The NHS ‘make-do’ culture is not safe

Doctors need to be protected and empowered on the front line in the fight against COVID-19, say Rob Harwood and Amit Kochhar
Location: UK
Published: Wednesday 6 May 2020
Doctors wearing PPE

The NHS has always been accustomed to ‘making do’ and the financial pressures of the past decade have exacerbated that.

We have got used to situations where necessary beds, equipment or staff are not available and we have felt the pressure to do what we can to provide what care we can despite that deficiency.

The NHS system is now experiencing a situation unique in its history – an unprecedented demand, a demand that can only be safely met if we are properly equipped. As well as national calls and lobbying for the right equipment, we need to reflect also on how we each behave in our own workplaces – are we permitting unsafe practices for our ingrained culture of ‘make do’?

Some may experience more pressure than others

All doctors want to do the best for their patients, to deliver the best care they can within the constraints. Some doctors are likely to feel more confident or comfortable asserting what is needed and saying ‘no’ if they feel they cannot provide safe care. Some doctors may be more likely to be listened to when they do raise concerns and get the resources they need, especially in such a hierarchical culture as the NHS.   

BMA surveys have highlighted that doctors with BAME (black, Asian and minority ethnic) backgrounds can be less confident in raising concerns, more fearful of being blamed if something goes wrong, and are more likely to experience bullying or harassment in the workplace. Our series of surveys on PPE (personal protective equipment) during this crisis have shown BAME doctors more likely than white doctors to say that they feel pressured to see patients without adequate PPE. As the crisis takes an increasing mental toll on staff, BAME doctors are more likely to say they can not access the support for well-being they would like.    

These are very concerning findings about highly committed colleagues. We must ask, are we doing enough to support them?

Fear of disclosing disability or health conditions

It has been suggested that all doctors find it difficult to acknowledge ill health within themselves. Expectations of superhuman resilience and heroism may create stigma in the profession around admitting we have the same vulnerabilities and health conditions as patients. The recently published NHS Workforce Disability Equality Standard found that just 2 per cent of the clinical workforce had disclosed a disability and this decreased with age.  

A crisis demands urgent change

Culture change is not easy. It takes time to change ingrained attitudes, behaviours and ways of doing things. But this crisis adds urgency – now is the time to recognise that if we fail to change behaviour it may prove fatal.

Bullying must be dealt with

Healthcare organisations must ensure that there is no pressure on staff to undertake work where those staff believe they are being exposed to unnecessary risk. Complaints about bullying behaviour must be very rapidly investigated and resolved. While there is little hard evidence, it is conceivable that bullying behaviours could pressurise colleagues into taking on work that is unsuitable for their risk profile or working with inappropriate PPE for the clinical situation.

Be inclusive and support colleagues

We’ve noted that some staff groups have more difficulty challenging authority and being heard than others. If those of us in senior positions – from backgrounds that form the dominant culture within the profession – are finding things hard right now, shouldn’t we  pause and reflect?

How does it feel for colleague from BAME backgrounds, especially those who are more junior, or have other characteristics that mean they may feel excluded or lack influence in the workplace?

We need to make the effort to reach out, to listen and to understand how this crisis is affecting them. We should ask what support they need. Organisations should encourage ‘buddy’ behaviour. This will give us valuable insight into where and how the pressures are being felt and improve cohesion between colleagues at this time of great stress.

No one should be pressured to work with inadequate PPE

Organisations – whether in primary or secondary care – must accept that fully situation compliant PPE is an absolute requirement before any care can be delivered. This must be completely clear: that there can be no ‘it’s just for this single case’ exception. We must support each other to overcome that inclination to deliver care to our patients in any circumstance – laudable though that devotion to duty is. Care should only be given with appropriate PPE, appropriate because it actually protects.

Identification and redeployment of those at greatest risk

Organisations need to stratify staff into groups based on evidence of the risk factors that are likely to increase likelihood of severe illness or mortality from COVID-19 infection – just as PHE (Public Health England) has done for the patient population. This is likely to be a dynamic process as knowledge of COVID-19 develops and the epidemic progresses.

Organisations will need to review their risk stratification regularly as part of their planning for service delivery. They must be transparent and proactive in identifying those who are at increased risk. Some staff may be reluctant to accept their own vulnerabilities or to disclose underlying conditions or factors that put them at greater risk. They may be reluctant to move to areas of work that are safer for them. Organisations will need to communicate and discuss vulnerabilities, risk and measures to protect staff in a supportive and sensitive manner.  

All kinds of work have value

Many senior doctors feel that they should lead from the front, that they should take on the cases of the greatest difficulty and greatest clinical challenge. But we need to take care that this is not read across as accepting the greatest exposure to risk. Staff should be encouraged to understand that all work has value in this crisis. No one should be made to feel devalued if they take on work that is not ‘frontline’, with reduced risk to keep them safe if they are vulnerable. That is what a caring employer should do, and translates the true spirit of the public’s ‘clap for the NHS’ into meaningful action.

Rob Harwood is chair of the BMA consultants committee and Amit Kochhar is chair of the BMA staff, associate specialist and specialty doctors committee