Sunday, 22 May 2016

Calm under fire.

I'm a little baffled by the new contract proposal. I don't understand how you can mentor someone who has been on maternity leave to make up the time spent as a mother and not a doctor: equality doesn't mean that to me. Only women can deliver babies - they shouldn't be disadvantaged by that reality. I also don't understand why night shifts that start at 7.30pm don't attract the same pay uplift as shifts that start at 8pm (it is entirely possible I have missed something), and I don't understand why the same contract discussion is still taking place when it has been well demonstrated that not only does this contract not solve the problem the government is trying to fix, but that the problem itself is not a problem. Surely, we do not still linger on the misconception that radical working changes are required to improve survival expectations of patients admitted at the weekends.

Guessing what lies beneath the contract chicanery is a fool's game: we can tell you what the evidence suggests to us - that the NHS is being teed up for greater private provider involvement, but the current political oversight of the NHS is something of an evidence-free zone. Who can reason out the illogical reasoning behind our current situation?

And this is the knuckle-gnawingly frustrating thing about the whole situation. Logic doesn't prevail. Evidence doesn't talk. It reminds me of what it is like trying to explain to my three year old why she can't have more ice cream, while she is having a hissy-fit about not having more ice cream. Nothing gets through.

I can't count the number of people who have shaken their heads patronisingly at me, and said that junior doctors are being naive, that this is politics. The implication is that politics goes by different rules, and we should be OK with that. We should be OK with a world in which reason, evidence and grown-up dialogue are usurped by the diaphanous concept of 'winning'.

Where the sad reality leaves us that is that there is no clean way out of this. Jeremy Hunt talked, the morning after a proposed contract was agreed, about this not being about who won, but how long will that last. Can junior doctors trust him not to go crowing about winning the day after they agree what has been proposed? Could they stomach what would come after if they rejected the new contract?

The Department of Health keeps reminding us that this is about providing a 7 day service to patients. I suspect many are not convinced about their real understanding of what this means. But we do. We all know the areas of our service that we want to improve, we all understand the limitations to achieving what it is that we want to achieve; yet I imagine many of us still have plans for what we are going to do next.

In this crazy world of doctors having to play politics, understand the nuances of PR and social media, we are all still going to work, delivering the best we can for our patients today, and thinking about making our future services better still. There are elements of the service we work in that we have no control over. We can't predict what the current Health secretary wants to do next, and we can't predict how the next one will want to make his or her impact. What we do know is that they will want to do something, because when was the last time a Health Secretary trusted the people who run and deliver healthcare services to know what the best thing to do next might be?

And it was ever thus. We have been tinkered with, reorganised, and in some cases catastrophically buggered around with, all in the name of improving what we do now, since the NHS began. And yet we have continued to deliver better healthcare. The care we deliver now is not perfect, but our outcomes are better now than they ever have been.

There is also a silver lining. When was the last time that consultants and junior doctors felt so connected? The sense of solidarity pervades the NHS. Consultants now have a better grasp not only on what the problems of being trainee are, but what the day to day frustrations they experience are. They may only have walked a few days in the shoes of their juniors, but it has been enough to erase the rose tint from their own memories of being a junior, and focus on the reality of that life today, in the current NHS.

So we have solidarity, but we still have the threat of imposed change. Of course we do - and it won't go away. But in reality, it doesn't change very much. We always operate within the limitations of our current framework, yet great change is always possible.

The system may be telling junior doctors that they aren't appreciated, but we don't need to toe that line. Consultants, nurses and therapists are all capable of creating teams that any junior doctor would want to work in, and of delivering better services together.

It's not much, I know, but perhaps we would do well to remember that any framework creates opportunities, and however down-trodden we feel right now, we can still hang on to the prospect of creating something better for our patients.

While the metaphorical mortar shells are flying overhead, we must keep calm under fire, and do what it is that we have always sought to do: put the patient first. 

Saturday, 14 May 2016

On a raft without a paddle

Werner Herzog's cult movie 'Aguirre, the Wrath of God' opens with a shot of a Spanish baggage train weaving it's way down some steps cut into an Amazonian mountainside. As the shot zooms back, the scale of this path carved into the hillside becomes apparent - they start at the sky, and seem to weave their way into the bowels of the earth.

Aguirre is a notable movie with for a number of reasons- it is dark, weird, beautiful and atmospheric; Klaus Kinski is terrifying - up there with the Child Catcher from Chitty Chitty Bang Bang (you know I'm right). He doesn't do or say very much, but there is always menace, and an ominous verbal tick punctuating the movie foretells all manner of darkness. But what has always grabbed me is the story of its making: I was told (who knows how reliably) that Herzog wanted to recreate the reality of the conquistador's progress through the Amazon rain forest by undertaking a conquistador's progress through the Amazon rain forest. Let's call it Method Directing. Those steps on the mountain in the opening scene weren't there before the movie was made: Herzog got the cast and crew to carve them. They weren't very happy about it, but what could they do? They were marooned in the jungle with a maniacal director and a scary actor fully absorbed in a scary role. 

There's a moment in the film when the group needs to make its way down the Orinoco on rafts. There's no CGI here, and from I can work out, he put the cast on one wooden raft, the cameramen and crew on another, and pushed them down the river. He clearly didn't get much footage from it (he repeats certain shots), but the picture of fear on the actors faces is not faked: they were being pushed down some rapids in full 16th Century attire on hand-made wooden rafts. 

I thought of this scene recently at the British Geriatric Society conference, during a conversation about leadership. Herzog displayed the form of leadership that involves putting your team on a raft and sending them over the white water, while waving at them from the bank. This reminded me of some of the leadership behaviours I have witnessed in the NHS over the last 10 years. It seems to be particularly prevalent at the moment at the top of the health tree. 

I wonder if Herzog was angry that he got so little footage from this escapade, and gave his crew a bollocking. Let's imagine he did. Perhaps his crew could have pointed out that on a wooden raft, they didn't have appropriate camera rigging to get steady shots, that they couldn't capture decent sound while being on a different raft to the people they were filming. Perhaps, they argued that they spent so long worrying about their personal safety, whether they would be OK without life-jackets, that their minds weren't entirely focused on the job at hand. In fact, one could argue it's a miracle they captured any footage at all.

Sound familiar?  Ever get the feeling that we've been put on a raft, pushed down the river, while people shout from the safety of the river bank that we need to work harder and be better? Look after an ageing population with increasing complexity? You can have some more money, but we want you to save even more through being more efficient. Provide elective and emergency care across 7 days? You can't have any more money for this, but we will magically pay you more, while keeping the overall salary budget the same. 

The NHS is currently Herzog's crew on the raft. The major problem with this whole situation is that the patients are the cast on the other raft, and they too haven't had much say in how the whole process works. It's not hard for them to act the role of scared explorers on a raft, because the only difference is that they didn't know they were explorers.

The scenario I describe relates to a still prevalent leadership style within the NHS that is counter-productive. You can push people down a river, but usually, you only to do it once. Next time you go near water with them, they will keep you between the river and them. Perhaps you can argue that the end justified the means, but you'll have to make your own assessment of the price of art (or happy healthcare workers).