3 Aug, 12 | by BMJ
I recently attended a symposium at the Tavistock Clinic entitled Cultures of Care: Cruelty and Kindness. As the Tavistock is a psychoanalytic institution, there was a lot of focus on understanding the problem and the discussion was complex and challenging with the shameful examples of Mid-Staffordshire, Winterbourne View and the Care Quality Commission’s report on the elderly to keep us grounded in reality.
A presentation on the work of the Commission on Improving Dignity in Care for Older People made it very clear that high quality care is about valuing front-line staff who will then go the extra mile for patients. Common sense, you might think, but why so difficult to enshrine in practice? The presentation was sensible and humane but there was some frustration that it didn’t really get to grips with what goes wrong. After all, there are countless documents that advise about good practice; the real challenge is to understand why such very sensible ‘lists’ don’t translate into more compassionate care?
One response to this is to think about how, and how adequately, we process anxiety in the system. Healthcare workers are constantly in touch with existential anxieties that trigger our most primitive feelings – including rage and fear linked to madness, decay and death. If this is not worked through adequately, not only do the individual staff members suffer, but the whole system becomes dysfunctional. This in turn causes more anxiety for individuals which feeds a vicious circle. Healthcare organisations then become driven by a frantic attempt to distance anxiety and deny reality. We see this in the compulsive re-organisations and reactive policy initiatives that overwhelm the system, but also the failures, for example, to address the needs of an aging population and engage more sensitively with the reality of death.
We then heard from Dympna Cunnane, who combines being a Jungian analyst with being a consultant to organisations and programme director at the London Business School. Dympna was able to make comparisons between the Health Service and work she’d done for the Oil and Aircraft industries—especially in terms of how they address risk and manage internal relationships. It was fascinating to realise how many of the major problems that undermine our culture in the NHS are live issues for these industries as well. Talking for example about “Disasters” in the various organisations she has worked, she explained how the problems are always known prior to the disaster, but, because “failure” is not allowed, such knowledge cannot be shared and reviewed and small signal events are ignored. She talked about cost cutting and conflicting priorities, about remote, often narcissistic leadership, about responsibility being pushed down the system and a culture of fear where people daren’t speak out.
Sadly, these issues all resonated strongly with my experience working over recent years in the NHS. Whilst the comparison between these industries and an increasingly industrialised NHS didn’t surprise me, the link with “disasters” and the idea that these issues are seen as just as much a problem to the smooth running of the Oil and Aircraft industries is interesting. It confirms the truth that attending to the culture of an organisation is not a soft woolly peripheral concern, but directly impacts on the primary task. And if this is so for heavy industry, how can we dare to continue to ignore this fact in our health and social care organisations where a thoughtful caring culture is so obviously fundamental?
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.”