I seem to be the one on this blogging team most preoccupied with dark things. I’m afraid it’s no different today. I’m hearing more and more stories from the ‘front-line’ that worry me. Not, this time, the absence of PPE, or testing – in hospitals, at least, those problems seem to be lessening. Not the inexorable cost, the exhaustion, the anxiety, of day-in, day-out working in Intensive Care – though that remains a constant, often exacerbated by the disturbing numbers of NHS and care workers in those beds. And not the grim experience of residential and domiciliary care workers, sadly still neglected. What I’m hearing about are stories of conflict, with little evidence that much is really being done to understand and address it.
The way in which the NHS was able to increase its Intensive Care resources for people seriously ill with Covid-19 so quickly, and at such a scale, has been little short of amazing. But, of course, it has come at a cost. Resources have come from already over-stretched budgets, and from an already under-staffed workforce. Doctors and nurses, and other clinical staff, have been transferred from other specialties, leaving those services much less able to get on with their valuable work: work that, not to overstate the point, gives crucial meaning to the lives of the specialist staff involved. Those ‘left behind’ in such services during the pandemic are understandably worried about their ‘client group’, concerned about the break in continuity of their commitment to, and work to address, those needs. Some see the fact that the increased capacity in adult Intensive Care has not all been used (so far) not as a matter of relief after necessary ‘worst case’ planning, but as a sign that too much priority has been given to responding to Covid-19. These factors seem to be leading to smouldering resentment in a significant few, too frequently overflowing into outright expressions of rage, to rows in corridors, to hostility and division.
There are other dimensions to the underlying currents of conflict that threaten to bubble to the surface in our hospitals. Chris, in an early post, referred to the importance of being able to improvise at such a time as this. And many staff have done just that, rapidly setting up new wards, providing ‘crash course’ training for staff who have to make the transition to intensive care work, securing PPE, or making countless other things possible. It won’t surprise anybody that such creative behaviour, necessary at such a time, goes against the normal bureaucratised, risk averse, forensically governed way things are done. Too many of those improvising are finding themselves the targets of challenge and ill-feeling from those whose job is normally to enforce such a regime. Some of the improvisers are finding themselves the subject of thinly disguised ‘set ups’, where they feel threatened with exposure or punishment for their creative, pragmatic responses. The challengers may genuinely believe that what they are calling out is serious: for years they have been anxiously required to follow and enforce ‘the rules’. Or it may simply be a way for them to show some muscle, express frustration, at a time when their roles and skills seem to be undervalued.
You don’t have to be a psychoanalyst to be able to advance some ideas about what is going on. Any parent of more than one child lives with these realities. The threat to self-worth, or of things that one values, when others, and their concerns, become the focus of attention, and, yes, even adulation, can arouse bitter feelings – and not just in rival youngsters. Panic that one has been forgotten, envy, resentment and retaliatory rage can readily emerge, often under the pressure of crises. And there is another issue here: when there are ample supplies of pie, or indeed attention, at the supper table, the fact that your sister gets more than you is hardly a problem. But when such things are scarce, the conflict is amplified.
What is happening in hospitals (and probably elsewhere) has to be seen against the background of financially strapped, often deeply indebted, organisations, with resources which, at the best of recent times, have fallen short of what’s required to address the needs they are there to meet. Often, unhealthy, poorly managed, competition between services for these resources has been going on for years, with consequent troubled feelings for all concerned. For decades I managed mental health services. Our annual ‘cycle’ involved making detailed, evidence-based, passionate arguments to commissioners for more funding for dangerously thin services, feeling we had succeeded, and then watching as great, gaping holes in the finances of hospitals working with physical illness had to be filled. At best we were left with the insufficient resources we began with. This did not do a lot of good to relationships between the sectors. Though, at least in those less dramatic days, those of us meeting across the boundaries could do something to mitigate the effects on working relationships – if we recognised the problem, if we cared.
That, of course, is the point here. It is not enough to recognise the human cost for front-line staff ‘fighting’ Covid-19, to applaud them, to provide mental health support for them if they need it. Without doubt, such a response is vital, but a wider view is needed. Those workers will be carrying their stress and anxiety, their determination, their ‘end of their tethers’ states of mind, into encounters with colleagues in other services in various ways. They may or may not be aware of how they are presenting themselves. Many of the most angry or seething staff in those other parts of the system may actually not be in touch with either the source of their feelings, or the costs of their behaviours. They are almost certainly not feeling sufficiently valued, heard and soothed.
Intelligent leaders will recognise the cost, the emotional climate, across the whole of their organisations, and from top to bottom, generated by the work to respond to the virus. They will communicate this recognition, tell a story about what’s happening that helps all staff feel understood, trust that their concerns matter. They will acknowledge the effects of a near overwhelming focus on the response to Covid-19. They will manage to get over to everybody that things, and people, that are currently not top priorities, are still valued. They will reassure staff in those services that their feelings are understandable. It will be good if those leaders find ways of naming, and calling out, the dangerous or unhelpful feelings, and their expression, without shaming or punishing, but with a clear appeal to the mature response, to ‘better natures’. Ways of getting such messages into services and teams across organisations, through leaders and facilitators, need to be found. A strategy, and resources, to offer support, mediation and help with managing conflict where it erupts is vital. Without such intelligent, empathic, and mature intervention, there is the real risk that the culture that emerges after the pandemic is truly over will be far from healthy.
Then there is the issue of stretched resources. Many of us are watching as already stressed, under-resourced health and social care services rise to the challenge of Covid-19. Some of us would dearly love to see similar attention being paid to other serious problems and needs, in the UK and world-wide. We know, of course, that the political will to meet such challenges has to be there, and the willingness to invest resources to address them. Health and social care staff, as the current crisis is demonstrating, are personally invested, not just in the effort to respond to the virus, but in working to reduce any number of other kinds of ill-being, vulnerability and illness. If people see other services ‘paying the cost’ for years after this crisis, there will be understandable fury. Unless they witness an honest appraisal of the full range of needs, the affront to their concerns and values will continue. Unless there is, not a magic, but a serious, commitment to action, to find the resources required, after this crisis, resentment, conflict and despair are likely to infect our health and care system for some time to come.