A few years ago, I was climbing in the Indian Himalaya. After driving to the road head, we walked for four days to our base camp. There, one of our group suffered with high altitude cerebral oedema. We carried her back down the valley for 12 hours until we reached the road head and found a car to take us to the nearest hospital.
Once inside the hospital, I asked, “Have you got any oxygen?”
“I don’t know Sir, I’ll go and see,” came the reply from the nurse.
He appeared with a rusty oxygen concentrator, which he wheeled along the ground. We couldn’t start it and so, while I made attempts to fix the concentrator, the nurse wiped down the yellowing pair of nasal speculae with a rag.
“Surely you must have some oxygen and a mask?” I asked. “This is a hospital.”
With a characteristic shake of the head, the nurse replied, “This is India.”
This has stayed with me. The acceptance that they couldn’t provide even the most basic therapeutics—and that we shouldn’t expect them to have any equipment—has troubled me since. How would they ever improve healthcare if their expectations were so low?
Just recently, I have begun to notice this creep into work in the UK; “Well, it’s the NHS . . . what do you expect?” The problem is that if there is no expectation of improvement, then the comment is self-fulfilling. The blame can’t lie just at the lap of senior clinicians and managers; it is down to all of us to try to improve. This means cleaners, the volunteers in the League of Friends teashop, the nurses, midwives, physiotherapists, occupational therapists, social workers, junior doctors—all of us.
Few of us like change and our response to it follows the Kübler-Ross model of loss. That is: denial, anger, bargaining, depression, and acceptance. Many people get stuck in one of these, which is definitely maladaptive and can be pathological. However, the Kübler-Ross model misses the final stage, which is “resolution.” This is the process in which you can use the negative experience to improve. This is an active process and that means that you have do something.
Part of this is cultural. Earlier this year, I was in Atlanta in the United States. “Georgia Tech” is the state of Georgia’s science based university. As I jogged around the well funded campus—with its own baseball, American football, soccer, softball, and tennis stadia—students and faculty members were wearing the campus T-shirt, which in big yellow letters stated: “We can do that, we go to Georgia Tech.” It seemed unlikely to me that any institution in the UK would be able to produce a T-shirt like this without being a laughing stock. But we don’t need T-shirts to shout about how good we are, we just need to be good.
Most of the problems of the NHS will not be solved by people just accepting poor standards. They won’t be solved by people saying, “Well, it’s really difficult.” It is really difficult and you need to try, and then fail, and then try something different. Failing and trying again is incidentally something that doctors, as a group of first time high achievers, are not good at.
Money alone won’t cure the NHS of its ills either. Effort, being bothered, flagging up patient safety issues, not allowing standards to slip, working with all of your colleagues (including the cleaners, porters, and other doctors) are small ways in which we can all effect improvements that cost nothing.
Real improvements come from system changes, but we have to point out where those systems need changing when they are bad and celebrate them when they are good. Even stalling in the “anger” part of the Kubler-Ross model can be useful if a sufficiently large group of people feel angry enough and use their anger to pull in the same direction. But please don’t get stuck in “acceptance” of sub-optimal practice and standards, because that won’t help you and it certainly won’t help your patients.
Ben Gibbison is a specialist trainee in the Severn Deanery.
Competing interests: None declared.
Patient consent obtained.