It’s the end of the year, and what a strange year it has been.
A year ago when I wrote my first blog, on vaccine hesitancy, things felt pretty dark. We went in to lockdown for the second time in 12 months, and it was a lot tougher than the first. Gone was the warmth of Spring 2020 and the novelty of kids being home schooled in the sunshine.
A year ago in Primary care we were working hard to return to something looking like normal, as we tackled the backlog in long term condition management and cancer diagnosis. Vaccines were our way out of the mess, and primary care delivered the bulk of that. As a friend said to me “It’s the only way I’m going to see my grown up kids again.” I saw colleagues with incredibly busy day jobs throwing themselves in to vaccinating, and I don’t know where the energy came from.
As the year went on and as the success of the vaccine programme unfolded, just when it should all have been getting easier, things seemed to get harder again. The scale of the unmet need became apparent, our urgent care work seemed to grow week by week, and we found ourselves at the centre of an unedifying spat between the Press and the Government over face-to-face consultations. Happily this blog is not about that; suffice to say we were trying our best.
As this year comes to an end, cases are rising again and we find ourselves in the middle of a huge vaccine programme. It feels all so depressingly nostalgic. There is of course optimism as cases and hospitalisations decouple, but we’re all pretty tired. There is acknowledgement of that; I read and hear it everywhere. The word I hear again and again in that conversation is “resilience.”
I think I know what it means. I checked the dictionary (Collins): “Recovering quickly or easily from illness or hardship” or for an inanimate object “capable of regaining its original shape after… deformation.” That definition makes me think. I don’t think that is how the word is used day-to-day, certainly not in healthcare. “Resilience is the ability to cope under pressure, a person who copes well under pressure is said to be resilient” I read in an NHS Resilience Training toolkit.
Do you notice the subtle difference between the two? The former implies a temporary stress, which is absent from the second definition. Collins suggests when we need “resilience” it is to allow us to return to a normal state after some short sharp shock. The reality is many of us are living in a constant state of abnormal, and we struggle to even remember what normal looked like. Even worse, I worry that the emphasis on resilience implies we are accepting healthcare will be forever an over-pressured work environment.
The House of Commons Select Committee on Health recently published a report on Resilience and Burnout you can read here. The section on Systems and Working Cultures is worth a glance and it warns against focusing on the resilience of individual staff members instead of systems. The evidence from the HSIB, for example, encourages exploration of “where the system can be better designed, so that it can better adapt to demands and shift the burden from individuals on to the system.” What that says to me is the ongoing pressure is not sustainable, the system has to change, not the people.
Long term stresses and pressure are everywhere. The workload pressure in primary care, especially around urgent care, can be intolerable. Linked to that is the demand of supervision; Doctors are trained to consult with individual patients, through shared decision making – that is very different to overseeing large numbers of patients assessed by other professionals, and thereby taking on clinical risk for others.
A busy stressed system amplifies the risk of error, inevitable in any health system which sees huge volumes of health transactions. The System thinkers will point out this is nothing to do with individual performance, it is an inevitable outcome of high volume health activity even with a tiny statistical failure rate. Even if 99.9% of consultations are error free, the residual 0.1% ends up being a large number.
Complaints result from that. They are hugely stressful for staff, who are the secondary victims. As the health system responds to complaint and (rightly) seeks redress for the patient, it rarely sees such errors as a system problem, it is much easier and simpler to focus on the individual. I have sat in many significant event and serious incident investigation meetings over the years and it is common place to chase the failings of the individual not the failings of the system.
We end up with staff who are tired, demoralized and afraid, and our response is to talk about “resilience” as if it is yet another failing or deficit that needs to be addressed. “Staff need to be more resilient in these difficult times.”
The 2020 NHS People Plan offers “The Promise” for staff. It is one page and worth a quick glance. Something is missing for me though, probably in the “We are a Team” section. Perhaps it should say: “Human Factors means we will make mistakes, but we will never be targeted individually in lieu of a systematic approach to improving systems to make healthcare safer.”
I’d much rather we stopped talking about resilience and talk about kindness instead. How would that change the corporate conversation. “We need to be kinder in these difficult times.”
I remember many years ago when I was a junior doctor something went wrong. Exactly what doesn’t matter, but the outcome was an error, a misunderstanding, and a very upset patient. As the junior doctor involved I felt awful. I felt responsible, and spent hours ruminating over what had happened and why. What was confusing was the implied blame and disinterest of those around me. I had messed up, but was expected to carry on regardless as if nothing had happened. I was expected to be resilient. I was called in to my consultant’s office a little later for a conversation that changed everything. “What happened was not your fault”, he said, “sometimes things like this happen, it is important to realise that, and it’s ok to feel like you do.”
He could have explained the difference between individual fault analysis and system thinking. That would have been interesting and useful, although I’m not sure how well developed system thinking in healthcare was back then. In any case kindness and being told “It’s ok” was what I needed. It’s ok, just because this happened it doesn’t mean you are a bad doctor.
So as we move through what is hopefully an improving phase of the pandemic, and as we work hard to restore normality, I think we need to be very careful how we use the word resilience. Our staff don’t need to be told to be stronger or to be more robust. They need to be told that we understand the pressures, and that they will be supported and valued in the darkest times.
The best leadership we can offer is to be able to spend time to understand how they feel, listen to their fears, and to simply respond with “It’s ok.” Empathy not sympathy, because we have been there.
“It’s ok” means, these are tough times, the pressures are huge. You are doing your best and you are valued for that. It’s ok to feel sad. It’s ok to feel tired. It’s ok to feel stressed. You came in to healthcare to care for people and we will do what we can to help you carry on doing that, brilliantly.
So when we think about resilience, maybe the place to start is simply to say “I hear you, it’s ok.”