Enquiries and Whistleblowing in the NHS: what is the problem?

Posted by: Philip Stokoe at 18:33, February 24 2013.

I write this as a clinician who worked in the NHS for 19 years and was a Clinical Director for 3½ of those. I have not been gagged but I am very aware of colleagues who have been. Why is the NHS so sensitive?

In order to understand this, I think it is important to clarify some of the basic assumptions that I bring to understanding organisations. I have summarised this in a formulation that a friend of mine has entitled the Healthy Organisation Model, which is only my version of the model developed at the Tavistock Institute of Human Relations and the Tavistock Clinic. Groups and organisations, designed as they are by human beings, ought to be the best way to achieve most human tasks. In theory they are but in practice often they are not. More than 75 years of study has shown that what gets in the way of organisations fulfilling their potential are unconscious mechanisms set up to avoid anxiety. The reason that this is counter-productive is because anxiety is an inevitable consequence of attending to the task. The same is true of the individual; we often go to quite a lot of trouble to avoid anxiety and yet, in its purest form, anxiety (by which I mean nervous energy) is the thing that indicates that we are still alive. In my view the Tavistock approach to consultancy assumes that an organisation ought to be functioning well and asks the question what is getting in the way?

Turning for a moment to the individual, we know that, confronted with anxiety, the individual assumes a default state of mind that I like to describe as fundamentalism because the world is divided into black and white, solutions are omnipotent, thinking is hated and certainty admired. In this state of mind, the individual turns to what he or she knows best in order to make sense of the world and, particularly, the current threat. (I shall be speaking in a later blog about curiosity and interest as the particular mutation that makes human beings different to the other animals.)

One more thing to be said about these processes by which individuals and organisations avoid anxiety: these things happen outside normal awareness, below the surface or, as I would put it, unconsciously.

Those of us who have worked in the public sector in health or in social services or indeed in the law or academia will be aware that, since Margaret Thatcher, politicians appear to have taken the line that she introduced, namely that professionals should be viewed with great suspicion. For the moment I want to limit myself to the NHS.

Of course it is true to say that many medical consultants misused the NHS outrageously for many years. Many were arrogant bullies and many paid only lip service to their NHS duties so that they could put more of their energies into their private practice. However this was never the full picture and was never true about all or anywhere near the majority of medical consultants. Clinicians have to make decisions which could be described as rationing; on a daily basis we decide whether or not to offer treatment, bearing in mind a range of demands from a range of patients on services with limited resources. These sorts of decisions are part of the clinician’s regular work. Nevertheless governments since Margaret Thatcher’s have all taken the view that clinicians can’t be trusted to take rationing seriously; instead it is better to have the services run by professional managers whose background and training lies in commerce and industry. It is because of this agreed and received wisdom that there are now so many professional managers in the NHS.

I said earlier that anxiety is a normal accompaniment of engaging with the task. The task in the NHS is to deal with physical illness to which the accompanying anxiety is fear of death, or else it is to deal with mental illness for which the accompanying anxiety is fear of madness. Now, following from what I said earlier about the unconscious nature of the processes of defending against anxiety, we might ask what this would look like in this context.

In a healthy organisation anxiety ought to be passed up the hierarchy so that it can be received, thought about and, thereby, turned into “information”. But where there is a defensive system operating, the anxiety is either passed back down the line, or else it is experienced in a way that evokes that fundamentalist state of mind which I described earlier. If the anxiety hits a clinician, he or she will fall back on what they know best; clinical work. They will therefore try to understand the source of anxiety by thinking about it clinically. Since the source of anxiety is exactly to do with clinical issues, this works and allows the patient creating the anxiety to be best understood. However, if the recipient of the anxiety is a manager whose expertise lies in finance or accountancy, they will interpret the anxiety according to that model. In other words they will perceive the source of anxiety as being to do with an economic threat (often this will be seen as arising from one of the clinicians) and they will respond by trying to take a managerial, economic control of the situation. Everybody who works in the NHS will know what this looks like: it looks like tick boxes that have to be achieved so that a service can retain its funding.

Managers become convinced that clinicians are the source of their anxiety and that this is because clinicians are making intolerable financial demands of the service (because, as we have already learnt, “clinicians cannot ration”). This creates a fundamentalist state of mind that is driven by a fear that something terrible will happen. This becomes a vicious circle; the fear of something terrible leads to further controlling measures that are clearly unpopular with clinicians and which make the managers more convinced than ever that the clinicians need to be better managed. This idea operates as an unconscious belief in the system. Since this is a fundamental building block of the unconscious mind of the organisation, the fact that it is merely a belief (which means that it is open to testing) is not known consciously. The conscious version of this unconscious belief is that it is merely one of the facts of life. In the fundamentalist state of mind, there are no beliefs, there are only facts. So, for example, fundamentalists in religions take God and particularly their version of God to be a fact; which is why questioning the existence of their God is experienced by them as an assault on the basic foundations of life.

This state of mind which takes over in all of us when we are made to feel particularly anxious was called by Melanie Klein, who was the first psychoanalyst to describe it, the paranoid schizoid position. Since there are only two dominant images that control this universe, absolute good and absolute bad, the only question that has to be answered is, “which side are you on?” You will remember that George W Bush in his speech declaring war on terrorism following 9/11 said, “if you are not with us you are against us.” I am making this point because it is crucial to understanding the madness that has seized the mind of the NHS. The more adult state of mind, one in which the world can be seen to be shades of grey rather than stark black or white, is hated by the fundamentalist who perceives the mechanism for processing shades of grey as weak. We call that mechanism “thinking”. Thinking can only occur in mind able to tolerate uncertainty. You might say that the experience of uncertainty stimulates the development of the capacity to think. Descartes was not the only philosopher or politician to seriously damage Western civilisation’s ability to think but his two famous contributions to philosophy, dividing emotional and intellectual experience into two separate planes, and the second, the oft quoted, “I think therefore I am”, are, in my view, profoundly wrong. If you have to say anything about thinking it would be something like, “I think, therefore I have made an enormous effort to drag myself out of the quagmire of black and white certainties but I am aware that I can collapse back into that quagmire in a fraction of a second”.

And so we return to the NHS. You will remember that we left the management system certain that a threat exists and this threat essentially arises within the clinical workforce. The belief that clinicians are a threat to the economic integrity of the NHS is not perceived as a belief (which would therefore be open to question), it is held to be a fact. My argument is that, in these circumstances, the NHS is operating in a fundamentalist state of mind. Thinking is perceived as weak, perverse and probably mere manipulation.

At the same time, within the NHS, clinicians are daily involved in enquiries. The contact between a patient and a clinician is the stimulus for an enquiry. The patient says I have these symptoms and the clinician enquires into the patient in an attempt to discover the cause. I believe that it would be true to say that the essential nature of the work of the health service is that it is always an enquiry seeking to find the truth.

So here we have a fundamental conflict at the heart of the NHS: the patient’s interests require that the basic state of mind of the clinical service is a culture of enquiry. The managers interests, because they rest upon a belief that clinicians would cost more than resources could bear if they were not properly controlled, foster a culture of blame. The state of mind characteristic of a culture of blame is fundamentalist, whereas that accompanying a culture of enquiry is more adult. The culture of blame turns an enquiry into an inquisition aiming at finding the object of blame.

The Tories plan for the NHS which, I believe, most clinicians would agree is unworkable, is not the cause, on its own, of the current dismal level of service. The cause of that started with the last government’s decision to apply year-on-year “efficiency savings”. In a system where the main resources are people (clinicians), year-on-year cuts quite simply means year-on-year of cutting services and, since the demands from the management system for tick boxes and other controls requires an enormous effort from the management structure to collect the data and deliver it to the funders so that the services can continue, the only place to make cuts is in frontline services which, of course, is exactly what is happening all around us now. If somebody “blows the whistle” this threatens to draw attention to these unconscious beliefs but, of course it also reinforces those beliefs because it is experienced as blaming. And so the whole system reinforces itself and moves further and further away from a grown up interest in truth.

It seems to me to be a necessary quality of all healthy organisations that they foster a culture of enquiry; this involves a benign interest in itself, its constituent parts and its relevance to the larger society that it serves. This has to be most true about an organisation whose identity is founded on principles of benign enquiry. The point about this brief blog is not to state the bleeding obvious but to try to explain why no amount of pompous and moral-high-ground statements about wiping out gagging agreements will change anything. Unless you understand that the system is entirely trapped in a fundamentalist state of mind in which the only forms of communication are experienced as blaming, you will not enable any movement towards an adult, thinking state in which enquiry is not perceived as something to fear but as the reason for life.