There is a deep-seated impulse in most of us to roll our sleeves up and try to engage with, and help each other, in a crisis.
Most of my career as a medical psychotherapist was spent running a therapeutic community for young adults whose personalities had been pushed badly out of joint by very difficult childhoods. In a therapeutic community, the community itself is the main agent of treatment, so new members find themselves part of a collective, sharing responsibility for each other and participating in each other’s therapy. Patients who had spent years sitting around passively on hospital wards, obsessed with harming themselves, suddenly found they were expected to join cooking rotas, gardening sessions, vote in meetings, contribute to important discussions and generally be there for and look out for each other. For some, this was a painful and difficult process; others took to it easily, their impulse to reach out and be helpful hovering just under the surface, waiting for the right sort of environment to let it emerge and nourish its practice.
It is a few years now since I’ve worked in a therapeutic community, but there have been numerous occasions in the last few weeks that have reminded me how transformative such phenomena can be. That sense of stepping-up in the face of adversity, reframing a crisis as an opportunity, re-engaging with what we have in common, to free ourselves and each other to be the best we can be.
My local mutual aid WhatsApp group sprang from nothing in the early days of the crisis, posting cards through every letterbox with contact numbers for people who were completely isolated. Some of the texts were from hundreds of miles away: ‘could someone check on my uncle at XXX, he’s 86 and a bit confused.’ Within seconds, someone had volunteered and the relative reassured. The local mosques, temples and churches have their own networks and insights into the community and have raised huge sums for local foodbanks. Meanwhile, you could mistake the people who run our local corner shop for social workers, so attuned have they been to the most frail and needy of their customers. Literally hundreds of thousands of people across the country have volunteered to help, either through official schemes, or in locally organised neighbourhood groups, or just as individuals paying attention to the needs of their more vulnerable neighbours in a way they might not have done before. And all these activities demand creative solutions, thoughtfulness and sensitivity in the face of the difficulties imposed by the lock-down and social distancing.
The city council in Leicester has stepped up in all sorts of ways – helped by our good fortune in having a directly elected mayor. In addition to organising financial support to the small and medium size businesses that abound in the city, many functions of the council have been repurposed. School caterers have been kept at work cooking and distributing meals to the most vulnerable; pop-up cycle lanes have been created overnight, taking advantage of the quieter roads and helping hospital staff get to work; a city-wide system for distributing PPE to care homes and community workers is reputedly working well; a band of council workers helped by volunteers are regularly checking on the elderly living alone and other vulnerable groups; library staff and schools are distributing e-learning materials etc, etc.
But perhaps for me – with a long career in the NHS behind me – it is the way the hospitals have rapidly stepped-up to the crisis that has particularly astounded and impressed me. Senior leaders, for so long bound up in red tape, wearisome business planning meetings, endless regulatory activity and mistrustful relationships, have been given a free hand to reorganise to give their patients the maximum chance against Covid-19. Numbers of intensive care beds have been increased by using other areas, wards reconfigured, clinical practice adapted, co-operative relationships established across specialties, staff re-trained. The new Nightingale hospitals were set up within two weeks, not just the buildings, but a new way of using space and managing patients on ventilators by stretching skilled staff across many more patients. But the Nightingale hospitals were just the tip of the iceberg, the most visible manifestation of amazing changes across the whole of the NHS, including primary care. These rapid changes, together with lock-down, prevented the worst of the scenes in Lombardy from happening here.
I have heard the NHS described as a hippopotamus: for most of the time, lumpen and slow moving, but also capable of charging at massive speed. And this response is not just down to senior leaders: everyone has had to change the way they think and act, from CEO down to porters and cleaners. With the PPE crisis so severe in the early days, it was often very junior staff who took the initiative to provide protective equipment for their colleagues, buying up stock from local hardware shops or teaming up with a local school to make and provide them with visors. Just as important, others have been thinking how to nurture and sustain their teams through these difficult times, knowing that staff are the most important resource we have. I’ve recently heard of a ward manager on a covid-19 ward who has started taking in novels and luxury bath toiletries, to encourage her nursing team to look after themselves during their time off – the symbolism of this gesture saying it all.
I was struck by one of the NHS clinicians I am supporting reflecting that unhelpful aspects of medical hierarchy have evaporated, and that inter-disciplinary and inter-departmental relationships have become less rigid. This move towards a human ‘community’ of care, rather than the more industrialised, impersonal culture that previously tended to mask, if not squash, cooperative collaboration and common purpose, touched her – and me. I don’t wish to idealise what’s going on, nor minimise the individual cost to people, but such stories do bear witness to what’s possible. It is very much to be hoped that all will remember, and learn from, this experience, and its benefits.
The NHS prepared for a surge that didn’t play out, thanks to lock-down. They were ahead of the game in most places. The information we have about the impact of this pandemic changes all the time and there is a need for people to continue to think on their feet and adapt quickly. Hopefully, the same level of creative co-operative problem solving is now being focussed on creating Covid-free environments so the hospitals can start to function again at full capacity for other patients.
One of the many reasons I retired early from the NHS was that it became harder and harder to nurture a sense of agency in either the patients or the staff team. I no longer felt able to do the best for my patients. The culture had become obsessionally anxious and over-regulated, psychiatry was focussed on fire-fighting and increasingly blind to therapeutic opportunity, the therapeutic community ethos had become countercultural and mistrusted.
How can we hang on to this new-found sense of collaborative agency that the pandemic has liberated? Clearly there will have to be a return to more thorough business planning processes soon. But this pandemic has reminded so many people of what is of real value. The challenge will be to recreate management and much lighter-touch regulatory systems that nurture our values, our collective agency, and serve the enterprise. For too long economic efficiency has been aligned with austerity, but a truly efficient system is one that gets the best out its workforce and doesn’t shackle their initiative, their creative thinking, and their wish to do well for each other.