Admittedly, some people appear to thrive on conflict.
“No drama Obama” was known to have a “circle of people who were collaborative and nondefensive” whereas Hillary Clinton was reported as having “a staff consumed with infighting over how to sell their candidate”
Why do some organisations develop cultures where conflict is managed productively whereas others have cultures where members work against one another? In their classic work on the social psychology of organizations, Katz and Kahn (1978) observed that “. . . every aspect of organizational life that creates order and coordination of effort must overcome other tendencies to action, and in that fact lies the potentiality for conflict” (p. 617). Put simply, conflict in organisations is perhaps inevitable given that humans therein need to manage their mutual interdependence. According to a news story published eight hours ago, the presidents of 22 different Medical Royal Colleges and Faculties say the planned all-out strike by junior doctors in England at the end of April over a contract dispute could be damaging to patients and should be suspended.
And they say ministers should hold off imposing the controversial contract.
The presidents are asking both sides to “step back from the brink” and re-enter negotiations. But the major conflict is not within the medical profession – with most consultants supporting their juniors (in light of the knowledge that the consultants are likely to be targeted next). The major conflict is between Jeremy Hunt and the Department of Health and the entire workforce. This is obviously where Jeremy Hunt’s delusions of grandeur in comparing his post to the CEO of an international successful organisation must end.
In an interview with Dr Fiona Godlee, Editor of the BMJ, Jeremy Hunt calls the notion that poor funding threatens patient safety is an “incredible dangerous argument”. Hunt says “safer care costs less”. This is a useful soundbite, but most junior doctors of my generation can remember carrying the bleep for many medical wards and the Medical Admissions Unit at once. But now apparently it’s even worse – with rota gaps meaning juniors are literally having to be in more than one place at once. Clearly, if a NHS Trust is spending all its money on PFI and PR, it won’t have the luxury of having one extra doctor covering the wards at night, which would make a huge difference in staff welfare as well as patient safety.
“More importantly, you have to step back – there’s never been a time when people haven’t claimed that the NHS is short of resources.”
So, curiously, the Secretary of State produces an Aunt Sally argument, an undeniable extreme. But the question is whether things have got any worse or not under his tenure. The same problem applies to his other statement, “I don’t think that workforce planning has a strong point for many decades.” The issue is that planning has undeniably got worse, with the Department of Health cutting the number of permanent nursing staff, whilst footing an agency staff bill. Jeremy Hunt here is doing what members of the medical profession have indeed complained about: that is, focusing on the money at the expense of other arguments, such as clinical leadership. For safe staffing, the situation is clearly more complicated, as the NICE guidance would have shown if Hunt had not kept it hidden from view.
The use of overtime or temporary staffing styles raise many questions as to the quality of patient care and have led to great job dissatisfaction amongst the nursing community. But this is not the only identifiable cause of low morale amongst nurses – others being the bursary issue and lack of pay rise for many. The use of temporary nurses to staff patient care units has been intimated to be associated with a higher incidence of patient in-hospital injuries, medication errors, and 30-day patient mortality. Additionally, understaffing a patient care unit is also detrimental to the quality of patient care as it is mooted that each additional patient cared for by a registered nurse increases 30-day patient mortality while also increasing nurse burnout and overall job dissatisfaction. Meanwhile, increased direct patient care by registered nurses leads to less hospital-related deaths and shorter hospital lengths of stay. So a reasonable conclusion is that maintaining a permanent nurse staffing level in all patient care units that best meets pre-determined nurse-to-patient ratios in all nursing shifts is therefore paramount for patient safety as well as nurse satisfaction.
“Trusts have said, following Mid Staffs, we need to make sure that every single ward is properly staffed.”
Jeremy Hunt, arguably, needs to see a counsellor over this fixation with Mid Staffs.
This would’ve been a perfect time to mention the importance of ‘whistleblowing’ – and even a brief mention of the legal loophole where junior physicians aren’t protected in whistleblowing whilst upholding patient safety (see the recent Dr Chris Day case.) No such luck, unfortunately.
But this is from the Daily Mail only last July 2015:
“A ‘toxic’ culture of bullying amongst NHS staff is putting the safety of patients at risk, a health minister has warned. Lord Prior revealed that a quarter of employees have been victimised by their own colleagues, a rate unheard of in other organisations. He said the health service needed to learn lessons from the supermarket chain Asda where staff feel valued and turn-up to work with a sense of pride. By contrast, he spoke of how many doctors, nurses and back-office healthcare staff had become ‘switched-off’ and disillusioned.”
Hunt continues:
“I would like to see us investing an increasing proportion of our national income on healthcare. That’s why need a strong economy. I did make that case very strongly in the spending review, not just the £8 bn that the NHS asked for, but the £10 bn.”
However, the testimony from David Laws says otherwise. But these cuts in corporation tax and capital tax gains tax won’t find themselves, you know?
“The challenge for us is whether we’re going to use the money in the best way to deliver high-quality care.” That’s going to need strong support from clinical staff. Managers cannot do this alone.”
Except with 98% of juniors having balloted to go on strike, and Jeremy Hunt himself launching an investigation into staff morale, I wonder how Jeremy Hunt feels that he is going to generate this support. Hunt also curiously states elsewhere in the interview that patient safety relies on a motivated workforce.
Hunt later states triumphantly, “We need to avoid big national programmes, as that’s where we tend to get the biggest waste.” But any head of operations for a massive corporate will tell you ‘big’ also means economies of scale, meaning cheaper procurement. And the advantage of national programmes is that you prevent reduplication and you mitigated against fragmented operations with poor strategy. Here, one suspects, Hunt is being driven by ideological dogma rather than logic once again.
This all prepares Jeremy Hunt ‘for the big one’.
“Doctors have never worked harder. People are stretched and pressurised. It’s very tough at the moment – probably tougher than it’s ever been. I think that it is difficult to judge morale in the heat of the dispute. Look at the big picture. There is a Government which is committed to putting resources in, treating the NHS as different. As the economy grows, we are willing to put more resources in. As a Government, we are totally committed to producing the highest quality healthcare as anywhere in the world. Doctors care passionately about their patients, and we need to create an environment where doctors feel most comfortable about this. It’s no accident that people who are most positive about a 7 day service have the highest morale, like in Salford. There is no shortcut to morale – it’s about creating a culture.”
Err… slight problem…. Salford didn’t need the change in contract of junior doctors to implement their 7 day services (except chief supporter Sir David Dalton later then decided to impose a contract with a sizeable number pulling out of his letter within hours.)
“There is a lot of pressure on professionals on the frontline at the moment.I think the junior doctors dispute has been a very unnecessary distraction. We didn’t need to have a big argument about this.”
And such an argument could equally be advanced by Pol Pot under different circumstances.
“It’s a much safer contract.”
But what about the disappearing safeguards?
“It’s disappointing we haven’t had a better discussion.”
And Jeremy ‘My door is always open’ Hunt clearly is not taking any blame for that one.
“There is a measurable weekend effect in mortality rates. Nobody should hold a gun to the head of the NHS and say, “we are not prepared to discuss this.” We need to discuss 7 day consultant care, 7 day access to social care, 7 day diagnostic care.”
A problem with this is that the junior doctors will be first to want to discuss the ‘weekend effect’ – and we all know how Hunt has deliberately lied about the conclusions of the weekend effect in Dr Fiona Godlee’s own journal, the British Medical Journal. Another big problem with this – who’s going to pay for all the other 7 day promises? It was also a manifesto pledge of the Conservative Party in 2015 that they wouldn’t put up income tax, if the Party were to come into government. One of the big management consultancy firms is about to report on that particular cost estimate, it is rumoured. This all comes from a government which prides itself of economic credibility.
Asked if he would do anything differently if he turned the clock back, Hunt’s answer is quaint, if rather deluded.
“It’s such a huge tanker. You feel privileged, and very daunted about how you can possibly make a difference. I have learnt that world class organisations only talk about the right culture. The right culture cannot be imposed from top down, from the Health Secretary, it has to come from inside. I started off by feeling that I could only create a culture of transparency and honesty. But I realise now it has to be transparency +. It’s now about creating that learning culture, and that will be a long process, and I’ll be long gone before history judges as to whether I’ve been successful.”
One’s heart might bleed, if it were not the fact for the problems in a Liverpool trust reported recently.
“An NHS community trust has been likened to Mid Staffordshire NHS Foundation Trust after a catalogue of failings were identified in a report. There was a culture of bullying and harassment and sub-standard patient care at Liverpool Community Health NHS Trust, the review states. The report criticises trust leaders for being too focused on achieving NHS foundation trust status and driven to reduce costs. The report, by Capsticks Solicitors, states that cases of “inappropriate and unsafe” care were not addressed and response to such incidents was ” grossly deficient”. Staff could not speak out about poor care, they said, adding: “The culture in the Trust was not conducive to raising concerns. It was hierarchical and seen by some as oppressive. Speaking out about concerns was not easy. Such was the impact of this culture that some staff were driven to the brink.”
And the date of that?
Only last week.
Jeremy Hunt curiously forgot to mention that bit.
References
Katz, D., Kahn, R. L. (1978). The social psychology of organizing. New York, NY: McGraw-Hill.