Accept our limitations and loosen organisational loyalties
A personal view by Hilary Pillin, Healthcare Consultant at AACE
It is often said, by those who work in the NHS, that you have to be in it to really understand it – it is a world of its own, a family you belong to, unlike any other organisation.
And whether or not this is true, without a doubt, working in the NHS creates strong feelings of loyalty – along with many other emotions! But, just as we talk of it being ‘one NHS’, we also recognise that it is made up of many disciplines and organisations, and sometimes it is fair to say we find our loyalties conflicted and our family dysfunctional.
When I started working in the NHS back in the 80s, it was in the acute sector in a district general hospital, before the terms ‘trust status’ and ‘internal market’ had entered the NHS language. After just a year or two, having started on the lower rungs of the management ladder, I found myself ‘in charge’, on-call in the evenings and weekends, running around, literally on occasions, trying to find beds somewhere, anywhere, so that we could admit those in need coming through our A&E doors.
That was 25 years ago, and whilst in hindsight (which is a wonderful thing) the pressures we experienced then were not on the scale they look and feel like today, at the time we would regularly find ourselves bemoaning the state of the NHS, disbelieving the stress we were under, getting frustrated at the constant policy changes, the rising expectations of patients and wondering if we would ever ‘get on top of the workload’ or have enough money. Worst of all at that time, having to say sorry when things hadn’t gone to plan, especially for our eminent clinicians, was something that many not only feared, but found stuck in their throat when it became unavoidable.
Despite all the changes that have taken place across the NHS landscape over the past 25 years or more, some things never change – the bemoaning and disbelieving, the frustrations and rising expectations – but thankfully we are much better at being honest and holding our hands up when things sadly go wrong, which is still miraculously rare in relative terms.
Accepting that the NHS isn’t perfect is a difficult thing, but the one thing we – society, politicians, those who work tirelessly within the NHS and, please God, the media – really do need to come to terms with is its limitations… our limitations.
There is barely a day goes by now when there isn’t a news headline or story, or a TV documentary or radio phone-in programme depicting the NHS ‘in crisis’, negating the fact that we have one of the best, most generous and exacting healthcare systems in the world. This in itself is enough to test even the fiercest held loyalties of those who are the subject of such publicity. Having a whinge about your own working conditions and the day to day difficulties you face in trying to do your best for patients as an NHS employee is one thing, but being told by ‘outsiders’ that you are failing, not coping, are potentially doing harm or not performing, often seems unfair and disproportionate, and can be taken very personally whatever your role.
This is not what you joined the NHS for. On top of working flat out, when taken to heart, this can cause all sorts of damage, not only to the individual, but to how an organisation behaves – defensively. With the level of scrutiny and performance micro-management trusts are under on a daily basis, it is not surprising that loyalty and pride can lead to protectionist and insular responses. Take, for example, the issue of delays in transfer of care in A&E.
Although we all recognise there are system-wide pressures, ambulance services feel compelled to defend themselves in terms of their own position and the risks to their patients, seemingly pitching themselves against colleagues in the acute sector, who equally defend their position that they are trying to keep their patients safe – whilst everyone points the finger at social care to claim it is ‘their fault’.
The Five Year Forward View described by Simon Stevens, is the current attempt to essentially ‘get on top of the workload’. It is an approach we should, I believe, put our cynicisms aside for and feel a tad excited about. Having seen many attempts to reorganise, reshape, restructure and reconfigure the NHS in the past, this is the first time I can see that there is an overarching objective of joining the dots up, working from the bottom up, to make the system work better for patients…more and more patients. A difficult task bearing in mind how many dots there are.
The problem with making it work however, is not the never-ending issue of whether there is enough money – there never will be. No matter how much money you throw at the NHS it will happily absorb it and the lack of it is not the only hindrance to progress. The big problem we have, ironically, is loyalty – because the success of the FYFV depends on integration. A buzz word – but it is an important word. Integration means an NHS without borders offering whole-system solutions.
Achieving this while there remains parochialism and defensive behaviours and strategies that evolve because of the very pressures we are trying to ease, requires strong, impartial leadership. It also requires a significant change in the culture and processes of commissioning – but that is another story too big to cover here.
Whichever part of the NHS you work in, no matter how much you moan about it, there will always be that tendency to be overwhelmingly loyal to your sector or profession – whether acute, mental health, primary care, community, ambulance, allied health professions – because you, of all people, know what those services are there to do and you see good being done every day and night. You understand the complexities of all the parts that make your organisation function and you feel the full force of the challenges it faces.
Most of all, you have a fair idea of what needs to change in order for your sector to function better. Working in the NHS ultimately makes you a problem solver, whatever your role and whatever level you are at. After all, you joined the NHS ‘to make a difference’. I would point out, having worked in the ambulance sector for 20 years now, that those who work in the ambulance service are notorious in being un-thanked and un-rewarded problem solvers!
The challenges faced by the NHS are so often portrayed in siloed terms in the news: “Nurses are crying, doctors are quitting and we don’t have beds for patients” (The Mirror), “Paramedics in crisis” (The Guardian) “A&E Crisis exposed” (The Telegraph), “NHS Mental health care in crisis” (The Guardian), “District nurses could be a thing of the past without urgent action” (The Independent) – and there are certainly gaps to be filled, but just filling in the gaps will not change the way we work and what is on offer. We will simply be trying to hold back the tide with the same sea defences, and these can only go so high.
And so, the Five Year Forward View, together with the Urgent & Emergency Care Review, has sought to bring the problem solvers together to find system-based solutions that will achieve a new vision. What hasn’t been factored in however, is the deep-rooted loyalties that fuel the vested interests of all of the providers being told to integrate.
All too often our organisational attentions are focussed, out of necessity on righting our own wrongs, balancing our own books and filling our own gaps. However well-intentioned are the aims of the problems solvers and the visionaries, unless the newly termed ‘system leaders’ are able to be objective and hold onto the holistic aims of the FYFV, these siloed, vested interests have the potential to stymie the development of the best and most radical solutions that will transform service delivery.
We need to stop looking at sector-specific problems – ‘waiting times in A&E’; ‘not being able to get a GP appointment’; ‘ambulances not reaching patients fast enough’ and instead look at who our patients are and what they really need. The ambulance sector knows that it wants to address the needs of our local populations and improve outcomes by offering more Hear & Treat and See & Treat responses for example – but these can only be effective and offer value for money if there are the more appropriate services available in the community, out-of-hospital, that patients can be referred on to.
This new era of Sustainability and Transformation Plans cannot be about plugging the gaps and addressing deficits. It is meant to be about integrating services to create alternative pathways of care for patients, shifting the weight of care away from the acute sector to appropriate and more timely provision in the community or home setting.
When planning and designing future-proofed healthcare delivery, we need to be able to lift our heads up out of the mire we find ourselves in and, especially for those who are leading on the STPs, our organisational loyalties are going to have to be superseded by our common loyalty to the NHS and all of our patients if the right alternatives are going to flourish.
This will require all providers, and commissioners, to genuinely recognise and understand the competencies and capabilities of other sectors and professions, as well as our own limitations, and embrace working together, accepting the need to share out the inevitably limited resources. It may mean specialist centres and services taking direct referrals from a health professional other than a GP or consultant; or having multidisciplinary roles working together as teams in ways they haven’t done before; or perhaps sharing our workforce through rotational rosters or allowing other, competent clinicians to take the decisions we believe that only we should take.
Some of this is already happening – for example, paramedic practitioners undertaking home visits for GPs; nurse practitioners and midwives working in ambulance clinical advice services; physiotherapists working in GP practices without the need for GP referrals offering radiological referrals, injection therapies, and referral into specialist services; pharmacists providing vaccination services; police, mental health nurses and paramedics responding together as one unit to those in crisis.
These pockets of new and innovative practice that use NHS resources differently and can demonstrate their effectiveness in terms of patient outcomes rather than time targets, need to be developed rapidly to become the norm for how the NHS is delivered, and that means letting go of current norms and sector loyalties to blur the borders of service delivery.
Relinquishing that little piece of our professional domain and ‘the way we have always done it’ needs to be seen as making the NHS stronger and better for patients, rather than our own role or profession somehow becoming less valid.
Just as we have learnt over the years that it is ok and important to be able to say sorry when things go wrong, we all, especially those leading our NHS organisations and commissioning structures, need to get better at accepting our limitations and loosen our organisational loyalties to support innovative solutions that cross borders both in and beyond the NHS family.
Hilary Pillin
Healthcare Consultant at AACE
