Abstract
Despite all the publications, investigations, books, column inches, airtime and screen-time dedicated to it, the practice of medicine remains, for all practical purposes, invisible. The image of the doctor continues to be an idealized model that reflects people's aspirations rather than their actual experience. 1 While medical practice is continuously improving, it has not kept up with patients' rising expectations. Many things are much better than they were, but few things are as good as people have been led to expect. 2 What patients expect is what they can understand and often amounts to a perception of attitude. Ironically, in the mid-20th century, when medicine could do a great deal less than it can now, much more attention was given to attitudes because, in practice, that was all doctors had to offer patients. 3 These attitudes: kindness, caring, good communication, honesty, reliability, trust – the interpersonal parts of doctoring, which are critical to patient perception – form the fabric of the cloak of invisibility that continues to defy a more complete understanding of the practice of medicine. These attitudes and attributes, built on critical personal values, have been eroded through pernicious dilution by our preoccupation with the rise of scientific medicine. 4, 5, 6, 7, 8 A survey by the General Medical Council (GMC) in 2000 reported that only 60% of doctors believed that those personal attributes were important to the point that if they were not done properly, something should be done about it. Forty percent did not believe that those attributes were important, and this proportion is roughly the same proportion of doctors who have doubts about whether, if it arises, something should be done about suboptimal or poor performance. 3
Yet, by every orthodox and conventional measure, the NHS is better than ever before. However, it is the well-measured truth that tells the darker lie – investment and access to care are important only if the care itself makes the difference. The fundamental issue of what happens to patients once they reach the hospital or doctor of their choice has, until recently, remained largely invisible. More and more, any progress made is seen through the filter of actual patient experience. Waiting times are assumed, access is assured and the bar is raised. But can the skills that delivered on waiting times deliver for patient experience? Too often, the whole experience of care is so awful not because of the actions of individuals and despite the impressive care and professionalism of so many of the staff who care for patients, but because of the lack of values reflected in uncaring systems and processes that leave patients so powerless, frustrated and frightened. 9 For human beings it holds that satisfaction equals perception minus expectation – small, unexpected rewards can have disproportionate effects. 10 Time spent with a patient, a hand held, a small kindness, a caring act, honesty – any of these seemingly inconsequential actions have a critical impact well beyond their stand-alone worth. These critical but unmeasurable behaviours cannot be bought or commanded, they arrive with a set of values and thrive or wither as a function of organizational culture. They reduce fear and anxiety and revive hope and optimism. The provenance of such value-based behaviour is unknowable – like poetry that keeps its own secret, the motivation of our finest doctors and nurses resists the last thrusts of deconstruction. The importance of values cannot be underestimated. Of course, there are many, many dedicated, caring, talented staff in the NHS. Doctors, nurses, ward clerks and porters are the beating heart of the NHS. The caring and kindness offered by these people is the pulse of that organizational heart. When that caring and kindness is divorced from delivering on targets, there are bound to be unintended consequences. When care is unacceptable and everyone knows, nobody says and nothing happens, and worse, the same behaviour continues, unchallenged, then there is a problem. Without holding onto our values, there is a danger of becoming, quite literally, a demoralized profession, where nobody will tell the truth anymore about what is good and bad, right and wrong.
The simple yet priceless values of pity, tolerance and unselfishness – the graces of civilization – underpin the attributes of compassion, caring, honesty, kindness, good communication and trust. Those values struggle to survive in a culture which is over-managed and under-led. The mania for setting targets has, over time, exerted a profoundly corrosive effect on the NHS, introducing a form of corruption much worse than the monetary kind. The unintended consequences are deep intellectual, moral and spiritual decline that renders all official statements doubtful. Clinicians hold trust as a currency; without it, the doctor–patient relationship is nothing and medical care cannot function. The health of that trust is in a parlous state. Doctors believe that targets have compromised patient care, undermining clinical decision making in favour of furnishing officialdom with statistics. The unthinking voices of those who have a shallow understanding of the real challenges of medicine attempt to reconcile the inexcusable and ill-judged with their ‘visionary’ strategy. The central challenge is not so much one of challenging people's behaviours but of rediscovering lost values. 11, 12, 13
As Deming famously said, 97% of what's important in most organizations isn't measured. 14 There is a vague, unformed sense that we are being ruined by our best efforts, which being directed at the wrong things (i.e. the 3% measurables) or even at the right things in the wrong way, means that we seem to end up in a worse position than the one in which we started. There are excellent doctors and nurses who find themselves beyond caring, numb to spin, hopeless and helpless. They easily recognize that the safety of patients is a lower priority for many hospitals than balancing the books and hitting performance targets.
In the absence of unequivocal commitment to a clear set of mutually accepted shared values, organizations tend to become unhinged during stress. 15
Our social and professional networks often overlap, which is why we don't always say what we really think. In fact, the anticipation of the upset is far greater than the reality. Why wouldn't clinical leaders say to colleagues who will be influenced by them: ‘It is the right thing to do, we should do it’?
Providing you give people a mechanism to put things right, speaking your mind is appropriate for a leader. Cultural change will happen, and soon. There is no choice. At the heart of that cultural change will be a new-found leadership of the NHS, and that leadership will use the springboard of rediscovering lost values to take them where they need to go.
‘Our lives begin to end the day we become silent about things that matter’
Footnotes
DECLARATIONS
Footnotes
Acknowledgements
None