Reflections, values and the zeal for reformation by @craigwhitephd

I have been reflecting a lot recently about my values, how these influence my professional decision-making and how I might want to focus these.   This was partly triggered by an invitation to speak in Oxford in December last year. One of my first clinical supervisors (@jen_unwin) had heard on the grapevine that I had moved to a management role and wanted to hear more about this.

Reforming zeal

We talked about her recollections of me as a trainee and this reminded me of something she had written on a competence assessment – “Craig is highly assertive. He expects others to live up to his high standards. His reforming zeal, while admirable, can lead to frustration with others. He is energetic and motivated and always has the clients’ and the profession’s best interests at heart.”

The following week, I was in a multidisciplinary ward round – presenting details of an assessment conducted over several months of a person who had been extremely mentally unwell.

Something happened in that clinical meeting that I will never forget. After the meeting (now 18 years ago) I wrote this letter (I retained an anonymised copy):

Dear Doctor

As you are aware, I attended the ward round this afternoon to discuss my assessment and recommendations regarding XXXX.  During this I was concerned about what you said to him and the effects that such comments are likely to have on his symptoms. As I said, he has extremely negative beliefs about himself and low self esteem. You said to him  “just be quiet, shut up a minute” and “you’ve had thousands of pounds of care, enough for twenty coronary artery bypass graft operations”. It is my opinion that your comments were unacceptable and unprofessional. I am aware that you have a longstanding relationship with this patient but still believe that these comments serve only to maintain his negative view of himself. 

I hope that you will reflect on the above and take my comments as a reflection of my concern for his wellbeing.

Yours sincerely

Craig A White, Trainee Clinical Psychologist

to Dr. XXXXXXX, Consultant Clinical Psychologist

I remember the sense of disbelief that none of the others present said anything. A few days after sending the letter, I was informed that plans were in process to suspend me – meaning I could not start my first job as a clinical psychologist.

• We can’t get an ambulance on a Saturday…

I’ve had to take similar stances personally too, most memorably when my brother in law Andrew was dying.  My wife and I were taking turns to sit with him through the night in hospital (honouring our commitment not to leave him).  He wanted to die at home surrounded by his family, aware that day the situation was rapidly changing.  “We can’t send him home on a Saturday, the ambulance service are too busy there’s a Rangers match on – they won’t be able to do that” was the initial response to my request that arrangements be made for his discharge.  There were 3 ambulances sitting outside the hospital A&E department.  Spurred on, I suppose by that ‘reforming zeal’, I decided to conduct a survey of the drivers:

Hello, sorry to interrupt your break.  My 37 year old brother in law is currently dying in a bed over in that building.  He wants to be with his Mum back in Ayrshire.  I have been advised that if a call came through today to take him back home to die that you would not be able to agree to this because you have too many other calls for people injured or in need at Ibrox today (Rangers football stadium).  If a call came through just now saying you were needed to take Andrew home to die would you be able to ?

I will spare you the rest of the details, though needless to say one of the most meaningful images I have is driving along a road in Ayr behind the ambulance later that Saturday, and through my tears seeing his Mum, Dad and my wife (his sister) standing on the roadside to welcome him home for the last time.

The needs of the patient must come first

I am often surprised that other people don’t always see things in the same way… and that others don’t feel able to speak up or persist with advocacy. People have a right to expect that their needs will be put before those of professionals or ‘the system’.  Don’t they?

Why am I drawn to these examples after several years ?  It’s not because I think that the examples from my experiences of hospital wards in North West England and West Central Scotland are common scenarios – thankfully they are not.   It’s not because I think that the majority of staff don’t put the needs of the people they care for first – they do, thousands of times each day.  It’s because I think that there are likely to be several times every day when ‘the system’ is more important.    My sense is also that there still might be too many people who are no longer able to challenge when their personal and professional values are compromised.   The fact that there is now an NHS Action Line http://www.scotland.gov.uk/News/Releases/2013/04/NHSactionhotline010413)  is also surely evidence that our workplaces are not as psychologically safe as they should be, that they don’t always support open, honest and respectful dialogue ?

The Arrogance of Excellence ?

There is still much to do, putting people first and confronting ‘the arrogance of excellence and normalisation of deviance’  (see Jim Conway’s inspirational blog at: http://goo.gl/RNXwN). The fact that there has been an identified need for national improvement programmes to enhance person centred care is testament to the fact that care systems aren’t yet reliably delivering this for every person every time.  Earlier this year Jim Martin, the Scottish Public Services Ombudsman (@SPSO_Ombudsman) told the Health and Sport Committee of the Scottish Parliament that the same issues from ten years ago are still appearing in the complaints that he upholds in relation to NHS Scotland (watch him at http://goo.gl/tr8K2). You just need to read Healthcare Improvement Scotland’s reviews of how adverse events are managed (http://goo.gl/pG3YR) to see that most NHS Boards in Scotland do not meaningfully involve people in the process of review and learning when things go wrong.  Why ?

We all need to work more effectively to explore, test and implement ways of becoming more reliable at putting people’s needs first.

I wasn’t suspended. Nothing further came of that particular threat after a week of protracted challenge and legal intervention on my part, though sadly my letter never reached the intended recipient (as a senior NHS manager removed it from his incoming mail). I was told that I had “seriously ruffled feathers of senior NHS staff” and that the letter was libellous (which of course is nonsense as the claims in libel need to be false for a claim to succeed).

Andrew did die at home surrounded by his loving family and all the people who called for help from the football match that day still received it.

Something to think about ..

• What will you do the next time you encounter a scenario that raises the issues outlined in this blog ?
• Do you still have the same values and passion that influenced your decision to work in the area that you do ?  What are they ?
• Are these consistently shown in your actions and decisions ?  If not, what is stopping you making this a reality ?  How do you feel about this ?  What could you do to rectify this ?
• Are your values shared by others that you work with ?  If you think not, could it be something that could lead to useful discussion with them ?

Craig White @craigwhitephd is Assistant Director, Executive Nurse Directorate with NHS Ayrshire and Arran and Professor at University of the West of Scotland.

Dedicated to Andrew John McPhail (1966-2003).