Getting off the production line

Bev Fitzsimons

Bev Fitzsimons is the Chief Executive of the Point of Care Foundation, a social enterprise with the mission to humanise healthcare. The Foundation runs Schwartz Rounds, a forum for reflective practice for staff in the NHS, which seek to help with the emotional and psychological impact of working in healthcare. The Foundation also runs patient experience programmes. A social scientist by background, Bev has worked in and around healthcare since the 1980s.

It is hard not to be despondent about the state of the NHS at the moment, with increased waiting times for ambulances and admission to hospital, a backlog of people waiting for treatment, reduced staffing levels, and a real difficulty hanging on to the clinical staff we have. But that is not the whole story. There is a genuine emotional burden in providing and receiving healthcare, and factors interfering with the process can cause moral injury [1].

The current working environment is brutal. Is it any wonder that we are losing our clinicians in droves? We attract high achieving, idealistic young people to our higher education institutions in ever greater numbers with the goal of becoming great doctors, nurses and therapists and making a difference to patients [2]. What is happening to make them want to leave, having worked so hard to get there?

As long ago as 2009, our Founder Jocelyn Cornwell wrote in the BMJ about the “difference between a hospital and a bottling factory” [3]. In it she describes both the benefits of standardisation (or indeed ‘industrialisation’) particularly in instances in which a patient’s journey might be reasonably predictable. Healthcare has many similarities with an industrial process: it involves many complex inter-connected processes, lots of hand-offs, it can be highly technical, and aspects can be standardised and delivered in the style of a production line.

Moreover, in some ways healthcare can resemble other industries. Like the law, healthcare can involve advocates – friends and family who speak on a vulnerable relative’s behalf. Like engineering or mechanics there is a diagnostic phase when the task (the treatment) may be unclear. Like education, the degree of specialisation means that the ‘inputs’ (the decisions about the processes of care) vary widely. In most cases there is a wide degree of discretion about the appropriate treatment or care that will be informed by both patient, family, and professional preferences.

But healthcare is different in so many ways. Health and care bear witness to the greatest joys and the greatest losses in people’s lives. People in need of care are uniquely vulnerable. For this reason, over-reliance on industrial processes is problematic. And, even leaving aside the inherent humanity of health and care, the systems required to achieve production-line efficiency are not generally well implemented in our system, which has grown up piecemeal, with new elements, changed structures and bits added on over time. For example, we regularly hear about multiple IT systems that staff are required to use, each requiring a different login and password, and often requiring repetition of input. Patients also report inefficient administration of appointments and communications which add to the stresses and strains of their condition.

Even if the industrial approach was the ideal, with the best will in the world, we are not very good at it, either as professionals working in the system or as patients or family members seeking to navigate our way through it. Flawed processes cause enormous frustration to clinicians and patients alike.

Orthopaedic surgery, perhaps more than any other aspect of healthcare, has benefited greatly from ‘industrial’ approaches to process improvement, with increased standardisation [4].

Koenig et al. [4] describe how standardisation of scheduling, preoperative testing, and perioperative coordination, was associated with improvements in cancellation rates, on-time operating room starts, and operating room utilisation. The same paper describes reductions in postoperative complications, shorter lengths of stay, and no difference in rates of discharge to home with standardised clinical pathways.

A more recent paper, by Montori and Allwood, argues that over reliance on industrial approaches “turns patients into widgets and clinicians into production line workers, the work of caring reduced to processing people through the system” [5]. Transactional processes can only ever be part of the picture. As they say: “to care is human; policies, systems, institutions, or technologies cannot care.”

Since our launch as a charity ten years ago, the Point of Care Foundation has held to a vision of a more humanised healthcare system. But to move from industrial healthcare to humanised care requires a radical change in mindset.

What is to be done?

Too often, the interests of staff and patients are somehow pitted against one another. For the radical change in mindset that is needed to create a more human system, we must escape this false dichotomy. We are all on the same side.

First, as a society, we need to acknowledge the nature of the work, and the work environment, of the health and care system. This work makes huge emotional demands on those charged with delivering it. This needs to be recognised, and space created for those very normal human responses to be acknowledged and processed. It is important for people to be seen and heard.

As a system, we need to pay attention to wellbeing. And by this I don’t mean yoga classes! Thinking of Maslow’s hierarchy of needs [6] it is astonishing that we hear repeated stories of the inadequate provision for even the most basic physiological needs for rest, food, hydration, and a place to sleep. We must pressure the system to be more human. For workers this means humane rotas and careful supervision, not treating junior doctors as cannon fodder, or denying people time off for their weddings or the funerals of loved ones. Neither clinical staff nor patients are widgets.

As leaders, it means prioritising the humanity of care. In the current context, systems leadership can’t quickly fix a systemic failure because it is built on shifting sands. However, the common denominator in healthcare is human and so isn’t relational leadership more important when the system fails? The Point of Care Foundation is responsible for implementing Schwartz Rounds, which is one manifestation of this. The underlying premise of Rounds is that healthcare staff are more able to work compassionately with patients and colleagues when they have greater insight into their emotional responses and when they themselves feel cared for. Having these practices embedded from early career / studenthood might just help us hang on to our staff a little better.

As co-workers, and sticking with Maslow for a moment, we can work to ensure one another’s psychological safety through respectful relationships at work. As Nick Schindler recently commented when discussing grief when a patient dies, people move miles to be with a great team (Figure 1).

Figure 1

Everyone makes a difference: I was reading today of the on-call room where the domestic staff have taken unbidden to making up the camp bed with clean sheets and towels every day. The member of staff commented “Honestly it’s made me feel more like a valued employee than anything else this week”, (Figure 2).

Figure 2

Keeping the focus on the patient

A concept which is familiar in the sphere of patient safety is that of the difference between the work ‘as imagined’ and the work ‘as done’. To do this well means keeping patients’ experiences at the front of our minds, understanding what it is like to be a patient or family member. One consultant we worked with described “… hearing about long and painful journeys to the hospital, getting lost, how taking blood can make the boys –and mothers – cry, and how clinic scheduling or delays can mean the families miss meals…”. These observations galvanised him to action in service of patients [7].

Let us not forget that patients, service users and families:

• Have expert knowledge, and understand the experience of receiving care.

• Have the right to be involved, as they are most affected by the care experience.

• Lend legitimacy and urgency to change – often changes that clinical staff have themselves been seeking.

• Can see waste and inefficiency.

• Understand personal and system obstacles to good care.

• Wish to share decision making and are realistic about what can be achieved.

• Are best placed to judge outcomes.

In short, patients can be clinicians’ greatest advocates and supporters.

As one colleague recently said, “I find that even if I can’t magically find a bed for a patient in a corridor, I can still get them a cup of tea. I’m not doing my job as a surgeon but at least I’m doing something as a human being. Healthcare in the NHS is really at that level these days”.

Conclusion

The imperfect, industrial nature of healthcare, which sacrifices the relationships inherent in care, has contributed to the exhaustion of care givers and patients.

Caring and being cared for is a symbiotic relationship in which both parties contribute to keeping the whole system going. As Montoni and Allwood say, “care requires a person to notice another’s human situation and to respond to it”. In a human system, no ‘big bang’ reorganisation or policy change is going to achieve the required changes to human behaviour. What will and does work however, is giving people – colleagues and patients – the space and tools to work together as a human system toward a common cause.

References

1. Rosen A, Cahill JM, Dugdale LS. Moral Injury in Health Care: Identification and Repair in the COVID-19 Era. J Gen Intern Med 2022;37(14):3739-43.

2. 2022 – the hardest year in living memory to enter medical school. Available at: www.theguardian.com/education/2022/ jun/22/2022-hardest-year-in-living-memoryto-enter-uk-medical-school

3. Cornwell J. What’s the difference between a hospital and a bottling factory? BMJ 2009;339:b2727.

4. Koenig KM, Bozic KJ. Orthopaedic Healthcare Worldwide: The Role of Standardization in Improving Outcomes. Clin Orthop Relat Res 2015;473(11):3360-3.

5. Montori VM, Allwood D. Careful, kind care is our compass out of the pandemic fog. BMJ 2022;379:e073444.

6. Maslow AH. A theory of human motivation. Psychological Review. 1943;50(4):370-96.

7. The King’s Fund (2014). PFCC final report for the Health Foundation. Available at: www.health.org.uk/sites/default/files/PFCC_ finalreport.pdf