automatic assumption that the opportunity costs of massive organisational and administrative upheaval are easily trumped by their benefits. 

 

Psychologically, the effects on staff of their threatening prolixity are wide-ranging and profound.  It leaves them feeling incompetent (“I must be so bad at my job”), impotent (“there are so many new things I have to do and I will never have the time to do them”), deskilled (“there are important outsiders who really know how the job should be done”), fearful (“what incident which may jeopardise my career is waiting around the corner”)  and in a state of Seligman’s learned helplessness in the face of repeated, random, aversive stimuli.

 

Stress and low productivity are on the same coin in the clinical currency of a systemic territory in which senior leaders, for all their protests otherwise, implement the competing imperatives and language of others (which, in the tradition of a malfunctioning system, are simply passed down the line) instead of sorting them in such a way that the end product of whatever service they are providing is continually improved.  And somewhere in this muddle is a blindness to the true nature of the product or possibly, even, a belief that the concept of a product is irrelevant or tainted in some way, the inevitable, destructive consequence of which is that activity and means become ends in themselves. 

 

Systemic mess needs systemic thinking. That is to say, going straight to solutions will simply tighten the problem. First, work should be done to reach agreed truths, which will lead naturally to certain consequences or conclusions.

 

A summary of ideas which could form part of a discussion about systemic truths in the NHS would run something like this.

 

• The right people are in the wrong place [the best brains have the least contact with patients]
• The less contact a member of staff has with patients, the higher his or her status is likely to be
• Careerism is rewarded at the expense of vocation [“moving away” is prized above “staying with”]
• Mission drift is fatal to most enterprises [the imperative of “treating illness” has been trumped by diffuse, shifting concepts such as “promoting recovery”]
• Internally driven agendas overrun the unique agendas of individual patients [ these are mainly promoted by governments and commissioners who are deceived by the fantasy that mandate is the best way to change clinical behaviour]
• More services create more work for other services [paradoxically, new services such as IAPT generate extra work for established services such as mental health teams in the community; this is because morbidity, pathology and need are highly elastic concepts which are stretched by a complex interplay of factors]
• Symbolic demonstration of competence, effectiveness or modernity tends to generate massive opportunity costs [this is usually in the form of “mandatory training” – a massive and inexcusable drain on resources – or the levering in of specialists or experts, such as so-called “lead professionals”, patient and carer development workers, and so on; often they are very able and diligent staff keen to demonstrate the wide-ranging nature and importance of their particular role, an approach which consumes clinical time without corresponding clinical improvement]
• It is always possible to do a better job with fewer staff: more does not necessarily mean better
• Productive, stress-lite organisations blend clarity about a central organisational goal and operational prescriptiveness with scope for autonomy, initiative and creativity [unproductive, inefficient organisations tend to have cells which identify with their own local goal which additionally leads to conflict and wasteful disagreement along boundaries]
• Organic change (i.e change derived upwards from clinical activity, experience and need) must nevertheless be imposed from above
• Productivity is among the first casualties of a failure to prioritise the competing demands which come externally from government, pressure groups and commissioners, and internally from patients
• Inspectorial bodies and commissioners mistake the presence of the sine qua non of an excellent, effective service with proof of the excellence and effectiveness of that service [this distorts focus and confuses staff about imperatives]