Changing the NHS – The need for a new Skills Mix – 1

Persuading the Reluctant.

How might we persuade frantically busy people to do give up some of their work? 

In the next decade there will be a radical change in the skill mix of most staff in NHS and social care. There will be several reasons for these changes.

Some will be the consequence of increasing demand from an aging population. Some because of radical changes in medical practice. Some through different patient demands, and many through technological change.

I often mention that fact that there are currently about 1 million consultations every 24 hours. In 10 years’ time most of the anticipated 1.25 million consultations that will be taking place will be different.

This will involve tens of millions of patients behaving differently –  an issue I’ll develop in a later series of posts – but also most members of staff working with them will be working differently. This fact lies at the core of what matters in many changes in policy and structure.

We will need millions of people to behave differently.

Over the last 15 years or so I have been involved in literally hundreds of conversations with clinicians about how they might work differently. Often (not always) these people are incredibly busy.

I remember, more than a decade ago, talking with a senior GP who said that he was puzzled as to why he knew less and less about what was happening in the outside world. Then he realised that he used to drive home listening to the 6 o’clock news and now didn’t get home till 8. (and was too knackered to stay up for the 10 o’clock news!). It was his ignorance of the news that reminded hm that he was now putting in 2 extra hours of work every day. If he had been younger, he would have missed playing with his children.

And here I was, adding the burden of a change programme to a GP already working so hard that he couldn’t listen to the news. That, and many more examples, made me recognise the humanness of asking people to take on broad changes in their practice.

Most clinicians I spoke to about change were very busy – often frantically busy – people. And part of the human paradox was that many of the changes in practice I was discussing would have them actually doing less, handing over some of their work to staff with fewer qualifications.

For me this is the core of the skill mix argument. We need to ensure that qualified people are only spending effort doing the work that only they can do. For the NHS to thrive this will be the at the heart of much of the change in the next decade.

And this reveals the essential paradox of much staff experience. Many clinicians were so busy that they couldn’t even think about change. Yet when you discussed taking some of that very patient-facing work that was overwhelming their work experience away, they resisted it.

They became very anxious about the loss of that work.

Our conversation would often then take a couple of different directions. Even many of the busiest clinicians seemed to have a nagging worry that if some of their current patient-facing work could be carried out by someone with less training, it would somehow threaten both their personal future employment and the future of their particular clinical profession.

This fear can lead clinicians, in the face of reforms to improve their working lives, to resist them.

“Do you mean to suggest that someone without my years of training can carry out some of the work that I do now?

If I stop doing that (and that – and  that!), where will it end?”

This is not an unusual reaction. I am sure that if you have these discussions with very busy clinicians you will experience this reaction more often than not.

Prima facie this appears odd. They are so very busy, and here we are suggesting something to make them less busy, yet they resist it.

For me this reaction usually leads to a discussion where I assure them that, “It’s OK, there really will be enough sickness to go around in the future. However good we get at prevention over the next decade, there will be no shortage of sick people for you to work with”.

This assertion usually gets a smile of recognition. But that smile doesn’t stop the anxiety. It’s the same anxiety that I highlighted in my post about the GMC in the autumn – when they asked the NHSE to say that there wasn’t a plan to get rid of doctors. (This within weeks of the NHSE committing itself to a long-term workforce plan which planned, over the next 15 years, to considerably increase the number of doctors).

So, this anxiety about their important work (and about them) becoming redundant is real. (even if historically their jobs are safe).

There is a second emotion behind clinicians’ anxiety about limiting their patient-facing work. One that springs not from anxieties about maintaining their future employment but from the morality leaned from their training and practised as part of their professional identity.

Most clinicians have internalised an important sense of duty to their patients. Much of that sense of duty springs from their feeling of personal responsibility for the medical work with the patient.

This is a very important part of clinical morality. ‘I feel responsible for what happens to my patient. If you are telling me that some of the work with this patient is going to be carried out by someone without clinical qualification – that worries me.’

Of course, in the real work of NHS care the ‘ownership’ of a patient as in “my” patient, is a bit fictional. Even in a single pathway of care few patients are owned by a single clinician.

In autumn 2022 I had a successful cancer operation followed by weeks of radiotherapy. I am sure the surgeon saw me as ‘his’ patient. Even during the 10 hour operation there were 3 surgeons and 2 anaesthetists. Then whilst in hospital I worked through (at least) 40 clinicians who looked after me.

And during that time never saw the head surgeon who had me as ‘his’.

The practice of modern medicine (and not just surgery) depends upon a complex range of clinical relations which precludes a personal ‘ownership’.

All that is true, BUT the relationship that clinicians feel they have with their patients does matter – a lot. And part of their resistance to a change of skill mix is anxiety about what will happen to ‘their’ patient.

I’ve explored these two sets of experience that have lead to resistance to the introduction of a further skill mix, not to say that this makes change in skill mix impossible. Quite the reverse.

I’ve done it to investigate how real anxieties about the future may well lead clinicians to turn their backs on changes even when they badly need them.

That’s why those of us arguing for change need to really listen to these emotions about resistance and ensure that as we argue for change, we do so with a strong empathy about why such busy people don’t want to give up any of their busy work.