Surviving Work in Healthcare

Helpful stuff for people on the frontline

Elizabeth Cotton

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781472464286
• eBook ISBN: 9781317048091
• Topic: Business
• Subtopic: Business General
• Index: Business

The book takes as its starting point the crisis of healthcare in the UK: impossible health targets managed through command and control management and a stomach-churning rise in racism, whistleblowing and victimisation in the NHS. The use of nationally set productivity targets combined with austerity cuts have increasingly put clinical best-practice into direct conflict with funding. Health targets have become politically controlled, and performance has become a cynical exercise in ticking boxes, cascaded within trusts and bulldozed through frontline services. This has led directly to a precarious system of employment relations, subject to the continual restructuring of services rather than the goal of creating functioning interdisciplinary teams that stand a chance of capturing clinical excellence.

This book is written for workers and managers who are on the frontline of the battle for decent healthcare. The content of this book is based on the 'ordinary' expertise of the people who are actually surviving it and helpful ideas about making the best out of a bad lot.

Surviving Work in Healthcare will be of interest to healthcare professionals and anyone working on the frontline of healthcare as well as students of management, human resources and psychology.

1 Understanding healthcare systems

“Working in health and social care is a political thing. It doesn’t matter what your ideology is, we’re dealing with political phenomena like the winding down of the welfare state and the fact that 30% of health workers are also on benefits because they don’t earn enough.”

Surviving work conversation: understanding healthcare systems

MARIANNA: By systemic change I mean that the discourses and meanings have changed that are associated with health and care. They are concretised by financial arrangements, but actually they are based on political ideologies in my view.

JULIAN: It seems to me that the financial structure that we’re now struggling with could never have taken place if the idea of the welfare settlement hadn’t been so seriously challenged. The welfare state became renamed ‘The Nanny’ without asking where the money had gone and why. There’s also been the relentless denigration of professionals. So you had an attack on the instruments of welfare – undermining its value as a humane social function – it becomes this endless debate about the destructiveness of dependency. Then you attack the workers – calling them charlatans – and attack them so comprehensively whether they’re care workers or social workers. Currently the current junior doctors’ contract is a disgrace. I speak with some feeling about it because my daughter is one. It’s the relentless substitution of the professional class by the consuming class. The ideological context is just as important as privatisation.

MARIANNA: Vulnerability has been associated with failure. For example if you are sacked from your job you must be doing something wrong. If you are ill it is your personal failure. This is underpinned by attacking anything that is to do with collective values, collective action and just relationality like communities, even families. Your metaphor of the mother and the nanny – a person we normally pay, a person we contract out to provide care, and that shift is so fundamental. It has such a deeper meaning and consequences. On the one hand vulnerability is just exiled, it’s a personal failure, and on the other hand those individuals are also consumers. No more citizens or people in need. The concept of being human is just collapsed into a concept of being a consumer.

JULIAN: It’s penetrated so much of the training now. The training I had as a social worker – the psychosocial underpinning of it – moving more and more into an instrumental competency-based training in which the relational has taken a very poor second.

MARIANNA: Actually the patient doesn’t know why his or her care is the last consideration in the whole system. You have different people who design care, different people who report on financial targets, different people who are on the front line. Nurses versus doctors are endlessly pitted against each other, and the patients’ interests are often going out of the window. That splitting is by design – introduced to break down this collective logic that underpins the collective values that in turn underpin the NHS. Universalistic values, this is what’s been attacked.

To hear the full conversation between Julian Lousada and Marianna Fotaki go to www.survivingworkinhealth.org.

Understanding healthcare systems

Keeping track of reform in healthcare is literally a full time job. Even senior healthcare professionals struggle to keep up with the daily reports on new policies, funding deficits, Care Quality Commission (CQC) reports, academic research and steady flow of crises in local services. This book was written during the summer of 2016 – holidays being the traditional period of radical cuts and new government policy slipped in while the healthcare leadership are tucked away in the south of France. No trade union can organise a meeting let alone strike action, and urgent emails are returned with auto messages of ‘I’m really tired, leave me alone’.

Not wishing to get all conspiratorial on you, but this is pretty convenient for the individuals and organisations that have failed to win the political battle to shut down the NHS but have made enormous progress in dismantling it by stealth.

For many people working in healthcare the bigger picture is a depressingly obscure patchwork of shiny ‘new’ management techniques, bad news, smoke, mirrors and a sense of déjà vu. On the last day of writing this book I clicked onto Twitter to find the long awaited results of a review of bursaries for midwives and nurses – all gone, replaced by student loans and unconfirmed announcements of a 40% cut in Health Education England’s budget. Goodbye to the development of the next generation of frontline health workers without even pause for a headline.

As the proofs came in there was a moment when I thought about putting a match to the whole manuscript because of the emergence of the Sustainability and Transformation Plans (STPs) which, despite their claims to putting power into local hands, represent a catastrophic reduction in funding and clinical decision making in the NHS. Nobody had ever mentioned STPs throughout the whole process of writing this book and yet by December 2016 their introduction by stealth threatens to obliterate what remains of any prospect of managing healthcare.

Campaigning groups that have very quickly mobilised around blocking STPs, such as in Liverpool and Sheffield, estimate that the plans include an implicit target to cut NHS spending by a further £25.5bn. They call them Secret Theft Plans or Slash Trash and Plunder. It is my considered view that public health services in the UK will die out over the next ten years. What is emerging is a downgraded model of sub-care, a regime of compulsory fitness founded on gaming data and demoralised workers. This radical shift towards un-care is welcomed with wide open strategic arms by the thousands of private contractors and employment agencies waiting to negotiate the next round of health contracts. As the great and the good retire and new generations of workers enter a confused market with no sniff of a pension or secure housing, the crisis in health is about to hit a tipping point. This is just my view; I sincerely hope I am wrong.

This book is written with this tipping point in mind, for workers and managers who are on the frontline of the battle for decent healthcare. In order not to add to your problems I have attempted to present a model for understanding and surviving work that does not ask you to risk your own health or sanity. The content of this book is based on the ‘ordinary’ expertise of the people who are actually surviving it and helpful ideas about making the best out of a bad lot. It is written in a non-academic and at times blunt way, but what it loses in subtlety it gains in authenticity. I believe that organising and psychoanalysis are ordinary processes for ordinary people that can be talked about in ordinary language. So, if you are a political or psychoanalytic purist, this book will annoy you, so save yourself the bother and put it down now.

Surviving work is a dual task – it involves both trying to change our working conditions while at the same time surviving them. Most of us cannot actually afford to lose our jobs, and that is a reality that has to be a part of the survival strategy. The proposals within this book are directed at this dual objective of transformation and survival under current conditions, so using them is not dependent on systemic change or winning the battle for the NHS. You do not need anyone’s permission to start to build your relationships at work, and whatever the outcomes of the next few years of reform, these techniques will put you in a good position to survive them.

The proposal that I want to pitch to you in this book goes like this.

From targets to teams

Over the last thirty years of marketisation of public services, the way healthcare is managed has moved away from a focus on delivering services towards a preoccupation with performance management. We have seen the growth of New Public Management (NPM) techniques to address a problem of demand outweighing supply in healthcare by reducing it to a technical problem of staff productivity and efficiencies. In stark contrast to this sanitised picture stand the Francis reports, following the Mid-Staffs inquiries, which offer us an insight into the crisis of care in the UK: impossible health targets managed through command and control management and a stomach-churning rise in racism, whistleblowing and victimisation in the NHS.

The use of nationally set productivity targets combined with austerity cuts have increasingly put clinical best-practice into direct conflict with funding. This has led to a cynical culture of gaming in NHS management – where ticking boxes has become a parallel system of political football. The balls that get kicked around include waiting times in Accident and Emergency (A&E) and ‘recovery’ rates in mental health which generally involve putting patients in ‘holding’ positions, where initial contact is made in a relatively quick time but treatment by senior clinicians much further down the line. This is not measuring treatment, it is measuring waiting lists.

In order to prove the efficiency of this new economic logic, the drive to introduce accountability measurements has been intense. Health targets have become politically controlled and centralised, with government ministers dictating what healthcare providers should do and by when, unencumbered by any actual clinical experience or knowledge of the communities where healthcare is being delivered. NHS performance has become a top-down command and control system, cascaded within trusts and bulldozing through frontline services. This has led directly to a chaotic system of employment relations, subject to the continual restructuring of services rather than the goal of creating functioning interdisciplinary teams that stand a chance of capturing clinical excellence. In response to the NHS deficit generated by escalating demand and chronic underfunding of adult social care, in 2014 the Chief Executive of the NHS in England, Simon Stevens proposed proposed A Five Year Forward View which aims to maintain quality services through innovation and cost savings in return for additional governmental funding by 2020–21. Part of this deficit relates to healthcare providers - estimated at £2.45bn - unable to deliver ‘efficiencies’, particularly in relation to staffing costs and the rising cost of agency labour. A key part of the Five Year Forward plan is the creation of Sustainability and Transformation Plans (STPs), which despite their progressive name stand to be probably the least sustainable plan for NHS restructuring to date.

STPs, clustered in acute and specialist care which represents the main bulk of provider deficit in the NHS, are tasked with eliminating the gap between costs and funding by creating 44 ‘local health systems’ that create ‘footprints’ for planning and delivering care. If they manage to do this in 2016/17 this allows them to access £2.1bn of ‘transformation’ funding, not new money but part of the £10bn NHS funding agreed in the 2015 spending review. The main bulk of this £2.1bn will go to emergency care, and smaller pots for efficiencies and transformations in service delivery.

The first thing to say is that these are not ‘local’ in any meaningful way. Despite their ‘localizing’ objective these STPs are massive structures covering on average 1.2 million people, merging local authorities and CCGs. Its hard to see how bringing together an average of five CCGs into one group could possibly lead to more local control over planning and securing good deals with local providers. If the last three decades of neoliberal economics and the consolidation of finances into a smaller number of corporate hands is anything to go by, its hardly going to put commissioning power in the hands of civil society.

Secondly, the timescale for the creation of STPs makes it impossible for these local actors to even call a meeting let alone carry out a serious strategic and inclusive exercise for the next five years of services over such large population sizes. Despite not many people knowing anything about STPs, the final STP Delivery Plans were submitted on the 21st October. These full plans were not published, rather they were sent to NHS England for revisions, with a likely publication in mid-December. On the 23rd December 2016 CCGs have to sign two year operational contracts with providers, starting on 1 April 2017. Even for the most committed local health campaigner, even if you knew about these deadlines, the chances of actually reading the plans and then organising a genuine consultation about them are extremely unlikely. It also means that service user involvement and accessible services are principles that will not even get on the agenda, leaving STP members to carry out the Kafkaesque job of ticking the sixty diversity and inclusivity boxes that they are required to do knowing full well that the real stakeholders have been left without any meaningful role to play. At its very best, this offers local health groups the option of a headless chicken approach to health management. At its worst it will lead to a radical decline in patient care and safety.

Now for the really funny bit. The principle requirement for STPs is that the CCGs and providers that form the main bulk of these STPs have to square the circle of NHS funding by cutting expenditure enough to stay within their budgets for 2016–2017. If they over spend, and do not improve patient care at the same time they will not be able to get any further ‘transformation’ funding. But if the books already don’t balance, are STPs are just being tasked to cull staff and services by the end of 2017 in order to secure future funding?

This cuts-dressed-as-innovation is a familiar slight of hand for those health warriors who were involved in the creation of CCGs where cuts in budgets combined with devolution of healthcare provision to local services and penalties for not implementing impossible targets worked very well in shifting the burden of responsibility from the government to local stakeholders. The task of balancing the NHS’s books in one year while at the same time improving patient care is literally impossible leaving STPs with the option of failing or gaming. This is not just a sanitised process of ticking boxes, its actually about cutting services and, increasingly, getting people back to work. With the advent of the DWPs new Health and Work Programme in April 2017, this derogation of duties of care will get worse.

Although the failures of a target-oriented healthcare system are widely understood, with even Jeremy Hunt calling for more transparency and fewer targets, the reality is that the entire system of monitoring public services rests on measuring targets that clinicians did not set. Unless this top-down model is addressed, then the appeal for innovation in healthcare becomes just another ministerial dictate with more than the usual hint of irony.

The first proposal of this book is that at some point the people working in healthcare are going to have to reject the targets set for them in Whitehall. Yes, we are going to have to negotiate with senior management about what targets are set and by whom. On a policy level this means securing a real commitment to local autonomy in decision making that responds to local needs and resources. On the frontline this means organising ourselves for the battles ahead – and the possibilities that we have to continue to work under a structure that is diametrically opposed to good patient care.

Mindless measurements and nonsense data

The other key problem is that this system of targets is maintained by a rigid system of measuring performance and outcomes. Even putting aside the misinformation that gets circulated about NHS finances, there is no shortage of data in the NHS. The problem is what sense we can make of it.

This drive to measurement in the NHS started out with Blair’s proposal that you cannot manage what you cannot measure. The problem is that just because you are measuring something does not mean you are actually managing it. Measurements only work if they inform better patient care, which, in the current climate, they do not, and in many cases are quite the opposite. We all know that much of the data that is collected makes no sense at all because it is designed around a model of care that is chopped up into neat pieces. What gets measured is not patient care, but carved-up part-care tasks such as waiting times and discharge rates. This Taylorist version of healthcare reduces the actual job that needs doing to part-processes – assessment here, medication there – rather than the actual job of responding to the whole human being in front of you. The measurements do not actually measure healthcare.

This system of measurement and reporting has a profound effect on how people are managed. Filling in forms becomes more important than finding the right treatment for a patient, and the clinician who wants to think about what is best for the patient is punished for inefficiency. It encourages clinicians to become mindless in their work, prioritising targets over the specific needs of the patient. Given that clinicians know this is happening, one way of coping with it is to stop thinking about it. To switch off our critical minds to the impact this has on patient care and safety.

For services in crisis these reductive measurements of care are used as a stick to beat the non-compliant clinician. A refusal to discharge a psychotic patient becomes a conversation about a backlog of online filing and a missing report from February 2014 with your line manager. This is not paranoid – it is what happens when people do not agree about delivering care and tired or inexperienced managers decide to enforce poorly designed project management techniques. It is a very common experience that these tools can easily become weapons in teams where there are conflicts over care. It is one explanation why mindless measurement tasks that cost millions in staff time and ev...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• 1 Understanding healthcare systems
• 2 Start where you are
• 3 Precarious work
• 4 Precarious workers
• 5 Walk the line
• 6 Groups and gangs
• 7 How to make friends and influence people
• 8 Making the best out of a bad lot
• 9 Helpful stuff for human beings
• Index