Cowper’s Cut: Why fear, risk and trust are key to beating coronavirus

The Covid-19 pandemic is the defining issue of 2020-21, for the NHS and the care system. It is already changing our economy and society. It will change our culture. Clearly, we can’t yet begin to see how durable those changes will prove, not how ductile they will make us.

Evolution, revolution and intelligent design

We can see one thing very clearly: what is coming at us now is a lot of change.

These changes will be a cocktail of the evolutionary and the revolutionary. As the US management writer Professor Leon Megginson noted in 1963, “According to Darwin’s Origin of Species, it is not the most intellectual of the species that survives; it is not the strongest that survives; but the species that survives is the one that is able best to adapt and adjust to the changing environment in which it finds itself.”

We are guaranteed a changing environment. And we will see the NHS’s considerable strengths in acting as an equitable healthcare delivery and production system. There is a time and a place for command-and-control, and this is it.

Alongside this balancing act between evolutionary and revolutionary changes (which will see the NHS stop doing some non-value-adding things, and probably never restart them), we are going to see a big need for intelligent design.

We’ll also need to address big second-order issues, such as the impact on very long waiting patients of an NHS elective shutdown of any significant duration, which is nicely explained by demand and capacity expert Dr Rob Findlay.

The government has signally failed to cover itself in glory over its Covid-19 communications so far. This is worrying, because while both the chief medical officer and chief scientific officer command general respect, the government’s response has mixed the inconsistent (health and social care secretary Matt Hancock’s contradictory message about herd immunity not being “part of the plan”, which chief scientific officer had mentioned on Friday) with the cock-up (Mr Hancock’s far-from-clear article for the Sunday Telegraph explaining the government’s strategy which was initially hidden away behind their paywall).

Fear, risk and trust

A lot of hard decisions lie ahead for us all: for the government, for NHS leaders, for staff across the range of jobs, for the public.

Governments around the world have been making different decisions at different times about how best to combat the pandemic. Of course the science guides these decisions (although as we have already seen, there is no consensus among epidemiologists).

But scientific advice is not the only factor in play. There are economic factors, and social and cultural factors which shape every nation’s response. The government’s decisions are ultimately and unavoidably political.

The following three variables will prove vital as we try to make the right decisions: fear, risk and trust.

Let’s be honest enough to start with fear. Few of us are much good with this, but fear is a wholly rational thing to feel. Fear can even be a helpful tool, if we can use it as a source of light, rather than of heat – it can be a dangerous fuel, if poorly handled.

Front-line staff, whether they are clinicians, porters, cleaners, healthcare assistants, or reception staff, will be afraid. They know the risks of Covid-19, and they are already seeing patients affected. One key task of NHS leaders is to understand this fear. It is going to be with us for months. How are we going to make this sustained psychological pressure sustainable?

Dealing with this pandemic as best we can will be the proverbial marathon, not the sprint. Managers know they will need to keep watchful eyes on colleagues who may already have been working under intense pressure for years due to the NHS’s ongoing workforce shortages.

There are two essential strategies for addressing fear. The first is the quickest possible expansion of Covid-19 testing for health and care staff. Now the advice on isolation has changed, the functioning of the system needs to be able to differentiate between colleagues who can safely work and those who should self-isolate for their own and everyone else’s good.

The second strategy is urgent national-level action on ensuring there are adequate supplies of proper face masks and protective clothing to keep NHS staff safe.

Fear and risk are related. Our colleagues across the NHS and care system tend to understand risk a bit better than the average person (both absolute and relative). But leaders will need to help by encouraging and hosting ongoing dialogue about the best risk management strategies that teams, departments and organisations can develop. This absolutely needs to be locally owned and led. There is not a “no risk” approach to delivering healthcare and care during this pandemic. There are trade-offs, and wicked problems.

Perhaps most importantly of all the strategies, there is trust (or there will have to be). There could be no better time to re-listen to Baroness Onora O’Neill’s 2002 Reith Lectures on this topic. These are going to be tough times, and they will teach us tough lessons.

My last HSJ column, filed just under a year ago, summarised the absence of any strategy for workforce, capital and social care. It is almost a year on, and absolutely none of these vital issues has seen much meaningful progress.

Now we have a pandemic new respiratory disease on top – and one which we must cope with despite a relatively low hospital bed base and critical care capacity when compared to most of the developed world.

This is going to be gnarly. It is welcome to see that various regulators are doing the right things to minimise regulatory burdens.

The national guidance also seems reality-based.

At a local level, leaders need to both encourage and model a set of high-trust behaviours as colleagues work out how best to respond to this crisis. Patient and staff safety must remain paramount – but normal ways of working will often not cut the mustard in these extraordinary times.

A major task facing NHS and care leaders, managers and colleagues navigating this will be to understand the trade-offs required between fear, risk and trust.

Thank you for what you are doing for us all. Please look after yourselves, and after each other.