"We pity in others only those evils which we have ourselves experienced." ~ J-J Rousseau (1712-1778)
We all want a better NHS and the present government has spent a huge amount of money to effect improvement. In order to ensure that the money was not wasted, and to measure how much the spending is improving matters, measurable targets were introduced. These were intended to show, for example, that waiting times are falling. At the same time, strict budgetary controls were put in place to ensure adherence to the spending plans.
The unintended consequences of these policies have been frightening. Among the worst is the phenomenon of "gaming", which reveals much about the mindset of the people charged with our welfare.
Seriously ill patients left to suffer
To meet the target that accident and emergency cases should be seen within four hours, hospital managements have instituted policies that mean that newly arrived critical patients may be left to wait while less urgent cases who could safely be left but arrived earlier are dealt with first. In this way the less urgent patients do not exceed the four hour deadline. This reduces the number of potential black marks on the hospital's performance target. But seriously ill patients may be left to suffer risking the eventual outcome of their treatment and, sometimes their lives.
It has also been reported that patients not seen within four hours can be left almost indefinitely. They can only be counted as falling outside the target once, so there is no longer an incentive to see them at all.
Also, to delay the start of the four hour deadline patients can be left waiting outside in ambulances. The clock in the reporting system only starts to tick once the patient has entered the hospital. This means that the ambulances are not freed to return to service as quickly. But, of course this is not the hospital's problem.
To its credit, the government is trying to audit the situation better and is stamping out instances of gaming when they come to its attention.
Management ignores impact on patients
But the real question is: how can a group of people in a position of power and control believe that it is right to focus on achieving targets, while ignoring the impact on patients. At best, fearful and vulnerable people are left without support or help. At worst, health and lives are put at risk.
Another horror which has come to light is the instruction given to cleaning staff in one hospital to turn over sheets instead of washing them – to save money. And this at a time when hospital-acquired infections are killing patients. Again you must ask the question: what is going on in the heads of those that make these decisions.
An insight into how this might happen was provided by a series of three programmes on TV where a management expert, Gerry Robinson (who had proved his ability to turn around failing companies) was asked to cut waiting times in an NHS hospital without spending extra money. A major obstacle that he encountered was the reluctance of the chief executive to come out of his office to see what was going on in his hospital. He hated leaving his comfort zone – which was analysing figures – and saw no benefit in meeting the people he was managing.
My argument here is a little complicated but please bear with me. The chief executive saw his job as studying financial and statistical reports and using them to find ways to allocate his resources better. He had been successful in balancing the hospital's budget, for example. He did not see it as part of his job to watch the hospital at work, gauge morale, understand logistical problems, pay attention to detail and judge the effectiveness of the team he was leading. He did not see how his skills and position, and his visible lack of concern, and complete lack of encouragement could affect his staff and help them with their problems. If that was his attitude to his staff, for whose jobs he was responsible, imagine how remote he was from the patients.
Quick and dirty ways to make the figures look better
With that sort of leadership, it is easy for a culture to thrive where managers just look at numbers and seek quick and dirty ways to make the figures look better. And once in existence a culture reinforces itself. (Presumably that is how the CE got his job.) Anyone with sensitivity, anyone with imagination, will not want to work long in an environment where callous decisions are routinely made. They will drift away. (And whistle-blowers are pilloried). Meanwhile, the administrators left behind will recruit staff who see things in the same way that they do: that the whole thing is a game where the sole objective is to get the numbers right.
Going into hospital is frightening. Sickness makes you vulnerable, and however minor your problem, you are surrounded by the suffering, pain and fear of others. Your own mortality is never far from the front of your mind. If this is exacerbated by a callous institutional framework more interested in its own problems and preoccupations, the experience becomes much worse.
Irreconcilable clash of cultures
So it is not surprising that Patricia Hewitt (The Health Secretary) faced such a hostile reaction when she addressed the Royal College of Nurses. Many doctors and most nurses are drawn to the profession by a vocation to care. I have been relatively lucky with my health so I have not had to meet too many nurses, but all those that I have met, have shown genuine care and empathy and have helped me through frightening times. It is lucky that these medical staff act as a buffer between patients and an uncaring administrative structure.
But in an uncaring environment these humanitarian instincts are undervalued. Doctors and nurses feel unappreciated. There is an irreconcilable clash of cultures. No amount of money spent by the government will improve matters if the bureaucracies through which they effect their policies tolerate – and indeed generate such callous behaviour.