Matilda played with her mother’s stethoscopes when she was a child. As a teenager, she pored over anatomy books. She devoted her early twenties to medical school and has been cramming for postgraduate exams well into her thirties. Last summer, she jacked it all in. Being a doctor ‘was turning me into a bad person,’ she explained to her nonplussed friends.
Many medics will recognise Matilda’s fear that her job was making her less caring, both to her patients and her family. The meltdown in the NHS is leaving doctors feeling even more burnt out than during the pandemic. The effect this is having on patients is frightening.
Doctors and nurses already have an abnormal relationship to pain
A common term in the medical world is ‘moral injury’, where workers feel the work they are having to do contradicts their own values. Talk to any emergency doctor, and they’ll say they are unable to provide what they would even consider the bare minimum standard of care to patients coming through their hospital doors. That regular sense of disappointment, coupled with total exhaustion from the last few years, can leave a long and dangerous legacy.
Healthcare workers regularly struggle with ‘compassion fatigue’, where the toll of seeing patients dying before their time starts to numb them. In a healthy work environment, they have time to process that and to take breaks. At the moment, with many trusts asking staff to cancel their annual leave and shifts being so busy it is difficult to go to the toilet – let alone have a short breather over lunch – there is no time to decompress.
Instead, the numbing continues, and experts in patient safety are worried about what that will mean for healthcare. The gravest scandal in the NHS in recent years is the cruelty and needless deaths at the Stafford Hospital between 2005 and 2009. This week, the man who investigated the horrific cases of patients dying on the floor, lying in their own faeces and being shouted at by nursing staff wrote to the Health Secretary. He warned that a repeat of that scandal at the Mid Staffordshire NHS Hospital Trust was now being played out across the country. Robert Francis KC led the public inquiry into Mid Staffs, and says:
‘Last year I was talking to people, professionals, senior consultants who were in tears because of their inability to treat patients in the way they’d expect. If they were in tears back then, I can only imagine how they are in the current situation.’
Francis warns that, no matter how much compassion staff have, ‘at the moment they can’t possibly perform to the standard required, that brings real stress into their lives. In some cases that may then result in inappropriate behaviour, but the main issue is that whatever their intent or however hard they are trying, the care they are providing stops being compassionate, stops being safe, and it’s not surprising when things go wrong.’
One of the most haunting testimonies to the Francis inquiry came from one of the doctors who’d been working in the emergency department at Mid Staffs during its crisis. Dr Chris Turner tried to raise the alarm about what he saw: staff shortages and bullying made it impossible to ensure safe care. He told the inquiry that he and others in the Stafford A&E became ‘immune to the sound of pain’. Today, he worries that this is happening again across the NHS.
It is difficult for most people to understand how you might become immune to the sound of pain. But doctors and nurses already have an abnormal relationship to pain and the human body generally. Most of us do not spend our days sticking needles into people’s arms, or cutting them open. Healthcare workers have to adjust to shrieks, flinches and screams being the soundtrack to their days. When it also becomes normal that you simply cannot treat all the patients who are in pain on your ward, you become able to ignore the sound of their suffering.
Turner now works as an emergency consultant in another trust and also trains NHS workers on how to avoid toxic cultures developing in their hospital. He describes how the current pressures have changed what is normal for him:
‘A few years ago, my dissonance was between really good quality care, and the care I was able to provide, which was still adequate but it wasn’t as good as the care I would have liked to provide. Now my dissonance is between the very minimum acceptable level of care, and the care that I actually can provide, which is significantly below that (standard). We have had points in the last few weeks where we have had literally no beds.’
Professor Lucy Easthope is an expert in emergency planning. When she was training mortuary staff earlier this year, she worried about how they would cope:
‘I was warning them that this winter was going to be worse than the one before. They were saying, ‘please don’t tell me that. I’ve got nothing left’.’
She is disgusted with the way healthcare workers have been treated over the past three years:
‘Everything the government insisted on in those early weeks of the pandemic made it worse: the NHS workforce was seen as easily exploitable, easy to pull on their heartstrings and emotional sense of duty, and easy to insist that they overwork themselves into the ground while being hailed heroes’.
Staff soon realised that their employers weren’t keeping their side of the bargain, whether it be in providing adequate PPE at the start of the pandemic, or giving them the pay rises they needed to keep their lives affordable. Easthope sees the current strikes across the NHS as part of the moral injury that staff have suffered.
Dr Jo Daniels, a senior academic who specialises in staff mental health and wellbeing in the NHS agrees:
‘All the doctors and nurses I’ve spoken to want to care but are being put in a position where they are not able to deliver it. They commonly report feeling undervalued and unable to take breaks, sit down, have hot food. Their basic needs aren’t being met. Their study time and teaching sessions are being cancelled, which adds considerable pressure on them if they are able to meet the requirements of their training’.
She also points out that rest and wellbeing areas or support set up during Covid, where staff could take a break or reflect on what they’d experienced, have often disappeared in hospitals. This has sent a ‘terrible message’ to staff, she says.
Dr Turner feels hopeful that he and other campaigners on patient safety have made enough of a difference that moral injury is now better understood in the health service. And while the understaffing of the NHS is a long-term problem that will take years to fix properly, there are changes that the service, and indeed the government, can make quite quickly to show they will keep their bigger promises. Professor Neil Greenberg, a psychiatrist who is an expert on mental health and NHS staff, says:
‘If NHS managers can make even a small number of realistic promises about how they will improve the mental wellbeing of staff, and then deliver as promised, this will very much help to regain staff trust. You can’t just sit and talk about improved wellbeing, conditions, salaries and staff numbers and then nothing happens. But once you go some way to meeting people’s expectations, then that gives them hope that it’s going to get better which in turn is likely to improve their mental health.’
It is easy to dismiss the Mid Staffs scandal as something perpetrated by bad people who made choices to be cruel to sick patients. What is more uncomfortable for politicians is realising that a bad system can have this effect on good people. Some, like Matilda, will walk away. Others will stay – but that’s not a good sign if they still work in a service that’s immune to their pain, not to mention patients.
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