Having looked at some of the wider issues around how political change might happen in the future I’d like to look now at some of the arguments for change inside the NHS.
For many clinicians the last few months have seen dramatic changes in the way they work. Those working in acute care with virus patients have found this a frightening, but a directly validating experience. Knowing your constant efforts are the very best that the nation can achieve to keep people alive validates your work.
For others, whilst there have been very striking changes to the way they work, they have been working in aspects of health care that have been impacted by Covid but are not about Covid.. They have not had to change their practice as directly as their ICU colleagues. Most of these changes are not completely new but are the result of a very fast acceleration of change that started in the last few years.
What is significant is the pace of acceleration in these changes over the last few months and whether these changes will continue after the virus.
As I have tried to do with my posts about the wider politics, I want to concentrate now on how we can continue these changes in the future, not by simply wishing change to happen, but through argument and narrative.
And, just as I did with those posts I want to concentrate on how we win the arguments for change against what will be strong counter arguments to return to ‘normal’.
I’ve commented before on the very radical change to the location where primary care is actually taking place. Up until the crisis the NHS answer to the question, “Where does primary care take place?” was simple. Primary care took place in GP surgeries and health centres
During the crisis the answer has been that it mainly takes place at home.
People are advised by clinicians over the phone or through the internet, but the patient undergoing the care is at home phoning 111 or being phoned by their primary care practice .
For many primary care professionals this runs counter to their core image and their experience of practice. For clinicians this is not a small change. If we want to continue this change in future we need to empathise with the sense of loss that many practitioners will feel.
For millennia, health care has been about the laying on of professional hands on the patient. Over time different medical kit has been used to help clinicians, but touching and looking closely at patients has been at the core of the best of practice. Now we appear to be saying that a phone call, email or Zoom meeting is as good. And many clinicians feel it isn’t.
In recent weeks I have listened to psychoanalysts and executive coaches talk about how much they miss actually seeing people face-to-face. The importance of how they enter a room, how they look (or don’t look) at you all matter to the practice of this work. But they also say that there are aspects of technology that help interaction. Some people say a lot more online than face to face. It can facilitate more truthful interaction. These professionals have been learning how to use these additional techniques. It’s not been easy, but it has added to best practice.
The same is true of primary care. Someone sitting in their own chair in their own room will find it easier to talk about how they have been feeling in that chair, in that room. ‘Playing at home’ they are deterred from talking about all sorts of things far less than they are when ‘playing away’. The difficulty for the professional is that they are no longer playing at home for much of the time.
So in creating arguments for change it’s important to empathise with clinicians that mainly want to see people face-to-face.
One of the issues that have brought about this change has been safety.
The crisis has placed professionals in the unusual situation of it being potentially dangerous for them to meet patients in person.
But a few months ago, those arguing in favour of ‘real life’ consultations felt it would be dangerous to have consultations in any other way. They believed they might miss important symptoms – and that would be dangerous.
This is a dramatic 180° turn. Arguments for change rarely move so dramatically.
When we return to normal, the virus will (hopefully) not be something that we are worried about catching when we go to see the doctor.. But let’s be honest, GP waiting rooms (and outpatient clinics) are places where we ask members of the public – likely to be sick themselves – to come and sit with a group of people (for some time) who also are likely to be sick.
Prima facie this is not a safe thing to do. In the height of the ‘flu season we ask people who are worried that they may have the ‘flu to come and sit with others who may have it as well. This really isn’t wise. Many members of the public know this.
If it were at all possible wouldn’t they much rather stay in the warm at home and have the doctor phone them? Then, in the 20% of cases where they have to come in for a test, make an appointment with the nurse to do that when there are fewer people around. (In the last two years my ‘flu jab appointments have been at exactly 2.17 and 3.09. I have not spent any length of time hanging about with a group of potentially sick people).
Some clinicians will have found the ‘new normal‘ of phone consultations much better. How will they express that experience?
Some patients too will have found consultations by phone in their own home easier to manage. How will talk about that?
One of the main ways to shape arguments for change is to find the real words people use to describe their desire for it. We have to help people express themselves. And to do that we need their words.