Will you choose a New Year self-defence revolution or a continuance of the more-for-less dictatorship?

 

Let me ask you a simple question. Are you going to make a New Year’s resolution to look after yourself better in 2017? Now for a more provocative one. Did you set yourself the same one for 2016 and then keep to it? So what will make 2017 different?

 

Resolution or Revolution?

The title, an unashamed play on words, was chosen with careful thought. I’d argue that the two are the same, sort of. A resolution – an agreement to do something, with determination (resolve), to solve something – probably requires a frameshift in behaviour perhaps best termed a behavioural revolution. I am guessing that is where 2016 went wrong.

You probably set the intention but then didn’t fundamentally change the behaviour i.e. a disconnect between resolution and revolution – the goal without the gusto. The trap is, of course, that if small incremental adjustments were sufficient to change the outcome then you would never have needed to make a commitment in the form of a resolution. The issue most people face is that a resolution to look after yourself, set in response to what’s happening in healthcare today, feels exactly like a revolution i.e. benign unless you take extreme action. That’s a feeling that the upper echelons are relying upon.

So, why do intelligent, highly trained individuals with a passionate drive for quality and an unwavering commitment to safety continue to accept ever greater pressure under the unrelenting onslaught of more-for-less? The answer is, of course, a multifactorial one behaviourally but its context is a disingenuous undertone of greater good rhetoric coming right from the heart of the system.

 

The Greater Good

There is little question that patients value the care and dedication of their providing professionals and this provides a positive motivation to keep going in the face of adversity. But ‘doing the right thing’ for the patients is not a universal commitment throughout our system, even though it is pretty much a universal chant.

In reality, regardless of the motivation behind their behaviour, the actual decisions and actions of certain groups beyond the clinical coalface (accepting that not all clinical coalface decisions and actions are the right ones either) are not only not for the greater good but could reasonably be expected to cause untold harm to patients over time. Let’s see if we can test this out.

 

The Greater Good Assessment

I have assembled 10 questions, based on current or recent decisions and actions by system leaders, that can be reasonably assessed for a patient-focused greater good or otherwise. Assign each a score, from -10 to +10, based on whether you think the impact is, firstly, positive (in which case requiring a positive score, otherwise a negative one) and if so, secondly, to what degree. To step beyond an emotional reaction to objective evaluation, I strongly suggest you take a few moments on each one to think through the cause and effect cascade. Here goes, accepting that each one starts with “To what degree is the following decision or action a greater good one?”:

  1. Giving a bonus only to Trusts hitting their financial control targets i.e. denying much needed support to the ones who are struggling?
  2. Only providing emergency funding to Trusts who can demonstrate that suppliers are going to withhold supply due to continued non-payment of bills?
  3. Running vacancy controls to achieve financial savings on posts that are critical for safe and efficient patient care?
  4. Addressing waiting list patients based on proximity to breach rather than clinical need?
  5. Blanket bans on use of agency staff?
  6. Raiding future capital budgets, for infrastructure, renewal and transformation, by switching the funds to in-year revenue support to make the headline figures look good?
  7. Bullying and threatening executive teams with special measures and job loss if they don’t sign up to targets, regardless of whether those targets are realistic or safe?
  8. Suppressing primary care funding and reform until upwards of a third of the profession wants to quit, take early retirement or emigrate?
  9. Extending ‘full service’ hours without resolving either the funding necessary or the manpower provision/ workforce planning?
  10. Expecting existing frontline staff to accept ever more load, pressure and responsibility, knowing that the unrelenting escalation of these issues deeply affects morale, burnout and safety?

Have a read back through and then tot up the total. You may have realised already that the maximum score is +100 and if you feel that the decisions and actions, all in widespread operation today, are 100% in the interests of the greater patient good, then your score should be 100. However, the aggregate score might not even be positive…

And now for the REALLY provocative question… If your score is negative, how well does it work out for the patients or you, to be part of the perpetuation of this scenario? Equally, if you have no work-life balance and possibly declining health or marriage, all justified as being for the ‘greater good’, and suddenly you realise it isn’t at all for the greater good and those perpetuating the rhetoric either have an alternative agenda or aren’t sharing in the pain (or both), how does that make you feel?

 

Staff Impact

In September 2014, I wrote an article titled Sitting in the Back Seat – as the NHS family car goes over the cliff edge, followed by, in September 2015, An Evolving NHS Catastrophe with Staff Welfare at its Heart. They are more pertinent today than the days on which they were written, and more scary.

The first invited the question as to whether it was morally and ethically acceptable, seeing what was happening around you, knowing where it was heading, knowing it was taking you with it, not to act to prevent or avert it. With this in mind, it is worth just seeing how you scored above and then considering whether each statement, all absolutely true and widely reported, was something you were unaware of versus knew about already. That might be an uncomfortable moment of reflection because although not knowing lets you off the moral question somewhat, it also reinforces just how vulnerable you are by not knowing what’s unfolding around you.

Let’s consider the second article, which focused on the impact of more-for-less on staff morale. It produced more words of support and praise (and not a single dissention) than any other article I have written, from across the UK and as far afield as the Southern United States. Without question, the responses were unanimous in recognising the impact of more-for-less on morale and the impact of morale on quality, safety and staff retention, all vital issues to a sustainable NHS. To say the least, it has been a year of uncomfortable progression towards the worst predictions in that article.

I have long predicted that more-for-less is unsustainable without genuine innovation that makes it genuinely possible. The key impact, as morale erodes, is on discretionary effort – the withdrawal of services provided above and beyond contractual obligations out of the vocational attitudes of clinical staff, coupled to a sense of pulling together. That withdrawal occurs in degrees, depending on the inherent morale in any individual, the passing of certain tipping points and the presence or absence of options. Go too far in the wrong direction and we have an unrecoverable catastrophe.

 

The Staff Catastrophe Unfolds

In the past year, we have seen large scale strikes by junior doctors, an exponential rise in the number of individuals applying for certificates to allow them to work abroad, a heightened rate of early retirement, record numbers ceasing to pay in to the NHS pension, GPs handing back the keys to their practices, growing operational gaps in rotas, shortages of even agency staff and a growing recruitment problem in many specialties.

The less visible but no less invasive effects can been seen on the faces of staff under ever increasing personal pressure, carrying the weight of safety on fewer and fewer shoulders, getting more tired and less resilient. This should concern everybody. It is a sign of an approaching tipping point and the storing up of a latent morale malaise that is only held back by comparatively few staff seeing viable or desirable options in front of them i.e. they feel trapped. However, it’s like a sea wall or levee, when it goes, it goes with a rush and it’s impossible to halt when it happens.

There is a considerable cause and effect cascade that comes into being as this unfolds. It is this cascade that produces a problem much akin to whack-a-mole, with leaders scrabbling to react to one crisis whilst it’s downstream effects unfold into another. It is likely to include:

  • Reduced resilience in primary care makes it difficult to recruit and accelerates decline
  • The primary care decline results in a flood of emergency patients into secondary care, breaking the back of an already over-stretched profession
  • The crisis in emergency care makes it difficult to recruit and gaps must be filled by agency staff who increasingly will only work in the fraught environment for top rates, itself accelerating financial decline
  • The emergency care implosion creates a flood into the hospital that results in the large scale cancellation of elective procedures, themselves being the financial life-blood of the Trust
  • Some specialties find themselves unable to conduct large parts of their work, resulting in a severe financial imbalance between activity and cost, often reacted to by further austerity measures
  • Trusts are then fined for non-compliance with national targets and this in turn loses them access to their STP financial support

Perhaps one of the most telling news items I have seen that captures so much of this was on just 16th December 2016, when Dudley Group of Hospitals, in a communication leaked to the Health Service Journal, told staff ‘to stop overspending or risk losing STF money’ as if the staff were wilfully and recklessly spending money, rather than trying to get the job done, safely. The big question it invites is just how you feel when you are on the receiving end of that communication? What does it do for morale?

 

Characterising Collapse

The core challenge facing professionals today is a highly complex and deeply uncomfortable one. It’s much akin to a game of musical chairs with a rather with cruel twist. The music playing would be the equivalent of the NHS limping on, each music stop being yet another ‘event’ representing a further nail in its coffin and the chairs the alternative opportunities for individuals finding themselves compelled, willingly or otherwise to re-think their working arrangements. The twist? In all likelihood (supported by considerable evidence), the music will at some point come to a complete crashing stop, leaving many in the middle of the mayhem without a chair.

Does this mean the end of the NHS? Only sort of. We are likely to experience the music crash as a spiralling implosion, out of which will come a ‘new’ system with a new funding model, most likely based on a heavier involvement of large multinationals and some sort of insurance or co-payment financial model. As nature favours the adaptable, it’s vital that professionals ensure they are ready and fighting fit (nature favours the fittest too) for this new system. However, in any evolutionary and indeed revolutionary process we cannot ignore that the shock that creates the change also leaves a long tail of the less fortunate who peril as a consequence of the change.

This is not without considerable evidence already. We have seen in 2016 alone, the almost complete devolution of the health system away from Government, a very clear indicator of impending crash, as well as a more recent set of policy changes that favour strengthening the (perceived) strong at the expense of the weak. The December dual announcements that Trusts hitting control targets would be awarded a cash bonus, whilst those requiring emergency cash support probably wouldn’t now get it except in extreme circumstances are a function of both the DH’s inability to keep the illusion going whilst knowing you need some higher functioning parts from which to rebuild.

But what does this mean for you? As the crash unfolds, differently from one Trust to the next, we will see a chaotic myriad of responses. These will include enforced redundancies and emergency decommissioning to preserve core functions and immediate solvency, whilst in some places we are likely to see staff not paid, itself an end-stage precipitator of implosion. Staff are most likely to be met with a “sorry, we tried but it’s the system…” which will be no consolation when you find yourself having to search for alternative employment.

The issue facing individuals is not that the work will disappear (yes, people will continue to get sick) but that it will emerge in unpredictable ways, probably with dictated less beneficial terms and there will be a great many people scrabbling for it out of the chaos. I am guessing this was probably not your game plan. Ironically, the most experienced may well find themselves with the most offers but with the greatest divergence from existing terms and conditions, as they are seen as expensive. I suspect, again in line with recent evidence, we may see a significant period in which there is almost no elective surgery beyond what causes an emergency if not addressed. This alone will create a massive imbalance between workload and available staff i.e. too many staff for the workload, creating an immediate reversal of recent supply and demand mismatches. Naturally, the system and Trusts will have no choice but to preserve emergency provision to prevent an onslaught of unnecessary deaths but it is also far from clear whether they understand and are prepared for this.

 

Not Enough Chairs

The primary concern is that when the music crashes, YOU may find yourself without a palatable chair. It’s clearly a conclusion gathering considerable momentum. What do you see when you look around you? I am guessing:

  • An increase in established consultants seeking jobs in other Trusts in the hope that it’s better or more secure
  • Senior colleagues taking early retirement
  • Colleagues choosing to work through agencies, in part for the money but mostly to remove themselves from internal management pressures
  • Nobody wanting to be service lead (an indicator of a poisoned chalice perception)
  • Colleagues moving to the Middle East, Australasia and other locations

I am guessing the question you ask is whether they are over-reacting or whether you are under-reacting? It’s an answer that needs careful evaluation because it has your security at its heart. If it is truly the latter, by the time you act, will there be a palatable chair?

As I have monitored the international job scene, I have noticed two trends. The first is that the recent sources of international jobs have been slowing down, particularly the more desirable parts of the Middle East. Secondly, and perhaps more pertinently, the salaries on offer for new posts appear to be considerably less than those of the recent past. This is a very strong indicator that these markets are switching from high demand and low supply to the opposite and thus have no shortage of applicants. If the trend continues and the crash arrives, it would seem that the early movers might just have had the right insight. The big problem is that nobody will know for sure until it is uncomfortably late.

An International move is without question a revolution-sized resolution for most people. It’s also not the only option. The new system will also offer many opportunities for those poised to seize them. But do you understand them and are you ready to seize them, or will you just be too exhausted by the time they emerge? That’s a tough question to consider but history supports the likelihood that the majority will not look deeply enough at what’s happening and thus only conclude the need for a significant change when it is completely unignorable.

To finish, and return to the original premise, perhaps it is time for a resolution involving a personal revolution. I am guessing nobody ‘wants’ to engage in revolution and that justifies somewhat both the hesitancy and the emotional crash that goes with it. However, when the evidence points so strongly to an imminent crash, it is vital for personal security that individuals question the security of remaining under the current oppression and ‘just seeing what happens’ and instead consider being part of the vanguard of change, however unpalatable or unplanned. After all, when the music stops, being recognised as a victim of circumstance just doesn’t compensate for being without a chair.

 

Two Referenced Articles

These are the two articles I made reference to in this article (just click on titles to open PDFs):

 

 

PathForward Coaching Programme

PathForward is a coaching programme aimed at supporting healthcare professionals to objectively evaluate their circumstances, with a view to either making important changes to protect themselves whilst staying put or to make sensible & objective life choices and changes where circumstance suggest this is warranted.

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6 responses to “Viva La Resolution

    1. Hi Nader

      Thank you so much for the kind words. I am not sure even I’d describe the thoughts as ‘lovely’ as ‘scary’ might be a better term but they were certainly thoughtful and positively motivated!

      Andrew

  1. Hi Andrew.

    Thats a very well thought out article and reflects fairly accurately the situation as I see it too.
    You mention the articles in 2014 and 2015- can I have the links please? I couldn’t find them on your “articles” tab
    I also note that when humans become unwell, they reach a point where their coping strategies become overwhelmed, and they decompensate and get a lot worse, rapidly. Do you see the same thing in the NHS or are we living though the end game now, and the future is just a grinding more of the same?

    regards

    Andrew W

    1. Hi Andrew

      I’ll post up the two articles, as they were posted on a different site (helpful, I know!).

      You are entirely correct about the coping strategies and their tipping point. In my experience, when people go over it, their behaviour often becomes quite destructive and especially self-destructive, as their ability to remain emotionally in control, not helped by a big kick into survival mode, disappears. It’s at this point I am most concerned because it’s a time when really they need to be even more high functioning than usual!

      As for the end game, I believe we are probably entering it at the moment. I suspect that the DH will not be able to fiddle the figures this year and the underlying effects on staff will bubble over as there is just no safety valve. As individuals start to crash or opt out, it will create a domino effect, a limited form of which we have definitely been seeing for probably 2 years now, escalating all the time. I’d be more hopeful if I saw literally ‘any’ sign to the contrary or any policy that wasn’t just a coping mechanism. But I don’t… If the direction is downwards and there is literally nothing to turn that direction, you have to conclude a crash.

      Thank you for your thoughts!

      Andrew

  2. Dear Andrew,
    Once again a very good article to start thinking of what one could do. I thought before starting to read it, you will give some helpful hints to practically start the resolution bit. Of Course, I understand that the article is to get people to subscribe to your courses and workshops. It is a brilliant piece of writing and am sure will get people thinking.

    best wishes

  3. Saw this coming 7 years ago when the job ended my marriage and I left the NHS. Now working for an independent provider of NHS services. No emergency work, no on-call, reasonable salary and GOOD work life balance.

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