Our Profession in today’s NHS
This is a essay a wrote for doctors for the NHS, who had a competition for junior doctors about what our profession means in the modern NHS.
In our shared office space, where a reprieve from the organised chaos of an 21st century NHS Emergency department can be found, amongst the photos of the consultant’s children and half read journal articles is Nye Bevan’s famous 70-year old quote is cut out and stuck on a board “The NHS will last as long as there are folk left with the faith to fight for it.” However, it is not these words that inspire me, it is the relentless continued actions of my colleges, who demonstrate their faith by continue to work for the benefit of patients despite the normalisation of inadequacy that exist within the NHS in this modern era.
Throughout the junior doctor’s dispute, and equally, in the many cathartic staff room complaining session I have rarely, if ever, heard doctors complain they do not get paid enough. The complaints I hear falls into three broad categories; not being able to undertake their jobs effectively, not being able to undertake sufficient education and having little autonomy over work-life balance. Burnout, compassion fatigue and work-related stress are all simple buzzwords that cannot give justice to the feelings held by all healthcare professionals in our over-stretched system. A nurse being unable to comfort a lady from a nursing home as she waits in a corridor, a ward junior doctor unable to get to a patient to prescribe pain relief because there job list runs to 3 pages and a consultant unable to review unwell patients adequately as pushed to free up bed space. I believe there is underlying misalignment of goals, originating from good intentions, that is contributing to these woes.
Patient’s not targets
One of the most persistence dogmas of post-war economics is that the drive for profit can optimise any system; cutting waste and promote efficiency. This has led to the implementation of rigid simplistic targets; such as the infamous four-hour A/E target being the yardstick by which the quality of our hospitals are judged. But those who set this targets, who, like the American Military setting body count targets in the Vietnam war, cannot see the obvious unintended consequences of this Kafkaesque management style. It is part of the human condition to follow the past of less resistance, therefore I do not blame the local management who create conditions that ensure the frontline staff have to aim for these proxy goals to the detriment of good care.
These targets can led us to feel like cogs in the machine, creating distance between ourselves and our patients. What we are judged and rewarded for is not necessarily what matters most. A nurse is judged on their ability to move a patient to a ward before 4 hours has passed not on providing holistic care, a Junior doctor is judged on their ability to complete VTE forms, not provide timely analgesia and consultants on their abilities to discharge patients, not on managing the complex unwell.
Luckily, in thousands of encounters, healthcare professionals have ignored and manipulated these targets to the benefit of patients, side-stepping the shortcuts and ensuring patient’s continue to receive excellent care, in reality and not just on paper. For this to be sustainable, these targets need to be re-aligned with what really matters to patients.
Unfortunately, private companies are much more adept at manipulating this system than public providers. Being able to target their bids for services that will improve the numbers the most. But when those numbers do not adequately reflect improvements in patient care cracks in the system are created. It is generally the most vulnerable of patients which fall through theses cracks, and it is left to our overstretched GP and A/E services to pick up the pieces.
Mentorship not training
There is a similar dissonance between what is officially required of junior doctors training and the reality of developing as doctors. Tick boxing, jumping through hoops and C.V points are all phrases frequently said with a heavy sigh by junior doctors describing the pre-requisite targets set by a distant, unimpeachable body. This contrasts with the excited voice used as they describe the actions of senior college performing at their best; when they have pulled the correct diagnosis out of no-where, performed the most difficult of procedures without breaking a sweat or have supported us in our greatest time of need. This is how we really learn; by the example of our colleges. It is this type of mentorship that is most valuable. What we need is the free time to enable the liminal discussing with our senior colleges to talk openly about how we transition from tentative juniors into respected seniors to achieve these currently unimaginable acts. I fear these valuable conversations are missed as myself and the senior college I respect spend our valuable time together both staring at the same screen, flicking through page after page of bullet pointed expectations, ensuring all have been met.
As our careers become more and more disjointed by shift work, we need time to work alongside these mentors consistently, to establish a relationship from which we can learn from each other; I fear a 4 or 6 month placement is not sufficient to undertake this. Again, rotating between departments and hospitals can lead us to feel like not only like a cog in a machine, but an entirely interchangeable one.
When the “winter” pressure increase and become a year-round phenomenon, an early casualty is dedicated educational time, we are lucky if the hour or two of dedicated teaching is ring-fenced, the opportunity to slow down and take time to discuss a case or to get observed are guided though a procedure become more limited. However, with the current political short-term view, this would be interrupted as a more “efficient” use of our time. This is a powerful argument for increasing redundancy and reducing the alleged efficient savings which can only measure short term economic gains at the expense of longer term, more profound, investment that is education.
Professionals not doctors
In medical school, a groan would go up as another lecturer would, yet again, show the clip from “doctor in the house” of the old school surgeon Sir Lancelott Spratt, authoritatively leading the ward round. Fortunately, in my short career we are moving even further aware from this stereotype. Now, when I think about who I would want to look after myself or my loved ones, they have often not even been to medical school (and hopefully spared watching Sir Lancelott Spratt!). Our practising and prescribing nursing and allied health professional colleges are contributing more and more to the decision making that is vital to good patient care; sharing this burden also frees us to undertake more of the educational opportunities that can be limited by the need to undertake what our experience and knowledgeable nursing colleges already know how to do very well without our help. Our new generation of student and doctors have much to learn from these essentially dual-qualified colleges.
However, there tick-box culture among our allied health professionals appears worse than ours, with an educational system seemingly modelled on infant school. Only when treated with equal respect by their training bodies will our patients give them the equal respect their deserve. Together, we will be able to take on the increasing burden of demand the NHS faces.
Leadership not management
Leadership is defined in many ways; but is only recognised when in the form of management. The leaders I really respect are those that make me question myself and to act as a better clinician. It is those doctors who really care about the more junior members on their team, those who have the respect of the nursing team so difficult decisions can be seamlessly enacted and those who really advocate for patients in the face of an inflexible and imperfect system.
This kind of shop-floor leadership is often undertaken by those who are not in official managerial positions. I do no look upon those in those with leadership tittles with envy, the work load seems to significantly outstrip the time provided considerably. But trying to emulate those with real leadership skills is a vital goal as many of us talking the tentative steps to becoming “seniors.”
Human interactions not systems
Working within these constrains in the 21st century can seem nihilistic and grim; the old guard talk about the good old days, those who have worked abroad talk about the utopia of Australia and those in the middle sometimes feel like they are stuck on a grinding treadmill. However, the solutions to maintaining our professional humanity in the sea of anonymous bureaucracy already exist.
Our professional, as researchers, are increasingly understanding the importance of patient-orientated outcomes. It has become the norm in journals such as the BMJ for patient’s to be involved in this research, helping to ensure we are asking the best questions of the data possible. Targets are not going to disappear, and they can be beneficial if used correctly. If we work closely with our patients, to ask them what really matters to them, and then ask of our systems how these can be adapted to meet these needs, real progress can be made in which our profession can have control over.
Job plans that have a significant quantity of allocated amount of time for most educational development, also allow for these patient-orientated improvement projects to have real ownership from doctors. Not only does this allow us to actually spend adequate time learning and developing (not just answering emails), but allows time for doctors to interact more with the important non-clinical aspect being a doctor; enabling us to work with managers for improvement and to work with each other for educational benefit. Secondly, this also allows the natural breathing space necessary to develop as leaders.
Ideally these job plans would involve rotas that gave the doctors who work them real autonomy over the hours they work, with enough redundancy built in that social engagement made many months in advance can be kept. Self-rostering rotas are a creative solution to this problem, and after having worked on one, I can confirm this is indeed game changing.
There has been much contention around the title of junior doctor. In the 21st century we do not need to worry about how our title defines us. We should instead be concerned how our actions and interactions defined us. To act in the best interests of our patients we need to hold on to our humanism in the face of modern atomised, commercialised culture. Fortunately, the humbling respect we still hold in society puts us in an ideal position to effect this change. If we define our profession as one that puts the patient truly at the centre of the an increasingly anonymised system, this trust will be continue to be maintained within our day to day individual human interactions, and allow us to develop into the right kind of mentors for the next generation of doctors, creating the conditions that keep our jobs as fulfilling as they should be.