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Could constant reorganisation be the NHS’ ultimate coping mechanism?

Esther Flanagan 17 September 2015

In this blog, Schwartz Rounds programme manager and clinical psychologist, Esther Flanagan asks whether the constant change experienced in the NHS is a consequence of the anxiety and pressures faced by healthcare staff and their organisations


I have always assumed that the constant change experienced in the NHS was largely motivated by a desire to improve care. Policies and procedures are supposedly implemented to attain standards and protect patients, despite their sometimes negative impact on staff.

However, after reading an article by Penny Campling on the culture of healthcare, I became preoccupied by her idea that the NHS constantly changes itself as a way of managing organisational anxiety. Campling writes:

“it is the uncritical promotion of constant change and imposition of new ideologies that is the main social defence system in the modern health service, overloading and fragmenting the system and distracting from the task of caring for the sick and dying.”

By social defence, I believe that Campling is referring to the functions and processes that develop in a system to help externalise the anxiety experienced throughout the workforce. Could the constant change faced by NHS organisations be a way of coping with the growing anxiety faced in caring for patients?

Change must be the answer

Maybe it is easier to first imagine an individual staff member. For instance, a clinician who encounters a patient who doesn’t seem to be ‘getting better’. In a scrutinising culture of outcomes and performance indicators, a patient who isn’t improving or who is deteriorating, is a great source of anxiety.

So when the clinician acts to change the situation, is it for their own peace-of-mind or for the benefit of the patient? Chances are, it’s both – though the clinician will probably not be fully aware of their own motivations.

As a clinical psychologist myself, I admit that if I had a patient who wasn’t improving I would rarely sit back and tolerate the anxiety; more likely I would jump to questioning my approach and looking for new options. Change must be the answer!

A good clinician surely does everything they can to try to help their patient? But could the search for new options and change sometimes detract from the person who is suffering? Is the threat that is placed on the clinician (e.g. feeling like a failure in their duty to ‘cure’), influencing reactive decisions to introduce change (and in turn avoid anxiety)?

Anxious leaders

Let’s apply this to a team – imagine a new leader is appointed, responsible for demonstrating an improvement in outcomes. They bring a fresh pair of eyes and notice areas of concern, introducing anxiety to the team. What might the team leader do first? New ideas are developed and old ideas are revisited, the sense of doing and changing something in itself can help to reduce both the team and leader’s anxieties.

Hopes may become pinned on change and the new leadership – although some staff may become withdrawn if previous attempts at change have failed. But would it be beneficial, for a while at least, to just observe the team, reflect on the existing ways of working and tolerate the anxiety before acting? What would it feel like to hold back from change even for a short while?

The impossible task

Let’s widen it out further to organisations in the NHS. Change seems unrelenting. Could this represent the immense anxiety and sense of helplessness felt by organisations? The impossible tasks of making all patient experiences good; of not making mistakes; of keeping all patients free from pain, distress or death.

How on Earth do organisations manage the inevitable anxiety when faced with the realities of sickness and death? Penny’s article made me wonder how much change is driven by a sense of fear and helplessness versus change driven by listening to, and understanding the needs of staff and patients. Are organisations allowed the time to pause and reflect, or are they under so much pressure to improve, that sometimes it leads to change for change sake? Are staff able to be careful in their choices to act?

This question reminded me of Paul Gilbert’s book on compassion and the difficulties faced in Western society through the constant striving to be better than others. By focusing on results, we get pulled into a change-driven system fuelled by a fear of failure. Gilbert says:

“In the NHS we are constantly reorganizing – and reorganizing the reorganizing – in order to meet targets that change year on year. Not only do these methods play havoc with our minds, morale and ability to develop cooperative working relationships (which are actually the gold dust of well-run organisations as well as of mental wellbeing) they are not very efficient either.”

On balance, change is ultimately positive and necessary in order to improve experience for patients. However, policy makers should resist the desire to implement change simply as a reaction to the magnitude of the pressures faced by the system.

Our instinct is to react to challenges, whether clinical or systemic, by changing something.  However, pausing for reflection before taking action may well lead to better outcomes.  A caring organisation understands the impact of changes upon its staff in the same way that a caring clinician understands the impact of treatment on their patient.

I look forward to exploring these themes in more detail at our conference in December ‘the caring organisation’, where Penny Campling is delivering the closing address.