Aidan Fowler Director of Quality Improvement and Patient Safety, Public Health Wales
Never start a blog with “when I was young”, but that is what this is all about. Why would an NHS consultant change their ways when they were not trained that way?
There is always a risk that this conversation turns into a version of the Monty Python ‘Four Yorkshiremen’ sketch, where each explains that his upbringing was tougher than the last (“We used to have to get up out of the shoebox at twelve o'clock at night, and lick the road clean with our tongues”).
But there’s a serious point here we don’t talk about nearly enough.
When I was trained (by the end of which, I was a consultant colorectal surgeon), I was taught to be self-sufficient, to expect little help (especially in the night), and as such invented solutions based on some learning. I only worked as part of a team some of the time, worked at the limit of my stress levels most of the time, and resisted some work because there was much too much of it. I was not taught to see change as a good thing, but as something to be kept at arm’s length. Success was holding out, not giving in.
I’m not talking about the distant past. This was the 1980s, making my experience fairly typical of a great swath of consultants currently working across the UK: of the over 73,000 specialists across the UK, 40% are over 50, and likely to be an even higher proportion of senior roles.
Were this group trained to work happily as a team, and share decision making with colleagues or patients? Were their cultural expectations to respond favourably to requests to “if it could be better let’s try a different way, just if you have time between your clinic and endoscopy”?
Of course this is changing, and I don’t for a second condone an approach where staff self-preservation comes first, with patients some way after that. However, the endless talk of engaging with the difficult consultant wears a little thin.
In improvement we’re rightly focused on the importance of context, and it matters here too. We have a group who’s reward for stellar school success was to spend six years learning facts and not thinking much (probably in a room on their own); then to be left with a few sick and deteriorating people (on their own again) seeing things no one should ever see; and then work outside their comfort zone trying to get everything right six days a week for thirty years.
Why then does it come as a surprise when my fellow consultants don’t always get loved up on our ideas for change that we shake all over them like a wet dog?
If this sounds self-righteous it is not meant to, it is not just the doctors who have these experiences, I know that. There are also many examples of consultants leading great improvement work which we should celebrate.
But we should understand that whilst this upbringing is changing, and often for the better, we should work with the reality of who and what we are dealing with. This isn’t a call to give up, but rather to redouble our efforts, and find new ways to embrace consultants in change and improvement work. This isn’t rocket science: giving dedicated time in job plans is one place to start.
To make change work, we need to be mindful of the cultural context of all staff, and remember consultants are part of a spectrum of people and behaviours in healthcare – even if at times they appear to be at one end of it.