Clare Gerada says that there are serious problems with working life in the NHS and that these must be tackled if the NHS is to have a secure future
Just as the historian Tony Judt said that “something is profoundly wrong with the way we live today,” I believe that something is profoundly wrong with the NHS today. The health service’s prevailing culture is one of fear, even though its staff are meant to espouse kindness and compassion. The service is becoming a place where staff feel attacked, unloved, and abandoned by their political and managerial leaders.
A quarter of NHS staff report that they have been bullied in the past year. This is a higher proportion than in any other employment sector and is double the rate from four years ago. Surveys have shown that the main concern of NHS trust finance directors is staff morale, ahead of waiting time targets or patient experience. For doctors and nurses, high rates of mental illness, emigration, whistleblowing, suspensions, referrals to the regulator, and complaints all point to a system in serious trouble.
The causes of this distress are not hard to find. One is the industrialisation of healthcare. The move from a national state funded, state owned, and state managed organisation to a fragmented system of multiple competing providers, outsourced management, and increasingly mixed funding sits uncomfortably with the public sector ethos of many NHS staff. Increased privatisation also causes widespread anxiety.
Steve Iliffe, professor of primary care for older people at University College London, said that changes to the state’s relationship with the health service go to the core of professional self identity. He said that the role of medicine was changing from “a craft concerned with the uniqueness of each encounter with an ill person, to a mass manufacturing industry preoccupied with the throughput of the sick.”
Iona Heath, a former president of the Royal College of General Practitioners, described the commercialisation of general practice as one of the “dark forces at work behind the subversion of professionalism.” In a lecture titled Love’s Labours Lost, she described the changes that had undermined professionalism during her own career. She reflected in particular on the disappearance of “any idea of a ‘gift economy,’ where professionals could be knights but recipients could be queens—once altruism wasn’t recognised, it began to disappear.”
The second major cause of distress is unprecedented change. Over the past 20 years, the NHS has existed in a permanent state of flux. Nurses, doctors, and managers want stability, security, and safety rather than a state of constant transition. For decades, governments across the world have used reorganisation and policies of “destructive innovation” to juggle the clinical and financial priorities of health services. Each attempt to fashion a new order produces a new state of disorder. In 2008 Don Berwick, then president of the Institute for Healthcare Improvement in Cambridge, Massachusetts, commented on this in his review of the NHS. “Each change made sense, but the parade doesn’t make sense,” he said. “It drains energy and confidence from the workforce and middle managers.”
The physician and philosopher Raymond Tallis says that successive “disorganisations” of the NHS have the effect of reducing the influence of the medical profession and doctors’ ability to shape the services they work in. Iliffe goes further; he believes that the process of industrialisation of healthcare means that professionals are changing the “colour of their collar from white to blue.”
Organisations and individuals can and must change, and they must have the social resilience to adapt to external stresses and the disturbance resulting from change. But if that disturbance is big enough, a threshold will be reached where the system undergoes a fundamental shift. In 2012 the NHS was exposed to a reorganisation so large that, in the words of its then chief executive, David Nicholson, it “could be seen from outer space.” The subsequent changes in routines, customs, practices, and ways of working have destabilised the complex ecosystem of the NHS. The result is that the older generation of doctors, nurses, and managers are less able to support their younger colleagues, leaving vulnerable members exposed to developing mental health problems and other symptoms of distress. 
Studies of group therapy can help us understand the destructive forces behind this distress. Like the NHS, group therapy can trace its origins to the aftermath of the second world war, when two therapists, Wilfred Bion and Siegfried Foulkes, developed the idea of treating injured soldiers in groups and sharing their experiences together.
With over 1.5 million employees, the NHS functions not as a single group but as a collection of groups within groups. It is effectively a web of interdependent systems, connected by a matrix formed through historical and cultural links and by the social solidarity and shared experiences built up over several generations.
Groups can have a positive therapeutic effect, but in times of distress they can be destructive and can threaten an organisation’s functioning. Gerhard Wilke, who trained as an anthropologist before becoming a group analyst, argues that our working groups can, depending on their circumstances, either make us safe by becoming a carer substitute or threaten our integrity by making demands that we believe exceed our inner resource. Wilke says that clinicians now feel like “naughty children, and managers as enforcers of utopian visions generated by out of touch politicians.”
Some destructive forces, if not harnessed, can destroy a group’s creative and healing potential and can undermine its foundations and functioning. Another group analyst, Morris Nitsun, coined the term “anti-group” to describe these forces. The concept of the anti-group is used in psychotherapy, and the sources of destructive forces are similarly relevant to the NHS. One force that reinforces the development of the anti-group in the NHS is the failure to create an empathic environment for staff; and the paradox of values—in which staff care for patients but employers do not care for staff—gives rise to profound bitterness. John Ballatt and Penelope Campling, authors of Intelligent Kindness, highlighted some of the difficulties that staff face in the NHS. “It is easy to forget the appalling nature of some of the jobs carried out by NHS staff day in, day out—the damage, the pain, the mess they encounter, the sheer stench of diseased human flesh and its waste products,” they said.
Clinicians have always worked alongside death, distress, and disability. They are used to hard work and long, unsocial hours, and this has not changed in recent years. What has changed is the working environment and the compact agreement between staff and employer. Doctors, especially, have seen the biggest change in their working life. Changes to training mean that the tacit agreement whereby the NHS provides sustenance, refuge, and support, and the doctor in training works as hard as possible for patients, has been fractured. Trainees are now expected to move location—sometimes every three months—with no certainty that accommodation will be found. They have little control over their working hours, space, days off, and job security, and no guarantee of support from superiors when things go wrong.
Another force that helps to create anti-groups in the NHS is, Nitsun says, exposure—which can feel shameful and humiliating. Policies are now being deliberately designed to name and shame. For example, NHS Choices and the Friends and Family Test encourage patients to post anonymous comments about a practice, clinician, or hospital online. The Friends and Family Test was described by Rachel Reeves, principal research fellow in the school of health and social care at Greenwich University, as a “foe to the NHS.” She said that the test used a methodology that was not fit for purpose and led to casual brutality being displayed towards those selected as examples of what is wrong with the NHS. Another policy designed to name and shame NHS staff is the new Care Quality Commission inspection regime. This has already created fear in those who are inspected, as well as in those doing the inspecting. One CQC inspector described taking part in the process as being more like being part of a “lynch mob, not a serious regulator.”
These policies of naming, blaming, and shaming mean that doctors can face humiliation for any alleged transgression, even if what is seen as a transgression is merely being an understandable outlier in performance, or refusing to participate in a process.
The policy is having its predicted effect. Three surgeons who were at the bottom of the league table—though this was in retrospect shown to be a result of coding errors—were named on the front page of a major newspaper, and grainy photos above their names added a hint of criminality to their situation.
The NHS is exposed daily to negative stories in the media. Its staff are accused of being lazy, cruel, and uncaring, and the service is blamed for failing to meet necessary standards. Doctors, nurses, and managers are seen as villains and are berated by journalists, who overlook the fact that the NHS still tops the list of what makes the public feel proud about being British. This barrage of negative stories corrodes trust, saps morale, and creates defensiveness. It also ignores the good work done by most NHS staff and the fact that the NHS delivers, in monetary terms, vastly superior services to many comparable health services.
In his plan to save the NHS David Owen, the former health secretary, said that the NHS was a vocational service and that, in order to continue, it must retain a generosity of purpose, philosophical commitments, and a one to one relationship with patients, who must be central to its purpose.
To do this, politicians have a moral responsibility to support those charged with caring for the most vulnerable people in our society; and they must be tasked with urgently improving the health of the NHS and those forces within it that are contributing to its destruction. If they do not, then we will all be the losers, and NHS staff may leave for pastures new.
Competing interests: I have read and understood the BMJ policy of declaration of interests and declare: I am medical director of the Practitioner Health Programme, a confidential London based health service for doctors and dentists.
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Clare Gerada medical director Practitioner Health Programme, Riverside Medical Centre, London, UK
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