As Robert Francis is a lawyer, he understands British legal culture, in which rules are deliberately kept as explicit as possible. Nuance cannot be the basis on which legal judgments are made, and so all the factors needed to reach a verdict have to be transparent and ‘hard’. But his final report on the mid-Staffordshire hospital crisis was wise enough to acknowledge the need for complex cultural change, and the challenge of making such ‘soft’ changes happen.
However, the actions that have emerged following the publication of his report in February seem to reflect his views less than the need of politicians to be seen to be doing something. The report may refer to the ‘softer’ less quantifiable aspects of healthcare such as ‘caring’ and ‘culture’, but the remedial steps announced so far seem to be based mainly on regulatory systems predicated on punishment and duty, not on motivation or positive intent.
Thus, the Secretary of State for Health announced ‘a new regulatory model under a strong, independent Chief Inspector of Hospitals’ and introduced ‘a new statutory duty of candour for providers, to ensure that honesty and transparency are the norm in every organisation’. Even the stipulation that nurses should spend a year as health care assistants before they take on ‘proper’ nursing seems a fairly mechanical way of changing values (as well as saying a lot about how we distinguish caring from curing, and the ‘proper’ role for nurses).
I may overuse the aphorism that ‘the floggings will continue until morale improves’, but if ever there was an illustration of its paradoxical ridiculousness, then this must be it. Concepts such as honesty, candour and openness patently cannot be forced onto staff, and so even at face value, such statements will only increase the cynicism that besets so much of the NHS.
The announcements are in themselves an important indicator of the deeper malaise in NHS leadership, where there seems to be no insight either into the manner in which the workforce functions, or into the importance of coherence between rhetoric and behaviour.
Let’s start with the workforce. Vocational occupations, such as medicine, nursing, teaching, policing, and even parenting, all depend for success on their practitioners’ professionalism. My personal definition of what professionals do, is to fill the gaps left by reductive methodologies. Once the rules have been applied, the spreadsheets completed, and the safety checks carried out, it is professional judgment that assesses the nuances and shades of uncertainty that highlight the impending disaster, the malingering patient, the struggling pupil.
The detective’s hunch and the doctor’s gut feeling are key skills, and without such professional behaviours, all the activities described above (even parenting – or NHS management for that matter) tend to lead to worse, and more expensive, outcomes.
Professionalism is the mortar between the bricks of the formal tools, holding them together, yet by definition it cannot be pinned down (or it would have been formalised into mechanical tools long ago). The systems depend on their professionals applying their nebulous skills effectively, but enforcement is nigh on impossible as the ephemeral nature of these skills means that we can’t easily identify deficiency as if wewere checking the accuracy of a temperature or the frequency of a bowel movement.
The motivated detective, keen for approval and promotion, will use his inspired hunches to brilliant effect, whereas his demotivated, burnt-out partner will stick to the rules and hide from disapproval and discipline behind an impenetrable ‘jobsworth’ shell, without actually doing anything wrong. The more we reinforce these respective behaviours, the more each detective will stick to them.
The key to successful change is to understand the factors that actually drive professional behaviour. Approval and promotion work better than disapproval and discipline. For professionals of any kind, the way to motivate them is to tempt them with increases in status, peer approval, patient benefit, pet projects, better income, and more fun in their work.
Of course, carrots need their obverse sticks, and the implicit threat of reduction in status, peer disapproval, patient disbenefit, lower income, and boring, difficult work probably all have a place in the successful management of professionals.
However, carrots work better than sticks – once a culture is perceived as punitive rather than encouraging, then motivation becomes logarithmically harder to achieve.
Jeremy Hunt’s edicts about firmer regulation and harder floggings are likely to be counterproductive, in the same way that thirty years of bullying clinicians to behave more corporately has had so little impact. Until they can understand and feel the benefit of a new behaviour personally, doctors, nurses, teachers and policemen will at best ignore or at worst sabotage each new exhortation, and feel less and less inclined to change.
The NHS is supposed to be a single state-controlled system, so there probably are important elements of corporacy that need to be developed, such as more consistent treatments, communications, and outcomes. But if corporate behaviour is important, then the way to implement these targets is by relating the desired behaviours to professionals’ own agendas. Include the clinicians in problems, involve them in their solution, ensure that the personal benefits and dis-benefits are clear, and so on – there’s a lot more to be said about this on another occasion.
However, the final point to be made is the most important. The incongruity of trying to bully professionals into less bullying behaviour will not be lost on any of the professionals working in the NHS, and the mixed message it gives them about the system in which they work means that their behaviours are unlikely to change.
This blog is based on an article published in Pulse in the UK on 22 April 2013.