A journey of a thousand miles begins from the spot under one’s feet.
–Lao Tzu, Tao Te Ching
Two of the lollipop men NHS grunts most love to hate put their heads above the parapet recently. The anti-GM crop man who is himself part of a GM crop said doctors had lost the human touch, and must in future care more. The minister whose brains if extracted and compacted would make a passable mothball fumed about the normalisation of cruelty in the NHS. The familiar vistas of patients managed like battery hens, caged in their beds and kept in the dark, were rolled out across the media. A picture was conjured of the NHS as a giant sausage machine, taking live patients in at one end, and extruding a grotesque string of body-bags at the other. In between, moths of death flit in and out of the shadows, undaunted by ministerial mothballs. If the NHS, by these accounts, can be summed up in one word, it is Hades, realm of the eponymous Lord of the Underworld, a dark realm which all may enter, but none may leave.
This vision of Hell – and let us not beat about the Burning Bush, for it is a vision that burns hard but has yet to be consumed – is sharply at odd with that depicted by others. Fighting for the hospital sector, Dr Zorro has been twanging his rapier, and all but snapped it, but still sticks by his conclusion: genetic engineering will out. A diverse assembly of members of the Royal College of Caring and Sharing continue to promote their various campaigns that God – or Berger if you prefer – be allowed to continue to move in mysterious ways, his wonders to perform. On these and other accounts, the everyday mundane NHS is still compassionate, and still cares: most patients, most of the time, get a good deal. It is hard to imagine two more opposite visions: the hellish NHS of the lollipop men, or the caring service of the NHS grunts.
At the risk of himself appearing to work in mysterious ways, Dr No vous propose that both sides are right, and the big picture lies somewhere in the middle. Instead of most patients, most of the time, getting a good deal, he suggests some patients, some of the time, get a ‘good enough’ deal, with ‘good enough’ here meant the Winnicott way: by no means perfect; even ordinary; but sufficient. At the same time, the big picture covers and includes the extremes: some healthcare is undeniably excellent, and some is indescribably atrocious. Let Dr No repeat that: indescribably atrocious.
Some is a much vaguer word than most: and here so vague as to be meaningless. All it really excludes is all or none. A few fits some, as does quite a few, even a good few, perhaps even more than a few. But we are still none the wiser. We don’t even know if we have topped single digit percentages: five percent is some, but so too is twenty-five percent. Fifty percent is certainly some, and then some, but it is only when we reach fifty-one percent we can, and probably will, say most. By such mysterious moves can we conclude that some means less than half, most of the time, perhaps even all of the time.
All of which is to say that, apart from at the extremes, where the exceptions stand out, it is remarkably difficult to get reliable objective overall data about ‘average care’. There are surveys, but these are vulnerable to self-protection bias, the natural tendency not to pan those who at some point in the future may hold your health, even life, in their hands. Instead, we form our most convincing impression of how well the NHS cares from anecdote: how it cares for us, and our family and friends. On these counts, Dr No finds, from his own anecdotal experience, normal NHS caring is, at best, barely adequate. There are good days, but they fight a constant and near-lost battle with the bad ones. He finds unsympathetic GPs in the surgery, and singing housepersons in the hospitals.
Add to that the sheer volume of other anecdotal reports of indescribably atrocious care throughout the health service, and the possibility of smoke without a fire becomes inconceivable. There are too many ‘isolated incidents’ not to believe that a pattern has emerged. Lightning has struck in too many places at once. Sometimes, in his nightmares, Dr No imagines the NHS is like Dresden in February 1945: a once fine city now transformed into a furnace of indiscriminate destruction. But that’s only a nightmare: in the daylight he sees a camel whose back is sagging. Not many more straws, and it will break.
Advocates of left shift notions for alcohol control no doubt fancy a similar right shift notion for healthcare: move average healthcare to the right – improve it – and the whole will move to the right. Even the really bad guys will get hauled to a better place; while those at the excellent end get pushed over the edge, from world class to cosmic class services. Dr has no truck whatsoever with numerology based alcohol policy, but, perhaps contrarily, he does have a lot of time for right shift thinking in healthcare improvement because, unlike psychic numerology, it is about shifting culture and norms. It works, because people’s behaviour is influenced by that of others around them. If the culture is one of leaving granny filthy and letting dry out like a wafer, then that becomes the norm. If caring for granny is part of the culture, then caring becomes the norm.
These changes cannot be brought about by bigger better inspections, longer tougher training, or any of the doodlebug schemes cracked up as hot favourites by politicians, pundits and those in our professions who should know better. It comes about because we, individually, decide to look after our patients. So, if Dr No does have a Christmas wish for 2012, and beyond, it is this: may we all, individually, in our own small corner, strive every day to do one thing, however small, to honour the ideals of one of our finest, greatest and defining achievements, the National Health Service.
A very Merry Christmas to you all.