The Trap that’s Catching Healthcare Staff by the Thousand

There is a very strong tendency in life for the person who created the dirty dishes to dump then in a sink and wait for them miraculously to be cleaned up by someone else. When my teenage son does this, it is hardly a surprise and sometimes we’ll ‘insist’ he corrects the behaviour and sometimes we’ll just get on and clean. However, imagine how this might play out differently if it were the parents doing the dumping. That’s exactly what’s happening in healthcare and this was a particularly disastrous week for it. Oh, and you i.e. front line staff, represent that sink. Just like that teenager, how do you address or respond to the problem pile that the parents keep adding to?

 

Understanding the Sink Problem

The fastest way to illustrate this problem is to simply layout the bigger picture, financial version. The concept of the sink is that it is the place where the dirty stuff (the stuff nobody wants to tackle) gets dumped and left, until someone else clears it up. However, there is a catastrophic misbelief that it can simply sit in the sink, without consequence, until someone is ready. Even with dirty dishes we see the growth of bacteria but in healthcare operational terms the consequences are far more severe. It works like this…

  • The population ages and grows in number, whilst the economy slows, creating a problem (that’s dirty i.e. nobody wants to get their hands in it) which manifests itself as a mismatch between demand, capacity and necessary funding
  • The Treasury (the ultimate parent and the first dirty dish dumper) dumps the problem into the hands of the Department of Health by providing insufficient budget increases to match the demand growth
  • The DH dumps the problem into the hands of NHS England (parent commissioner) by again allocating insufficient budget
  • NHSE dumps the problem into the hands of both providers, through tariff growth restrictions or marginal rates, and local commissioners (the CCGs) by restricting their allocations (remember demand continues to rise too)
  • CCGs dump the problem firmly into the hands of the providers by activity restrictions and local negotiations
  • Let’s step out of the sequences for a moment…

It’s important to appreciate that each is passing the problem down and, as a consequence, landing the problem effects further and further away from the problem source. We face a population-driven and economy-mediated problem – all bigger picture stuff – but a problem locus that passes through layers of leadership to ‘rest’ ultimately somewhere it cannot be passed on from – the sink!

If we thought of the same problem sequence through the analogy of actual dishes in a high class restaurant which is getting busier and busier but without increasing its kitchen porters in line with the dish cleaning requirement, it would play out remarkably consistently. We would be seeing the sink pile up, more and more, to overflowing, completely out of the sight of the key leader, perhaps the Maître D, who is telling the waiting staff to keep dumping in order to keep the restaurant working. However, the restaurant reaches a critical tipping point when it runs out of dishes, the kitchen porters quit (this is important) and the functioning at the front end collapses. The kitchen porters can then be ‘blamed’ for the restaurant failure. I think you are probably already seeing it differently. Back to the NHS because we haven’t reached the sink yet.

So, we are down at providers and it is easy to think we have reached the sink. The providers will get ‘fired’ if they don’t see the patients and there isn’t really anywhere else to pass the problem on to. Or is there? It’s vital to remember that the manifestation of the initial problem was a financial one and that was the set of dirty dishes handed down. So, the provider is lumbered with THAT set of dirty dishes. Locally, the problem evolves. You’ve got the dirty dishes funding problem coupled to the increasing demand and care complexity issues. In this case, the dirty dishes prevent providers from building capacity to manage the demand. But the demand tap remains on (and the flow is accelerating).

 

The Workforce Sink

The provider response, feeling they haven’t too many options, is to pass this set of dirty dishes effectively onto the frontline workforce. We have reached the sink. It affects different professional groups in many different ways but you will have experienced versions of it as follows:

  • Failure to increase staffing in line with demand
  • Vacancy controls
  • Restrictions on agency staff
  • Reduction in SPA time
  • Cancellation of study leave and reduction of study leave budgets
  • Constant stretch of working hours e.g. by shifting meetings out of normal daytime

Often we term this ‘more for less’ and it is sold on the basis that healthcare is a vocation, we must all pull together and it is for the greater good (so get with the programme). Not only is this an unsustainable fallacy but it is also completely disingenuous. When we examine ‘all pull together’ we start to realise that the problem effects are predominately exhibited in the sink and not in those closest to the source. The Maître D is praised for making the restaurant so popular whilst the kitchen staff collapse and leave.

It is very easy to see Mr Hunt receiving a Peerage and possibly a Knighthood as longest serving Secretary of State for Health, whilst front line workers collapse, have breakdowns, lose marriages, jobs and financial security, whilst also being blamed for a problem largely ‘dumped’ into their sink. If you look back up the chain, you will see that the degree of problem personal impact is almost linearly related to distance from the problem source i.e. Mr Hunt receives the Knighthood, despite being closest to the source (a social and economic, and thus Government-level, problem), whilst the front line staff receive… breakdown, divorce and notice, manifestations occurring in the sink. It doesn’t help when the kitchen porters are made to feel they are letting the side down and failing, justified with “you knew how hard dish-washing was when you accepted the role”.

 

The Sink Trap

I am guessing that the average kitchen porter isn’t vocationally driven to the extent of the average clinical professional (not to suggest in any way they aren’t driven or committed but purely to identify their role is not one that people identify with as an aspirational career choice). However, they do share a very common role problem with even the most senior of physicians – an apparent lack of perceived palatable options.

Often the KPs continue in their role because they are worried about the consequences of quitting i.e. will they be able to get another job. In healthcare, that similar problem is that you trained in a highly specific field in which arguably there is really only ‘one’ domestic employer. It is very easy under these circumstances to allow the perception of risk with change to leave you trapped into something that is both unsustainable and with severe consequences.

You may be familiar with the frog in hot water scenario. Although somewhat disputed in scientific terms, the basic premise is that put a frog into hot water and it will jump out but gradually raise the temperature and you’ll find it dead before it realises. The debate is not so much about death but what constitutes gradual. You could equally turn this around and suggest that the tendency of a frog to jump out of water rising in temperature is a marker of how fast the temperature is rising and the degree of problem it is causing. We are seeing a great many frogs leaping:

  • Loss of trainees to other international healthcare economies
  • Early retirements
  • GPs handing back the keys to their practice
  • Recruitment problems
  • Staff switching to agency rather than direct employment

I am perhaps more worried about you. Why? Because the majority of you will be reading this from the increasingly uncomfortable position in a pan of hot water, worrying far more about the consequences of leaping out than the implications of staying in. In part, that is fed by the enduring human tendency towards hope, in this case that the temperature has stopped rising or that the leader has noticed, finally, and will imminently turn off the gas. I can confirm that hope is critical and sources of hope abound. However, I am going to be harsh and say that the leaders and the pan of hot water almost certainly aren’t sources, as this week has high on proven.

 

The Very Bad Week

When considering the likely direction of temperature in our pan, we can only look at the news, factors and experiences that suggest a temperature rise versus a fall. This week has been characterised by a phenomenal number of additional burners but only one fall indicator, which we will deal with first.

On Friday, NHS Improvement (NHSI) informed hospitals that they should cease most elective operations across Christmas and into the early spring, with the intention of bringing occupancy down to an 85% level, which is commonly agreed as the level above which you start to see adverse effects on mortality and morbidity. It’s sensible advice in an over-heated system, going into winter in worse shape than it has ever been. But, the relief at the clinical coalface cannot be taken out of context and wider circumstances.

We have also seen this week, a raft of reports of Trusts saying they are failing their financial control targets, resulting in a massive problem for the parents and provider children alike. Sustainability and Transformation Funding (which is now bailout funding) is conditional on achieving these, effectively rendering Trusts without essential cash injections. The cessation of elective work will help with safety whilst virtually guaranteeing financial collapse in relation to control totals.

In this scenario, that enduring human hope throws up some denial that I am about to dash. Surely the system will then be forced to fund anyway? On Wednesday, NHSI announced that Trusts could be refused bailouts even if that meant not paying suppliers. The news was met with a plethora of comments with debate over whether than meant staff would not be paid. Consensus favoured the unlikeliness of failure to pay wages because of the unquestioned disastrous consequences if this happened. I have personally been involved with three Trusts that have come within days of not being able to run payroll but it has always been met in the end. However, I have to also say that the Trusts were not in the dire shape so many are today.

The message is clear. It says, from NHSI “we’ve been very clear you must manage within resources and we are going to stop bailing you when you can’t”. There’s a nuanced view of this that suggests knowing there is insufficient cash to fund bailouts (cash remains king), NHSI has fired the early warning shot that to preserve staff pay, suppliers will have to wait because bailouts are not possible. It’s a dire scenario I predicted twelve months ago but it seems to be arriving. However, before we feel too relieved that in a crisis wages will be preserved, let’s remember that almost every hospital Trust is reliant a significant number of agency staff and the agencies supplying them are suppliers, not staff. A cynical view may also be that it is a good way to reduce agency spend – don’t pay them.

However, what are the operational implications of this? Are those agency frogs going to leap back into the boiling water? Or, are you going to find yourself with a rapidly rising temperature as the demand increases but not the temporary relief?

In the same week, we also hear of Trusts telling staff to “stop overspending” to preserve STP funding, with one Trust mandating that this spend cessation is in staff like agency Healthcare Assistants, themselves employed to fill the 100 vacancies for registered nurses. All frontline recruitment has ceased. I am guessing if that’s the pot of hot water you are currently in, I don’t have to persuade you that the temperature is rising fast.

Although these aren’t the full gambit of temperature increases this week, I am also guessing there’s only so much you can take. Much like the frog, there comes a point where more simply equals ‘death’ (the acceptance of serious personal consequences) or a leap, which we already know feels as though it is risk-filled in its own right.

 

The Propensity to Act

It is easy to feel very trapped by these circumstances. The critical issue is to feel forced into making a change that you had never envisaged or in fact don’t really want to make. Whereas frogs seem happy to leap, you would probably rather stay put, just with a lower temperature. My hope is to encourage you to learn how to leap when leap is the safer course of action, or where remaining the same becomes clearly consequence-filled. Everybody has a different tolerance. Too many are ignoring the true implications of the rising water temperature. There comes a point where even the frog is too weak to leap, leaving it at the mercy of the water temperature.

You have a clear advantage and yet a massive disadvantage compared to the frog. He relies purely on instinct, which is hugely beneficial when it triggers the right behaviour. However, when it fails to trigger because of the gradual rise, he cannot fall back on objective reasoning. You can rationalise, take decisions, plan, monitor etc. But, your own ability to rationalise is also your biggest threat. You hold the ability to override the instinct when you perceive the risk of leaping to be greater and you are far more governed by what you’d prefer to happen i.e. emotional drivers, or the tendency to shy away from or deny the necessity for what you don’t want. That doesn’t mean it isn’t necessary but you have to be on guard against this tendency.

Perhaps the greatest difficulty humans experience is that they are happy to leap when they are certain but, in this case, certainty is only likely as an end state with dire consequences. Of course, we call it hindsight – after the divorce, the breakdown and the job loss, I am happy to conclude I should have leapt. Until that point, I am more likely to clutch to hope, despite almost every sign suggesting leap. To overcome this we need help.

The above is not helped one bit by the unignorably difficult condition that everybody’s circumstances are different. Whereas one person’s circumstances may absolutely require a leap to greater safety (whether they see this or not), in truth, the next person may be better off right where they are. The difficulty is summed up by a question – just how do you know which of those individuals YOU are before the answer is unignorable and the consequences actually experienced?

 

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8 responses to “Dumping the Problem in the Sink

  1. This article is long overdue and I hope as many doctors as possible read it.
    The tragedy is that without the help and connivance of fellow doctors, this dumping would have stopped short of the sink. Clinical managers, mostly looking to their own rise within the system , their discretionary awards and the boost to their pensions , assist the final step of the dumping, knowing that what they ask of their colleagues is untenable. Clearly each layer of dumper has its price and it is no use pointing fingers.
    You highlight the advantage conferred on the monopoly employer but no matter how strong this makes its position, it cannot function or deliver its without employees.

    1. Hi Funke

      You hit right on my primary concern and a point I made through the junior doctor strike too when the debate was ‘who will win?’ rather than the SoS considering that he could well win and end up with wildly insufficient doctors to run the service over time. It is a very real fear, or perhaps likelihood.

  2. excellent summary
    please include the fact in the year ~2000 the nursing hierarchy made it essential for Nurses to sit a degree this led to about 50 % of young women thinking of a career in nursing being disenfranchised and the ones sitting a degree being to academic to do nursing and moving into management or moving outside nursing hence a major reason for nursing shortage and billions every year in agency nursing
    also B female intake increased to medical schools over years to approaching 60% + – nearly all female doctors either go part time or leave ( as they can afford to as they often marry professionals — this requirement for nearly 2x number of doctors to cover this effect was never calculated in to need for medical students and medics
    all the other factors you mentioned means we are heading for a disasterous medical shortage if coupled with restrictions on medics form outside EU
    oh and the change in pension laws over past 5 years forcing 100s of experienced doctors to retire early !!!

    1. Couldn’t agree more. Once you reach pension thresholds, the primary ‘hold’ on NHS consultants is very much lost. It’s not just early retirement, as there are many experieced consultants moving across the globe at the moment. Many of these points fall firmly into not understanding the driving values and beliefs of the people you are working with!

  3. Hi Andrew. I think that the dirty dishes are not really financial dishes but Political ones. PM/Treasury/Mr Hunt pass an abhorrent lack of leadership down. Finance should be managed! No discussion/conversation with the nation let alone the NHS! There are numerous possible financial solutions. But no easy political one so we get catharsis. It’s a national disgrace! Like Nero watching Rome burn…..Doing nothing is not an option anyone will respect when the NHS/social care system collapses!

    1. Hi Michael

      I very good and knowledgeable friend and myself debate long and hard whether it is intention or ineptitude that is driving what’s happening. Ineptitude would be scary, given the power wielded to assert policy. Unstated intention (a hidden agenda) just undermines all basis of trust in a profession built on it.

      The REALLY scary prospect, we we both conclude frequently, is that we can both be right at the same time!

      Andrew

  4. I am sure that all of this is true and is undoubtedly a pre-determined government strategy to turn the NHS into an “emergency-only” service with all elements of elective work outsourced to non-NHS providers. This is all part of a carefully managed and predetermined plan that ends with the NHS as a “failing organisation” and all elective work requiring at best top-up co-payment insurance and at worst a totally outsourced insurance-funded service with the NHS as a “charity” service alone.

    This has been the direction of travel since the days of Kenneth Clarke. Anyone who believes that this will result in lowered tax bills is living in ‘cloud cuckoo land’ just like the smoke and mirrors of the £350m (vanished but “aspirational”) Brexit dividend.

    1. Hi Ivan

      You know we share common views on this! My inclination is that we are entering a period of acceleration, whether intended or not. I am confident of massive fall out prior to April 2017, I am sad to say. It would take Herculean manipulation and trickery in the accounts to hide what I fear is the underbelly of current financial lack of stability. It will pour out in quarter 4.

      Andrew
      PS Merry Christmas!

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