my duty to you

You don't have to be an actual junior doctor to be worried about surviving work in health and social care. So in this final column for Battles on the NHS Frontline I’m bringing out the big ethical guns and arguing the case for our duty of care to the people we work with.  THE DUTY OF CAREThe duty of care is a complex mix of rules and professional regulations that apply to all NHS staff, articulated in the newly amended NHS Constitution. It means that people working in health and social care have a personal duty of care to provide good clinical care. The high profile failures in patient safety point to the limitations of a purely regulatory system. In first place, is the hard reality that the fear of victimisation from colleagues and employers stops people raising their concerns about patient care. This guilty NHS secret led to the Freedom to Speak Up review that concluded that in order to get people to speak up the blame culture in the NHS needs to be addressed. This problem is often framed as the need to make the shift to a ‘just culture’ - one that makes a distinction between at-risk or reckless behaviour from just human error.  But the expansion of codes and regulations still leaves us with the problem how to build a working culture that looks systemically at care, rather than taking the Witch Hunt School of Management which individualises collective problems.  CANDOUR IN A CONTEXT OF AUSTERITYThe most common concerns in health and social care relate to connected issues of changes in service delivery such as outsourcing, work intensification, staff shortages and insufficient skills mix.  In a context of austerity one of the difficult areas for staff is whether to raise concerns over a lack of resources. Professional codes advise that if you know that there is a serious problem with lack of resources and prioritising them then you are obliged to raise your concerns. In this situation, the clinician is personally accountable for following their professional code and obliged to refuse instructions on the basis of their duty of care.  This puts health and social care workers in, at best, a political position and at worst an impossible one.  The new regulations on our duty of candour, although well meant, add a further nail to the transparency coffin - making the focus on establishing the crime and the punishment, rather than the pressing problem how to tackle the culture of fear that people work within. If our response is to regulate and punish alone, we are just setting up a system where silence is institutionalised.  Only martyrs need apply. OUR DUTY OF CARE TO EACH OTHEROne of the problems with the current marketized and legalised model of care is that it creates splits - between colleagues and between staff and patients.  In this highly politicised health care system the duty of care debate is dominated by the clinician’s responsibilities to their patients. This is not to suggest that patients aren’t at the heart of the NHS but to do this at the expense of the other duties involved in care has turned out to be a disaster.  If you ignore the NHS’s duty of care to the people that work for it so that 30% live on less than a living wage then you can argue that the NHS is failing in its duty to provide quality care.  The announcement of a £5 million occupational health fund for NHS staff - in response to burnout and long term sickness - indicates that many of us are failing in our duty of care to ourselves. Our duty to work in a way where our own health is protected.   The existence of a ‘pervasive culture of fear’ in the NHS where staff are unwilling to raise their concerns about patient safety also indicates a total failure of our duty of care to each other. The reality is that many of us cope with working in the NHS by shutting up and actually not caring very much about the people we work with.  It means that our workplace relationships are currently not sufficiently strong to risk speaking up at work or to manage difficult conversations about the mistakes and unfair choices that are inherent in the job.  A RELATIONAL MODEL OF CAREGiven the emotional nature of the work of care, you’d think we’d all be experts in forming relationships. But most working people cope with conflict and group dynamics by withdrawing into a ‘bunker’ - a safe place not disturbed by actual other people.   Drawing on the psychoanalytic concept of ‘working Intimacy’, developed by a practitioner Angela Eden, is really helpful here.  Within this relational model of work, providing good care involves three things: putting the job of work back in centre place and then agreeing some common principles that set the battle lines between what’s fair and what is not.   Because our principles in health and social care are compromised every day, these two elements can only be protected if we have genuine and functioning relationships with the people we work with. The third element of working intimacy is therefore that we have to get on with having actual relationships with the people we work with.  One of the difficulties of getting on with people at work is that for many people working in health and social care, we’ve got superegos like tanks - the internal voice that sees things in absolutes of right and wrong, black and right - you-must-do-this rather than what-is-realistic. It means that giving good care means challenging our internal Judge Judy and the part of us that wants to blame and shame others more than we want to understand them.  In this relational model, our capacity to deliver care and its associated duties rest entirely on us having relationships at work where mistakes can be made, thought about and addressed without anyone being burned at the stake.    SURVIVING WORK IN HEALTH AND SOCIAL CAREFor many of us working in the public sector our relationship with work is abusive, working without reward or a sense of belonging and taking the blame for someone else's actions. Materially and emotionally, the more vulnerable our own situation becomes the harder it gets to care compassionately about others.  So, in this last blog of Battles on the NHS Frontline, I’m going to summarise what I’ve learned from you about how to survive work in health and social care.  

• don't blame yourself: understand the social, political and economic factors that make your work what it is

• don't keep calm and carry on: find a way to actually feel what you feel about that - from anger to the need to punch and spit, feel it and find ways to express it that wont end up with you losing your joB

• don't be brilliant: resist the temptation to be a superhero and single handedly overcome the systemic failure of welfare capitalism. Try to be an ordinary person would you?

• don't go it alone: just stop fighting the obvious that you have to get on with the people you work with enough to talk to each other and where possible collectivise around what is important at work

  If the history of workplace organising is anything to go by this involves setting the battle lines - the principles that form the basis of care - and the conditions under which those principles can survive.  The over-emphasis on what needs to be delivered for less money comes at the expense of doing this. This political deficit means that a central task for all of us, whether patients or clinicians is to take a position on the values that underpin the NHS and to defend them.  This is both a political and concrete task. To defend a principle of care that is fair both to patients and staff, and to build sufficiently intimate relationships where we can work responsively rather than defensively.  Ultimately, surviving work depends on how we treat each other. It matters if you ask people how they are and listen to the answer, support someone with a concern at the next supervision or join a union.  Time to dig deep. This series of pieces Battles on the NHS Frontline was produced for Sage’s theconversation.com and will form the basis of my upcoming book - Surviving Work: How to manage working in health and social care to be published by Gower in 2016.