Guest editorial Monday 15 November 2010: Changing the culture of caring – a third way?

Irwin Brown of the Socialist Health Association reviews the three cultures of NHS bad practice, and wonders whether the true cultural challenge is a caring deficit.

Reading the transcripts of the Mid-Staffs enquiry, and hearing another series of bad news stories about the NHS in the media, should make us all think hard.  We accept the Kings Fund conclusion that the NHS delivers good care for most patients most of the time; that is what the “evidence” tells us.

What Mid-Staffs poses is a different issue altogether: how common is care that is not good? Do we achieve the more fundamental requirement that an appropriate minimum standard of care must be delivered all the time – with any exception being the subject of serious action?  

There is far les reliable evidence about patient care than about finance or process target compliance or even health outcomes – you can have a successful outcome and an experience far worse than it needed to be.  You are unlikely to “have a nice day”; but you are entitled to respect and expect your experience to be managed to reduce the pain, stress and fear.

Measuring the caring in healthcare
There is rightly great scepticism about data collected about patient’s experience, about surveys and about the analysis of formal complaints.

For some, the only real test is to walk about, especially at night or the weekend and feel the atmosphere, about as far from objective evidence as you can get.  

I can only express my feeling, based on my own experience - which is that standards of care in the technical sense continue to improve; but that there are far too many instances of poor care.

That can be at a low level with, say, nurses ignoring a patient in pain or basic communications being totally inadequate, but can also be serious incidents where harm happens or was likely.

The three cultures of poor NHS practice
It has been noted that there are three aspects of the culture within the NHS which have emerged from Mid Staffs and previous reports.

To paraphrase: there is a culture of fear, in which staff do not feel able to report concerns; systems to support whistle blowing are ineffective or (rightly) not trusted; senior managers are told to sort out problems, and not report them as concerns. There is a culture of secrecy, in which the management shut themselves off, especially from patients, preventing honest and open reporting of problems. And there is the culture of bullying / top-down shouting at people; a sadly prevalent style of management in the NHS - and a culture which prevents people from doing their jobs properly.

Changing culture – jolly hard to do
We need a major change in the culture of the NHS; not in the organisational structure.  If the health professionals want to be put in charge, then they have to address the issues arising from their collective failures so far.

Caring professionals do not generally conspire to collectively demand high-quality care.  Professionalism should be a force which delivers quality of care in all senses, not a version of trade unionism; although we also need strong and confident trade unions too, especially to support staff who dare to raise concerns.

Sadly, our current discussions around the NHS are focused on reducing expenditure by £20 billion, which everyone understands will imply less front-line staff, and on the redisorganisation of the NHS proposed in the White Paper.

Neither of these changes are likely to improve patient care, and there is a strong sense of foreboding that financial cutbacks will lead to longer waits, restricted access and greater risk of poor patient care.

The expenditure reduction programme (QIPP) makes a strong case for quality being linked to efficiency, in that changing ways of working will improve quality of care as well as reduce expenditure. In some instances this must be true: doing things properly benefits all.  Easier access to a GP; fewer admissions from A&E; shorter stays in hospital: all are better for the patients and should cost the NHS less.

But NHS history tells us that improving care often requires additional investment, possibly only in the short-term, not cuts.  It also shows how NHS organisations, faced with enormous top-down pressure to meet financial targets, respond with slash-and-burn, technical adjustments and short-term fixes.

I am not sure we have a strong enough baseline of “quality” to know whether QIPP actually delivers improved care overall, or not.  Probably not, I suspect.

The central thrust of policy is however that the power of markets will be the way change is brought into our NHS.  The theory is that better information will be used by patients to make choices about where they go for treatment, and the good providers will flourish and the bad will close down.  Thus the quality of care, just as the quality of consumer products, improves through innovation and competition within a market.

Maybe it will be so, but how long exactly does that take and what is the collateral damage along the way?

If the market reforms continue, we get a commissioning board and regional outposts instead of DH and SHAs; consortia instead of PCTs; Foundation Trusts; sundry Regulators, then actually the architecture is the same.

Which means that the culture won’t change.  The people in power will be the same, even if the names are different!  Culture trumps strategy every time (or so it says in the expensive textbooks).

What could we do instead?
We ought to pass the challenge to the professions themselves.  How would they bring the highest standards to the NHS and make it genuinely centred on the patients?

Do they think a market for healthcare and competition will bring about better professional behaviour?

Will market conditions make the NHS more open to scrutiny; more supportive of staff with concerns; more attentive to complaints; more ready to acknowledge and learn from clinical problems; more likely to spend on clinical audit and peer review?

What do they think? Not just for their own profession or tribe - but across an integrated NHS which is supposed to value partnership, co-operation and openness.

We have had at least three goes at change through markets and commissioning so far. None have worked.

Maybe there is a third way?