Careerism rewarded at the expense of vocation: the right people in the wrong place – the flaw in NHS DNA
Visit any mental health NHS Trust at random, perhaps with a little more savvy than the average CQC functionary, and you will quickly work out where to find the most able people. Often they will be gathered around a long wide table, veneered instead of the solid oak one which was likely to have been acquired at a knock-down price by a Russian oligarch keen to add some grandeur to his East Finchley mansion. It will be in an upstairs boardroom, streamlined with a turn-of-the-century suspended ceiling and soft, concealed lighting. Or they may be scattered in small groups with marker-pens and a bundle of flip-chart scrolls in a state-of-the-art, breeze-blocked training and education centre, thrashing out the minutiae of the latest form or protocol which, if they can just get it exactly right, will transform a clinical service or practice once and for all.
They will be serious, because looking after people with mental health problems is a serious business, but their discussion will be punctuated every now and then with a collective knowing laugh, often led by someone who appears to have senior rank, as if to indicate to an outsider observer that there is nevertheless a gently humorous seam for insiders to mine. Other punctuation is provided by certain words which appear to have meaning beyond their everyday usage and , as participants take it in turns to voice them, to confirm membership of the group: pathway, framework, stakeholder, toolkit, models, reconfiguration, mapping, scoping, interfaces, hand-offs, transitioning.
This imaginary outsider would no doubt try to trace the connection between these words and what he or she understood to be the business of the organisation – the treatment of people with unpleasant illnesses or conditions – and notice some mounting anxiety that she or he was finding it difficult, even impossible. By contrast, their mention from time to time seemed to reassure, even comfort, the erudite and self-evidently articulate participants, and to convey a sense of safety and solidarity; that the gradient was steep but they were at least on the right track.
An invisible baton, or maybe it was some kind of small totem or amulet, seemed to be passed round the group, mainly in a clockwise direction, and, as each member received it, conferring the cue to speak, their pronouncement was greeted with murmurs of agreement and approval. Our observer remained puzzled. Talk was certainly on the theme – the bold and inventive introduction of a new “model” -spelled out at the top of an agenda, copies of which were scattered around the table.
But, like the Conan Doyle dog which didn’t bark, the absence of something was more significant than the presence of so many difficult concepts so confidently expressed. There was no mention or even passing reference to how the model, now topped off with an impressive acronym, might improve the product of the organisation as a whole; or of how the aggregated contributions of the institution’s top brains might generate added value.
As the discussion continued, with the tone oscillating very gently between the congratulatory in response to a difficult job well done, and a nodding, slightly puzzled acknowledgement that there may still be some persisting problems or staff resistance to be ironed out, the possibility that some kind of dextrous sleight of hand had been in operation in a remote corner of collective thinking began to stir. The means – of reaching a partly or faintly expressed end, connected in some way with psychological health – had themselves become an end, with any benefit to recipients being incidental and certainly not visible on the radar.
Were our observer to stick around on the periphery of subsequent meetings of our cast of bright, committed seniors, another dynamic would gradually emerge – that of the clinical imperative being subjugated by an administrative or, to use a less neutral adjective, bureaucratic one. And this is mediated, made possible and cemented in place by a cultural and linguistic hegemony, populated and sustained by an array of vested interests which, while slowly paralysing the NHS, its host organisation, colonises and, where this isn’t possible, demotes clinical activity down the hierarchy of status and significance.
Whatever. Treating mental illness, disorder - or whichever is considered the least toxic way of describing particular, widely-recognised phenomena - is now a relatively simple matter. Generally, your politics will tend to determine how you understand and explain them. Just as the ancient Greeks believed madness (µανία) to arise either out of bodily humours on the inside (i.e. endogenously) or the action of the gods or fate on the outside (i.e. exogenously), so there are now essentially two explanatory camps, one seeing mental disorder as largely biological and/or genetic, the other as mostly the product of external events or factors, such as bereavement, trauma, unemployment, isolation, deprivation and so on.
Like most dualities, maybe, this particular one feels clunky and crude but it is there at the floor of the ocean of changing currents of thought and fashion in mental health. From time to time, new potential ways of understanding such as that of epigenetics (the expression of dormant genes in response to environment) seem to be developing enough momentum or force to disturb this bedrock but our ideological or political instincts will generally draw us towards one pole or the other - and extremist ideologues would no doubt say that these instincts themselves are either biologically or environmentally determined.
At any rate, putting explanation or theory to one side, most disorders can be mostly neutralised by modern drugs. It may not always look like this when patients are subjected over years to what seems like chaotic or capricious trial-and-error but this is mainly the working through of the law of pharmacogenetics – that is to say, that genes largely determine how individuals respond to particular drugs. Of course, there are numerous factors which impede or contaminate the process towards good-enough treatment – or, if you prefer, management – of a group of persistent illnesses which often generate much suffering, chaos in relationships and networks, and risk both to self and others. In other words, the concrete, objective and physical - easy; the meta-physical and subjective – difficult and taxing.
Personal relationships themselves, where they are conflicted, unsupportive, over-heated or regressive, will feed back into the illness; use of street drugs or alcohol (often preferred as a more acceptable, less stigmatising and instantly reliable alternative to establishment drugs which are heavily promoted and tainted by the market) will have at least some influence which, again, may be partly determined by heredity; and personality, too, may have a big effect both on capacity to ride the vagaries of the illness itself and on the ability to form trusting and reciprocal therapeutic relationships.
There is some research evidence to suggest that having a positive (a tricky concept, of course) relationship with the doctor who is in charge of prescribing will make a patient more likely to take and persevere with psychotropic medication. And there is plenty of empirical or anecdotal evidence to support the notion that patients do better when they are looked after or worked with by open, flexible, consistent and empathetic clinical staff who are able to establish democratic and trusting therapeutic relationships, mixing humour with an ability to apply coercion (i.e. via the Mental Health Act) humanely and sensitively when necessary.
Again, there is no real mystery or great complexity to this. But the ingredients or attributes that staff need in order to be able to work effectively and collaboratively are many and hard to acquire: for example, knowledge, know-how, experience, an ability to develop patterns to aid assessment and formulation combined with a resistance to stereotyping, creativity, thinking on your feet, confidence (the importance of which tends to be underestimated or unrecognised), the ability to combine apparently conflicting roles (as helper and gaoler, perhaps), and the cognitive ability both to handle tricky concepts such as capacity, human rights and self-determination, and also to keep in mind both the type and the individual simultaneously.
So, working with disorder of the mind (leaving aside what this means in detail) requires experience, intelligence (of thought), intuition and, least important, a certain amount of training – with each used to test the others. But perverse incentives – of better pay, greater status and, most important, the seductive and compelling reward of being listened to - draw bright, able and thoughtful staff away from where those attributes can be most useful into areas and activities in which what you say is always more important than what you do. And what appears unarguable and progressive, that is the promotion of able staff up the hierarchy into positions of vital strategic importance, is in fact the product of primitive magical thinking – the superstitious belief that the further removed you are from the body (or the mind and body), the greater your status must inevitably be.
The dangers and absurdity of this organisational primitivism can be seen most clearly in acute admission wards where the direct care of very disturbed patients, at a time when the scope for healing, learning and reappraisal is nevertheless at its highest, is delegated to the most junior and inexperienced – and sometimes least well-educated - staff. At best, the result is a kind of anxious, watchful warehousing; at worst, and more often, wards are lawless, anti-therapeutic places constrained by symptom-led activity and an embargo on thinking. By default rather than design, the primary goal has become to get to know the illness, a matter of simple, undemanding observation, rather than the individual.
Inevitably, the manifest folly of the upside-down hierarchy of mental health services is held in place by vested interests underpinned by human nature. Overpaid senior staff coast through risk-free, recreational meetings enjoying the comforts of unchallenging predictability, leaving junior employees to ride the contingent chaos of direct work with those in the throes of mental illness or disorder until, having served their apprenticeship, they can plan their getaway.
A careerist culture has instability and waste built into it. Because distinction comes from making a mark rather than carrying out and facilitating the basic, objective task of the organisation well, staff moving up through its strata are under pressure to introduce change or to mask non-change in convoluted language giving an illusion of change. Habitually, the right solution is applied to the wrong problem. What is wrong is that they are wrong – not knowingly or wilfully but because their reading of the organisation is a direct product of its established culture. In this culture, change is a primarily a function of seniority and hierarchy instead of something which is derived organically and progressively from its fundamental task and activity on the ground in work with patients. This has to be imposed from above, of course, but “learning from” must move upwards instead of being imposed or foisted, as now, on clinical staff who are resistant, not because of a dislike of being told what to do but because, instinctively, they recognise what they are being told to do impedes what they are there to do.
Staff who are motivated by a sense of vocation have virtues which are not prized in a careerist culture. They learn appropriately on the job and apply lessons adaptively; they like to use initiative and to work autonomously but will have a developed sense of when to refer problems and decisions outwards; they incorporate feedback from patients into their clinical behaviour and attitudes; and, as their practice improves and becomes more effective and less risky, they translate their experience into day-to-day guidance to junior staff who, because it resonates for them and has relevance, will be more receptive to it than to abstract directives which are passed ritualistically down a chain of command.
In a culture in which vocation is rewarded at the expense of careerism, clinical excellence and constant, informal feedback from patients and their histories are the factors which impose demands on clinical staff. In a careerist culture, status, position, fashion which is divorced from the objective clinical task, and a fixation with the carousel of constant change alienate clinical staff and subvert the incremental improvement of clinical care.