Cowper’s Cut: The arm round the shoulders

Commentators often state the obvious, so let’s get the cliché out of the way: healthcare is a people business.

Yes, of course there is lots of science in healthcare, be it material or social. One of the reasons healthcare’s an interesting industry is that it’s such a cocktail of the empirical, the relative and the relational.

The people business and the relational matter much more than we tend to explicitly acknowledge. Perhaps, that’s why we acknowledge some of it implicitly. So, we “heart” the NHS: it might be one of the last things we’re still culturally allowed (if not actually expected) to love unironically.

This is why I keep banging on about the NHS needing a chief anthropologist much more than it needs any chief inspector. Culture is a big problem for the NHS.

The basic irony, that the NHS (a machine built to help people when they are in need) has a culture where providing the right answer to central authority so often wins out, is not lost on anybody who thinks seriously about these things.

People have the power

So, if it is true that healthcare is a people business, we ought to wonder why the NHS is often not great at supporting its people.

This isn’t universally true, of course, but it’s true enough to write down here without needing too much qualification.

There is no serious dissent from the idea that, thanks to current demographics, resources, system configurations, non-learning cultures, organisational amnesia, some poor management and our old friend culture, the people of the NHS are having a pretty tough time of it.

Things can only get better?

There is a connected problem: the staff can’t see an end to the current pressure. I suspect that this latter issue is more seriously eroding morale.

Because NHS staff, like patients, need to believe that at some point things can only get better. 

Just now, I am not convinced that that belief is widespread. 

What’s missing from the NHS is two things.

The first is a sense of hope that the situation in the NHS is foreseeably going to improve. I’m sure I’ll be writing more about this in future columns, so I’m not going to pursue the theme today (or at least, not beyond saying that I think it’s been eroded by the politics).

The second thing may seem crass once written down, but it’s absolutely vital and it’s absolutely missing in a lot of the system.

It’s the arm round the shoulders.

Oh of course, everybody’s living up to their rhetorical duty to praise the brilliant staff of the NHS for their hard working dedication against the odds, blah blah blah… 

However, our problem here is that this is less a rhetorical duty of candour and more a rhetorical diet of candy. Sure, it tastes sweet for a couple of seconds but it leaves you no better off, with a sugar rush comedown and a durably negative effect on your vital regulatory endocrine system.

You can’t fake the arm round the shoulders. Obviously, you could issue a new national framework that all senior staff must (in a non-harassing, physically appropriate and consensual way) put their arm around the shoulders of all staff … but that’s part of the problem right there, isn’t it?

Nobody should seriously have to write a column about the fact that the staff of the NHS, from chief executives upwards, don’t at present seem to feel that anyone’s got the arm round the shoulders, and don’t seem to believe that anyone’s got their backs.

And the worst thing is that, by and large, they’re not wrong.

Who is to blame?

Maybe not all bad journalism indulges in “we name the guilty men/women syndrome”, but it’s not exactly rare.

So, where do we pin the blame for the shoulder arm ratio deficit?

On politicians? Um, not really. Well, not all of them.

Even if once upon a time, NHS staff might have looked to the health secretary for this, the political economics of austerity have left Dunning-Kruger Effect embodiment Jeremy Hunt looking like a man in the throes of Stockholm syndrome to whoever fancies trying to set the NHS agenda in his party. At Budget time, it’s Spreadsheet Phil, but latterly, it’s “good old” Boris Johnson and his “Fantasy NHS Funding Announcement Tourettes Syndrome”.

So, it’s not really Jeremy Hunt’s fault: we can’t expect too much of political prisoners.

“Boris” wants to be World King, or at least prime minister; Philip Hammond wouldn’t mind having a John Major style crack at it, either.

Do we blame national system leaders? That depends on the specific axes of evil we have to grind… but if we were trying to be fair minded, then maybe we shouldn’t focus on the bunch of people who’ll be up in Parliament and probably court, in the event of a serious care quality scandal (rather than the now inevitable financial overspend). They are working quite diligently to prevent the wheels coming off too noticeably, and to run the system into the softest sand they can find.

Here is a frightening thought: maybe there isn’t anyone whom we can meaningfully blame.

Maybe instead of blame, we should consider the reasons we have evolved a system, that has not designed in the arm round the shoulder. Because we sure as hell haven’t designed out the need for it. Quite the opposite.

In the absence of the arm round the shoulders… in the absence of realistic hope that the current pressures will abate… then what feels like a crisis of confidence in the NHS (medically and managerially) risks becoming the new normal.

The NHS has always run on discretionary effort. Staff resilience has only so much in the tank, and it feels like the machine is running on fumes.

I can’t predict exactly where this will lead us if I’m right about this. But it won’t be pretty.