Wednesday, 8 March 2017

Candour amidst all the obfuscation

All 3 diehard followers of my blog will know that I am a cycling fan. I was drawn to it during the ruthless reign of Lance Armstrong, yet even his egregious deceit wasn't enough to throw me off the sport entirely. In cycling, the winner of the race is only one part of a complex narrative - and it is this complexity that makes it such a compelling sport. Much of the enticing texture lies in the little stories that open and close throughout the race, in the shadows of the contenders, vying for the victory. 

While Lance painted a bloody great black mark on the sport, he also provided the chiaroscuro necessary for redemption. Restoration is only possible if there is a context for it. Lance provided the context, and in the absence of a truly great cyclist in recent years, the quest for redemption has become a significant part of the story - and this is where Team Sky came in. 

I liked a couple of things about Team Sky: I liked their disruptive influence on the sport: they clearly didn't mind not being liked, because it probably indicated to them that they were doing something right. I admired their commitment to clean racing. Their was something childishly optimistic about their insistence that cycle racing could be won cleanly if you were on top of every other aspect of performance. They asserted that if you planned every controllable detail and worked hard, then you could do well. It's not particularly artistic, but preparation creates the landscape in which compelling sport could happen. 

Lance Armstrong liked big gestures. There was something brutal and beautiful about the way he stared into the face of Jan Ullrich on the way up the Alpe D'Huez in 2001, before standing up on his pedals and buggering off into the distance. When we thought he was riding cleanly that felt like a big moment. It was also one of the moments that convinced many people that Lance wasn't clean at all. You don't leave someone like Jan Ullrich standing on an 8% gradient the way he did unless you have an unfair advantage. 

In the absence of systematic doping, cycling has become less explosive. The 'Big Bugger Offs' you used to see in racing, when one cyclist would disappear up the road, fueled by a high haematocrit and the Popeye-like influence of testosterone and growth hormone have all but disappeared. Cycling became something more granular, slower-burning, and in many ways more compelling. To understand a recent Grant Tour properly, you had to pay attention for the whole 3 weeks, as the battle played out in small margins over a longer period of time. 

And leading the way was Team Sky. Yet, recently, we have learned that perhaps they weren't leading the way - perhaps they were merely reinventing the way that cheating was done. I don't know if Team Sky has been racing clean or not. I don't know if Bradley Wiggins took delivery of something he shouldn't have in the 2011 Criterium, but I do know that for a team founded on the principles of riding cleanly and proving you could win without doping, they should understand the need for transparency, particularly in the context of a sport about which people still harbour doubts. 

Every time Chris Froome has won the Tour de France he has faced accusations of doping - he even went as far as releasing his training data, and with this in mind, one would have thought that Dave Brailsford would understand the need for good governance and a clear audit trail. Apparently, however, he did not, to the extent that he and his team are unable to account for the medications they ordered (including some rather high quantities of triamcinolone (used for treating allergies by no one except cyclists' doctors.....), and they are unable to say who they were ordered for. None of this proves doping, but it creates a fog of uncertainty. In a sport that has learned to treat fogs as evidence of cheating, Team Sky are guilty of either doping, or monumental incompetence. I hope it's that latter, but my head refused to let me make the assumption that it is. 

Transparency is something we understand well in the NHS. The duty of candour removes the need for discretion in transparency: when something goes wrong, you tell the person it affected. It's really simple. And yet, it continues to be misunderstood. Of course, there is complexity in its implementation, such as what defines 'serious harm' but it can be guided by the cognitive heuristic that asking yourself if you should tell a patient something usually means you should. 

Of course, the ability to be open about anything depends on a culture in which openness is not just encouraged but actively enabled. The trust of staff in their organisations to treat them well when they make mistakes is often low. The perception of scapegoating still exists, and will take time to shift. Even the slightest sense that they will not be supported when mistakes occur will discourage staff from being instinctively open; and the support for this needs to percolate all the way through the NHS, starting at the top. 

Yet what hope is there when one is constantly battling the sense that those at the top do not seem to really appreciate what candour is, and how it is done. Simon Stevens has started to do his bit, but Jeremy Hunt and Theresa May seem to have some form of aversion to it. We shouldn't be surprised  - in broad terms, while the past is no indication of the future, it gives you a sense of where their preferences and tendencies lie. So when Theresa May indicated that A&Es were being over-whelmed through the failure of GP practices to stay open long enough, one has to wonder firstly, where she is getting her information from, and secondly, who's next on her list of people to alienate. And when Jeremy Hunt talks about his frustrations that parts of the NHS are providing unacceptable care, and that he has provided the NHS with extra money, one has to wonder how many times he had to practice his comments in front of the mirror before he was able to say them convincingly. 

For people who work in the NHS, who have seen their work-loads ramp up over the last 5 years, (while their pay stagnates without any sign of inflation-indexing), the disconnect between what they know to be happening in the health service, and what those who run the health service say, is so wide, that truth seems to have been the main victim of the spending squeeze. Remaining candid with our patients in an environment in which too few people seem able to talk honestly about what is happening in the NHS is something which continues to take courage. 

And as with many things in the NHS at the moment, it is the courage and commitment of the staff in it that keep us aligned to the values that define the service. In too many places the NHS operates outside of the conditions necessary to optimise the performance of staff. It is galling to hear the problems of the NHS framed in ways that do not match our lived experience, but the problems go deeper than that. The culture I work in is at odds with the culture presented by our political leadership and my current definition of futility involves describing attempts to square that circle. Perhaps, though it was ever thus, and perhaps we are naive to imagine that the culture needed in our health service would percolate down. Perhaps the truth is that it needs to percolate up; perhaps we need to ensure that we support the transparency and candour of our staff in spite of what we hear on the political stage. 

I know that doesn't really help. It never really helps to be told, 'Keep going' in response to a problem you have outlined, but that is probably the best I can do. The reality is that things that shouldn't take courage (like telling our patients that things have gone wrong) require precisely that. This won't change quickly, it may not change at all, but of all the choices we have, the only one that is palatable to me is to keep plugging away in spite of the difficulties. And that is what I will be trying to do. 

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