1 February 2019 — OurNHS
Markets, machines and micromanagement are turning healthcare into officious, insensitive practice that demoralises staff and patients.
Early in this new year, on 7 January, the Prime Minister proudly announced a hopeful tonic for these troubled times: a Ten-Year Plan for our NHS, to transform it into a ‘world class service’. More money, better systems and state-of-the-art technology will all assure this, she said.
On the news channels doubt and dissent soon followed. Opposition spokespeople portrayed the extra funding as illusory; not even compensating for recent years of austerity, nor matching previous levels of funding nor, currently, those of comparable European nations.
Other pundits had other doubts and questions. How can even a reformed NHS deal competently with our burgeoning problems of ageing and mental health without an equivalently reformed Social Care service? And where is that? And how can the NHS possibly deliver these planned improvements when we have such massive, and growing, healthcare staff deficiencies? These questions led to many concerns and suggestions about how to train more staff and specialists, and then how to get their work better coordinated – Integrated Care was the buzzword heard several times, another panacea.
Yet some questions and challenges seemed remarkably absent. If substantial doubts were raised about the fitness of our marketised system to deliver such vaunted improvements, I did not hear them. In particular, the destructive relationship between the implementation of the Health and Social Care Act, 2012 (HCSA) and the consequent increasing loss of cooperative rapport and morale of NHS healthcare staff – and then their disintegrating career loyalty, tenacity and tenure. These were, remarkably, not mentioned by numerous tank-thinkers and pundits.
Why not? Do they not see how marketisation in healthcare fosters divisive and competitive fragmentation? And that these then erode and obstruct the kind of colleagueial trust and rapport that are essential to any viable integrated care? Have they not thought of how such human bedrocks are, necessarily, are the root-source of good staff morale, work satisfaction, health … and thus stable and adequate staffing levels?
Or do they think of marketisation, and its corralling HSCA, as a fait accompli, to be tacitly accepted as an immovable determinant?
There has been similar silence about other rapidly developing imperatives to healthcare management that further alienate, demoralise, intimidate and exhaust our NHS workforce. In particular are the varieties of micromanagement and gigantism: our proliferating devices to regulate, control and scale-up wherever possible.
In the last two decades successive governments, through their commissioned ‘experts’, have devised ever-more ways of monitoring, standardising and implementing machine-like compliance to ‘governance’. Scaling-up serves as another powerful lever.
But these devices are now, often, losing us far more than we can gain. For micromanagement easily turns healthcare into officious, insensitive practice; sapping any personal sense of agency, skill, pride, and the possibilities of more creative and nuanced judgements. Gigantism, too, disperses and destroys the human scale and personal familiarity that are necessary to spawn, nourish and contain our personal relationships and understandings.
If we destroy these things for our workforce, what are they then left with? And what kind of care can they possibly provide?
Almost all veteran GPs and psychiatrists, for example, will tell us that what largely motivated, sustained and guided their erstwhile better care has been the personal relationships and understanding they have developed with colleagues and patients. Yet they will also say that serial reforms have made such human elixirs almost extinct.
So money can’t buy you love. We cannot directly purchase or commission our human connection and resonance (though lack of money can starve these things): they must grow from more natural roots. This is something we have increasingly lost sight of.
We are seeing how the relationship between ever-tighter systems geared to ever-more technology, and the humanity it must care for, become easily misattuned, often hazardously so. For systems and technology are usually there to short-circuit or bypass the humanly complex and discrepant. Yet without great care they easily turn to human neglect: excessive or misplaced IT, for example, does not facilitate the human component of our work but distorts or displaces it. Hence as compliance-ensuring technology increases, so too does workforce personal dissatisfaction, and then exodus. This problem is now endemic across our Welfare services.
How, then, may we replant and sustain our better human sense in our large Welfare organisations?
Perhaps a different anchoring model will help: one that draws from the animate rather than the inanimate world. Rather than thinking of how machines work efficiently, we need to ask instead: what do complexly sentient and social living creatures most need?
Ecology and relationships need their own kind of understanding.