The People Manager
All posts from: December 2011
When things go wrong - and things do go wrong - do you look for someone to blame or do you analyse the complex inter-relationship of events, people and money? Politicians look for someone to blame and the tabloids call for their head. Very convenient .since politicians don’t want awkward questions asked about the contribution of their policies, the impact of budget cuts or the unintended consequences of a reliance on targets. And public executions in the press have always sold newspapers.
You would however expect some sections of the media to spot the potential for exposing a few government myths, like “cutting staff does not affect quality”, “more can be done with less” and “targets don’t distort practice”.
The public enquiry into the Mid Staffs Hospital deaths is just such an opportunity. Pity then that the Guardian seem content to call for the head of Cynthia Bower. It’s strange also, since she was not head of the regulator at the time of the scandal nor was she chief executive of the hospital.
So why has the Guardian used the public inquiry into the scandal at Mid Staffs Hospital to call for the head of Ms Bower? The answer appears to be Ms Bower can and should be personally held accountable for the failings at Mid Staff because as chief executive of the supervising Heath Authority she failed to spot and stop the neglect of patients. Further evidence of her supposed unsuitability and incompetence is the subsequent failure by her inspectors to stop the abuse of residents at a home for people with learning disabilities in her new job as chief executive of the CQC. Well, if that is to be the logic we would expect directors of social services to be losing their heads on a very regular basis.
If heads are to roll why not the one who appointed Cynthia Bower as the CQC’s chief executive at a time when the scandal at Mid Staffs had already broken? If this is about accountability the chief executive of an NHS trust is accountable to their board and the chair and most of the board appear to have supported the actions of the chief executive. Logically if the board, who are ultimately responsible to the minister, got it so badly wrong, either they should go or the minister should acknowledge that this was a failure of the system and not a failure of one individual.
Community care for older people is dead. Community care has been dead for sometime but its death has yet to be publicly acknowledged. The signs that all meaningful life had drained out of the concept have been there for all to see. There were the persistent complaints from the NHS about bed blocking in hospitals due to cut backs in social services, media campaigns against the closure of day centres and the removal of grants from voluntary organisation. Community care for older people no longer exists in any meaningful sense of the phrase: it has been replaced by cheap care.
Community care was about replacing institutional care which robbed people of their privacy, dignity and independence. Long stay geriatric wards were closed to be replaced by smaller homely nursing homes for those who required nursing care. Very sheltered housing was to replace residential care homes, the idea was that people would remain in their own home or in sheltered housing and the help would come to them.
If people had their own front door then the thinking was that they would retain their privacy. If the right levels of care and support were provided people would retain their independence and if people were seen as individuals they would be more likely to be treated with respect and more likely to retain their dignity. If people need help to wash, dress, go to the toilet, get into and out of bed it could be provided even if this involved three or four visits a day, seven days a week.
In the past institutional care was characterised by care routines that operated to suit the convenience of staff such as staff determining when people got up, went to bed, had a bath, what they wore and what they ate. Patients/residents deprived of choices and control over their own lives became passive, accepting and lethargic, and this behaviour came to be described as institutionalised.
People preferred to continue to live at home with help. The growth in the number of people over 80 put pressure on services and budgets. The budget pressure was relieved by buying care from the private sector rather than providing through staff employed by social services. The private sector was cheaper so the same amount of money could buy help for more people.
Despite the growing number of providers of home care it was logistically very difficult to get customers into and out of bed when they wanted. The problem was that a home care had a list of people to be visited, but someone had to be first and someone had to be last. So someone would be put to bed at six in the evening, someone would receive their lunch at 11am while someone else would gets theirs at 3pm.
Right from the beginning there were complaints from customers, about high turnover of staff meaning that frequently a stranger turned up to provide very personal care, of young and inexperienced staff and of staff whose English was poor. The private sector could not attract or retain experienced staff on the wages it paid. Employers were reluctant to invest in staff training when staff went as soon as a better paid job came up.
Costs were kept down by keeping overheads low which meant few managers and minimum supervision of staff. As social services budgets were squeezed they forced down or didn’t update contract prices. As the number of people being referred for support increased they “reviewed and reassessed” to reduce the number of visits and they reduced the length of a visit. Initially contacts were based on a visit being an hour; as demand grew the typical visit was reduced to 45 minutes and the “pop ins” of just 15 minutes were introduced!
Care in the community for older people had become care on the cheap. The report by the Equality and Human rights commission simply confirmed what cares and customers had been saying that this so called community care robbed them of their dignity, privacy and self respect that it often left them to lie in their own mess, cold, hungry and confused causing them to feel ashamed, lonely and frightened.
So clearly community care in any meaningful sense is dead.
The failure of community care is the failure of older people
You lie in your own mess. You are cold. You are hungry and confused. You can’t remember whether you have taken your pills. You feel ashamed, lonely and frightened. It will be hours before someone will let themselves in to wash and feed you before rushing off to their next client. No time to chat, probably no conversation at all, only the TV for company.
I speak of the failure of community care when I describe the collapse of care at home.
The savage cuts in social care funding will mean hospital beds are blocked as people cannot be discharged home due to lack of support services. Blocked hospital beds means longer waiting times for others to get into hospital for their operations. Some will be forced into residential care not because they need it but because community services are not there and families cannot fill such a gaping hole. Those who end up in a home may not be any more fortunate as local authorities try to force care home fees down to make their reduced budget stretch and financially struggling homes cut back on food and staff pay. Whatever happened to joined up thinking? Whatever happened to living longer being something for society to celebrate? Whatever happened to old age should be enjoyed not endured?
Community care has failed older people not because people didn’t want it, not because it wasn’t preferable to institutional care, not because it didn’t have the support of the professionals but because you and I decided (or others on our behalf) that we couldn’t afford to treat older people well.
I was recently surprised to hear an NHS board member described as a whistleblower. After all a board member is in a powerful position, has access to the chief executive and directors and is presumably privy to if not directly involved in all the key decisions. All the more so when their testimony was not exposing corruption or abuse but criticising the leadership of the organisation and its strategic direction.
The alliance between a chair of the board and a chief executive can be very powerful and it must be frustrating if you are a lone dissenting voice -but that doesn’t make you a whistleblower.
What this case highlighted was how tensions and disagreements are played out in NHS boardrooms. It is generally assumed that a strong chair backed by the majority of non executive directors can hold the chief executive and their senior management team to account. It is also assumed that a good working relationship between the chair and the chief executive is good for the organisation. But what happens if one or more of the non executive directors think the relationship is too cozy? What if some think that the chair seems more concerned with supporting the chief executive than challenging them and their team? What if some board members feel the chief executive has too much power?
I have seen this happen outside of the NHS where the long serving chief executive maintained their control over the organisation by influencing who was invited to join the board and by ensuring a turnover of non executive board members. This turnover was achieved by increasing responsibilities, requiring a greater time commitment and by replacing payment of expenses with salaries and thus justifying a new job description for non executives and looking for a new type of board member.
So how is the balance of power maintained in NHS boardrooms? The chair with the backing of the board can get rid of the chief executive. But of course the real answer is that each board finds its own way, which works just fine… until the budget overspend comes to light, the trust is named and shamed over its performance or there is a major scandal over the quality of nursing care.
And this led me to ask: what is the difference between a whistleblower and a trouble maker?
When I think of a whistleblower I imagine a fairly anonymous member of staff who publicly exposes the wrongdoing of an organisation despite the fact that this might cost them their job. The member of staff is acting out of a moral conviction.
If we want people to expose bad practice or high level corruption whether its shady practices in the awarding of large contracts or covering up the abuse of patients/residents we need to give them the promise of protection and the confidence that their allegation will be treated seriously.
The initial reaction to a whistleblower, however, is frequently to question their motives. Is this a disgruntled member of staff, does the individual have a personal agenda? Some in the organisation will view any public criticism as disloyal but the only real issue is whether there is any truth to the allegations.
I was concerned but not surprised at the findings of a recent Royal College of Nursing survey which found 80 per cent of the 3,000 nurses surveyed had raised concerns about issues on an NHS ward. Perhaps it is also not surprising that at a time of severe budget pressure nurses would highlight the impact on the ward and patient care. As managers seek to save money with skeleton staffing levels - not just on bank holidays but weekends and evening - it’s not surprising that nurses would complain nor is it surprising that managers will ignore these complaints.
It is the same for covering for vacant posts or staff absences; management will impose a blanket ban on the use of agency staff and overtime because of pressure on the budget and nursing staff will identify the impact on patient care: no time to ensure elderly patients drink, no time to help an elderly patient eat their meals, being unable to take a patient to the toilet when they first ask and having to leave them in soiled or wet sheets until they are less busy. The result is the now well documented and alarmingly frequent reports of dehydrated, malnourished and neglected elderly patients.
There is another type of whistleblower, frequently a new member of staff or someone who has been brought in as temporary cover for staff holidays. They are experienced staff and are clear on good practice and what they see as passing for routine care is not good practice. They quickly realise that there is little point raising their concerns with the manager or officer in charge as these practices have either been sanctioned or are ignored for the smooth running of the home. I have in mind the “liquid cosh” where residents who “wander” are over medicated so that they stay put in their chair, using the bed sheets tucked in tight to stop someone getting out of bed in the night, putting those who need assistance to bed straight after tea so they are all in bed when the night staff come on duty who in return will ensure everyone is up and dressed when the day staff come on duty, even if this means some people will be got up at 5am!
This of course is fairly mild stuff but a culture where everything is run to the convenience of staff rather than the needs of residents is one where indifference can soon result in bullying and verbal, maybe even physical, abuse.
In such circumstances it is vital that staff resist peer pressure and have the courage to speak out without fear of reprisals. These aren’t “trouble makers” but people who aren’t satisfied when poor care becomes acceptable.
The public sector is to foot the bill for economic recovery. The price to be paid in reduced take home pay and job losses will be felt by all those working in the public sector. The newspaper headlines warn of six years of austerity. This year’s budget cuts were painful, next year’s budget cuts are already being drawn up and it is clear things are only going to get worse. As staff fight to protect their pensions and jobs, do managers face an impossible task in maintaining morale?
I have worked in organisations where the budget has allowed for growth and the service has been held in high regard but morale has been low. I have worked in places where services were being cut to the bone and where criticism in the local press and from local MPs was relentless, yet staff morale remained high.
Two factors seemed to influence morale: the quality of leadership within the organisation and the people management skills of line managers. Yet in both sets of circumstances there was no direct relationship I could find between the level of morale and the individual’s commitment to doing a good job for the service user.
This seems to be because people’s commitment in the public sector is to the client/service user rather than the organisation. They don’t pull out all the stops for the organisation’s reputation, to hit government targets or to make senior management look good, they do it to make a difference to an patient’s life. They can be fed up with the way the profession is treated and feel undervalued and unappreciated by the organisation, but they will still do their best to help the individual because this is why they joined the profession in the first place.
In general people who work in the public sector are proud of what they do. People can feel very positive about the work of their team or service but negative about the organisation they work for. This often comes to light when organisations prepare for Investors in People accreditation. The senior managers fret over what staff will say to the assessors in light of budget cuts and management reorganisations but staff are asked about what they do and they are invariably positive about their own work and that of their team.
People who work in parts of the public sector are highly motivated by the prospect of helping people and making a difference to an individual’s life. If they get on with their line manager, trust them, feel valued and that their efforts are recognised, then what’s happening outside of their team/establishment has limited impact on their morale. This works both ways, as if there is conflict within the team, if there is a lack of trust in the manager then any additional pressure caused by staffing vacancies, service cuts or changes in the way work is organised will result in people feeling unhappy at work, looking for other jobs and complaining about their lot.
However bad the big picture gets experience shows that managers can influence morale in their team but if you were a teacher, nurse or social worker would you encourage your children to join the profession?