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Peter Bailey on the change of culture needed after the Francis report

26 Feb, 13 | by BMJ

How could they have behaved like that? It’s inhuman!

Reading the Francis report, I was appalled and shamed by the neglect and lack of care to which patients in the Mid Staffordshire Foundation Trust were subjected. Remembering though, that this was human behaviour, prompted me to wonder at the circumstances that are necessary for so many people who (no doubt) regard themselves as good to behave so badly.

In order to ignore the pain and suffering of other people, repeatedly, relentlessly, and even systematically, it is necessary to establish psychological distance from them. In essence, the person needing care must be dehumanised.

There are destructive forces at work at both the personal and organisational level within the NHS which have led to this catastrophe.

At a personal level, carers (and by this I mean all those with direct responsibility for the wellbeing of individual patients: healthcare assistants, nurses, doctors, etc) and their managers have been asked to do more and more while simultaneously being set impractical targets and being required to achieve “efficiency savings.” At the same time patients have been led to expect immediate service for every deviation from perfect health and demand cures for everything, including—at some level—mortality itself.  When people are asked to do the impossible, under penalty of criticism, complaint, and dismissal, psychological protection factors come into force.

There is a triad of behavioural characteristics that is common to the helping professions. These are perfectionism, an exaggerated sense of responsibility, and guilt. When such individuals fail, they experience terrible anguish, misery, and demoralisation.

When impossible conditions are set for staff they will inevitably fail. Those with this triad of characteristics will suffer badly. The lower the autonomy of the individual, the more likely they will be to resort to methods of avoidance in order to escape their psychological pain.

Dehumanisation of the patient is one method of dealing with the pain of failure of care. In this process, the patient’s individuality, personality, and agency are denied in the mind of the carer. The patient’s disability, frailty, incapacity, and lack of status in the system all contribute to reducing their humanity and therefore their right to dignified, respectful, compassionate treatment. When counting is more important than caring, patients can be treated as objects, and at a stroke of a pen in a tick box the bad feelings caused by failure can be made to disappear. The success of the strategy reinforces these behaviours and the culture of neglect takes hold. These behaviours are contagious as they become modelled to new recruits, whose horror at what they see when they first encounter the failures of care must also be accommodated by the staff already in the grip of the dehumanisation process.

In this environment, no one can be allowed to complain successfully about the failure of care. To do so threatens the defences of everyone who has colluded in the dehumanisation. Everyone would be forced to admit their failure, and experience their guilt, responsibility, and dereliction of duty. This feels like a risk of psychological death. Vindictive, bullying, and gagging behaviours soon follow.

All too soon, the whole healthcare system can become contaminated by dehumanisation of patients. The psychological consequences for the organisation of “owning up” to the catastrophic moral failure seem too frightening to contemplate.  From the board to the cleaners, all are in the same moral pit and can see no way to escape.

Let’s look now at what is coming down from the top. What are the politicians and the NHS controllers doing? Recent strategies can be considered from the perspective of the “Propaganda Model” described in 1988 by Edward Herman and Noam Chomsky in their critique of the failure of the independence of the press and other media. They looked at ownership, funding, sourcing, flak, and fear as dynamics in the press which contributed to the process of dehumanising people in the news stories they were writing.

These issues are wholly applicable in the processes at work in the NHS creating the conditions for dehumanisation of patients.

Taking ownership first, the NHS used to belong to the communities served by the institutions in their midst. The general practitioners, the medical directors, and the matrons lived among their populations and suffered the same fate as the people they served. The product of the business of the health service was the care that was delivered to people, and pride in the product shone from the polished bed pans. Now the NHS belongs to politicians and business interests as trusts and qualified providers seek to trade votes and chargeable episodes of treatment between competing interests. The core business of the NHS has changed from caring for people to trading. The units of currency are no longer people but objects, now seen as objects to be counted, stacked, warehoused, bought, and sold, with profit margins as the bottom line. This is where dehumanisation begins.

“Funding follows the patient.” This phrase gained currency as the internal market took hold in the NHS. In fact what was happening was that funding was following the targets. The humanity of the patient was ignored and denied in order to make this possible. At a corporate level, board time was spent on ways of meeting targets and attracting the maximum number of funded episodes (not people). The NHS now existed to deliver the numbers, not to deliver the care. Humanity was not a factor in this calculation.

In their critique of the press Herman and Chomsky looked at the source of the news stories and reflected that the dehumanised press chose stories that did not upset the corporate strategies of the media barons. Similarly in the NHS, the care that the NHS and politicians chose to talk about was that related to widgets: countable episodes such as cataracts, hip replacements, hernia operations, and the like. This increased the pressure on throughput, targets, and charging, while at the same time forcing the care staff to work with a production line mentality.

By “flak” Herman and Chomsky meant the defensive organisational response of the media to any criticism of their corporate strategies. Any societal group that challenged their dominance of the narrative of society would be demonised and demeaned through the media, which were belittling and ridiculing or marginalising their views. We have seen exactly the same “flak” from politicians and the NHS centre, scapegoating disloyal managers, lazy consultants, greedy general practitioners, uncaring nurses, and unqualified care assistants. Gagging clauses are commonplace in NHS contracts preventing whistleblowers from telling their stories.

Fear was the final driver for dehumanisation in Herman and Chomsky’s critique of the press. It operates similarly in the NHS. Fear of dementia, old age, overload by immigrants, superbugs (HIV, multi-resistant TB, SARS, influenza, MRSA, etc) and any other passing nightmare—including fear of horsemeat, is recruited to distract attention from the core problem: the dehumanisation of patients in the commercial NHS, where patients are reduced to the status of objects.

What is astonishing, given the power of these drivers meeting in a chaotic storm from above and below, is not that Mid Staffs happened. Rather, it is that the NHS has proved so resilient.

There are many good people working in the NHS with their eyes wide open to the horrors around them, and critical of the changes that have led to this misery. There is a will to put things right now, and a key moment in which to do so.

Solving the problem requires solutions from the top and the bottom at the same time.

First, the senior executives responsible for the dehumanising condition of the NHS should go.

Next, their replacements should state clearly that the patient and the consultation come first and care itself is the output and purpose of the NHS, not the internal market and the buying and selling of episodes.

Finally, staff at every level should be helped through a process of supervision to accept the limits of the health service and of life itself, helped to experience and bear the pain of mortality and rationing, and share their humanity with the patients they must suffer with, rather than cause to suffer. Supervision is notably absent from the NHS model. Every carer needs a listener: someone with whom they can reflect and express the pain of caring, giving vent to guilt, anger, depression, jealousy, irritation, and frustration. The supervision must be provided by experienced peers who understand the job from the inside and who can model the same caring behaviour that they are encouraging in their supervisee.

In this way, we could transform the NHS swiftly and be proud of it once more.  It would become fit for purpose again and it would be better placed to deal with the stringent financial conditions that prevail.

We don’t have a moment to lose: it’s nearly too late.

Peter Bailey is a retired general practitioner, Cambridge

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