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Whose side are you on?: Patients, Professionals and Power

December 10, 2013

“You, the professionals, have forgotten the power you have if you act together. If you allow people to be picked off because you don’t like them personally…you will lose. But if you stand together in a positive, professional way, you will win and more importantly, the patients will win as well”. Thus spake Robert Francis QC on the subject of whistleblowing at the recent Chief Nursing Officer for England’s summit. It’s an interesting comment for a couple of reasons: firstly because although it goes some way towards recognising the difficulties whistleblowers face, it situates them not within the structures of the health care system, but within character defects of individual nurses – and (arguably) even more specifically within that stereotypically female character defect of bitchiness; and secondly because it seems to hark back to some Golden Age when nurses were indeed aware of their power. But there never was such a time. And the reasons why there never was such a time are to be found, in part, in attitudes like M’Learned Friend’s.

I have written before about the underlying assumptions that seem to inform Robert Francis’ recommendations on nursing. For example, the idea that too much education somehow ‘squeezes out’ compassion and needs to be counteracted by ‘up to a year’ working as a Health Care Assistant before training commences, is rooted in a masculinist worldview that justifies the exclusion of women from education (and conveniently from professional status, and power as well) by characterising caring activities as somehow ‘innate’ or ‘natural’ to them. Education for women is, according to this logic, best left alone. Now it appears that a predisposition to backstabbing, or, if you like, an inability to distinguish personal dislike from structural failings, has been added to the list of reasons why women cannot be trusted in the workplace.

That these attitudes are still so influential is all the more depressing when one considers that at least since the election of the Thatcher administration in 1979, the power wielded by traditional professional elites (of which Robert Francis is undeniably a part) in British society has come under sustained assault. In a very over-simplified nutshell, modern Conservative ideology has tended to assert that professional groups are self-serving (they place the furtherance of their own agendas above the interests of those on whose behalf they are supposed to operate), resistant to change and anti-competitive. The solution is to roll them back and replace them with a more market-orientated economy which, while ostensibly privileging the customer and ‘choice’, also provides handy money-making opportunities for new and (hopefully) more politically-sympathetic elites.

In the context the health service, this mindset has seen the ousting of doctors from the top of the  hospital tree in favour of managers (or the re-casting of doctors as managers under the terms of the Health and Social Care Act) and has, increasingly, placed not the producer but the consumer of care at centre stage. It is not a co-incidence that the Conservative-dominated Coalition had been in office for barely a month before it announced the Public Enquiry into the Mid-Staffs scandal. Their political antennae immediately grasped that granting it would afford them an unmissable opportunity to stage for the British public not just the culmination but the symbolic enactment of the transfer of power from the old elites to the new consumer. In some ways, the closest parallel to Francis is the miners’ strike of 1984, which symbolically enacted the humbling of Thatcher’s other major target, the trades unions.

There are important differences however. A professional himself, Francis was noticeably reluctant to ask doctors, his fellow-professionals, to shoulder much of the blame for Mid-Staffs. Instead, he went after less-well established groups who in recent years have posed something of a threat to the old professions: managers and, to an even greater extent, women – in the guise of nurses. Arguably, Francis represented a second-coming of the professions, a reassertion of their values. The loser was nursing. Since Francis it has become clear that pace the supposed direction of movement in British society generally, the conceptualisation and future development of nursing remains very much at the mercy of the prejudices and preconceptions of a middle-class male elite. But at the same time a new landscape is also emerging; and it’s those officially-empowered service-users who are increasingly defining our roles. What you might call a classic double-whammy.

It is, of course, impossible to argue against the primacy of the patient. The health service exists for its users and should revolve wholly around their needs. But for nurses, our history of powerlessness dictates that even the waning of the professions comes at a price. Insofar as nursing has ever made an argument for its own distinctiveness, it has been this – that we offer holistic care, patient-focussed and built on compassion. If physios, occupational therapists, ECG technicians and even doctors have now conceded that they must occupy the same ground – because it’s what the patients want – where does that leave us?

Unfortunately, if we are looking to the advent of all-graduate nursing  to provide the answer to that, we may be disappointed. As Michael Traynor argues in his excellent new book Nursing in Context: Policy, Politics, Profession, ‘there is an assumption that the critically-minded products of universities, including nursing graduates, will be just critical enough to help their managers’ organisations to work more efficiently but not so critical that they ask questions about…whether things could fundamentally change’ (p. 30).

In the specific case of nursing, what this may mean in practice – as hinted by Robert Francis in the quotation at the top of this post – is that questioning is to be encouraged, but only if patients, rather than nurses themselves, are the intended beneficiaries. In this context, (and I’m sorry to keep going on about it) the Caremakers scheme could be seen as useful reinforcement: not only does it channel undergraduate/new graduate energy in an officially-sanctioned and relatively harmless direction; it also distracts people from asking more difficult questions.

The point is that it’s all fine and dandy when the interests of patients and nurses are (as is often the case) identical. But what happens when they diverge? It isn’t difficult to find an example where this is already happening. Take twelve hour shifts. To be fair, nurses themselves are divided on this one, but many people love their three-day week, claiming it has restored their work/life balance and ‘given me my life back’.  Service-users, by contrast, are almost uniformly hostile. Even more interestingly, many also seem to believe they have the right to a say over not just nursing, but nurses’ working conditions too. A jaw-droppingly vitriolic piece by Mary Dejevsky in The Spectator last October made this strand explicit.

‘For a profession that is still predominantly female’ wrote Dejevsky ‘the 12-hour shift is a boon. [Nurses] gain valuable family days, without sacrificing the money they would lose by working part-time. Some take second jobs…But there is a conspicuous absentee from this discussion: the patient’. She concluded with a rallying call: ‘[Nurses] are currently demanding minimum staffing levels on wards. We should demand maximum eight-hour shifts’.

Nursing is caught in a crusher. On one side, its historical powerlessness continues to overshadow it; on the other, new interest groups – using remarkably similar weapons to those deployed as instruments of control by the old elites – now view us as a soft testing-ground for their own political muscle. In her piece it’s telling that Dejevsky comes very close to accusing working mothers of selfishness, but is conspicuously silent about the fact that junior doctors routinely work far more hours per week than nurses. The message is clear: the little power  that has been conceded to us is only ever to be used in the interests of others. Remind me again what century we’re in?

Traynor, Michael (2013): Nursing in Context: Policy, Politics, Profession. Basingstoke; Palgrave Macmillan
For the Mary Dejevsky article, see:

  1. Elaine Maxwell permalink

    Brilliant blog, I think I’ve just found my candidate for a long vacant position- professional leader of nursing

  2. Wow! Brilliant stuff, Grumbling Appendix! I loved the observation that nurses are being enabled to be “just critical enough to help their managers’ organisations to work more efficiently but not so critical that they ask questions about…whether things could fundamentally change.” As you suggest, the organisation (the NHS) should not belong to the managers; it should belong to the patients and to the professionals who care for them. Both patients and nurses are disempowered and both need to be empowered. How can nurses work effectively and enjoy balanced lives if they are as disempowered as their patients?

  3. Hi Tony,
    I agree that we should all want to see the empowerment of patients. What we don’t want to see is a concomitant disempowerment of nurses. It’s disappointing when people like Mary Dejevsky decide to champion patients’ rights by attacking nurses – on the other hand it is perhaps not that surprising, since blaming an already-weak group is such a readily-available and easily-understood (for which read ‘lazy’) tactic.
    What I would like to see is nurses and patients championing each other – which can only happen if they show each other mutual respect and refuse to be drawn into these outdated arguments.
    What’s really REALLY bizarre is that since writing the post I have realised that Mary Dejevsky and I have met – and that’s not all: believe it or not, I have in my possession a photograph, no less, of the two of us standing next to each other in 1978. Ask me how THAT happened, somebody!

  4. I’ll bite – how did it happen? 😉

  5. Funny you should ask that. I did Russian ‘A’ Level at school. My LEA had a contract with this posh residential facility in Banbury (or it might have been Bicester, I can’t remember now) which used to host intensive study weeks on particular subjects for ‘A’ level students. When I was in the Lower VI (don’t ask me what that’s called these days) I went on the Russian one.
    It was called Villiers Park. They used to rope in post-grad students from Oxford University to act as tutors. MD (who is a primarily a Russianist) was a tutor on the course I went on. She was perfectly nice – if anything she was a bit too soft.
    For someone like me, who was normally educated in a single-sex environment, the fact that our group of twelve students was composed of equal numbers of boys and girls was very distracting. My Russian teacher was expecting hard graft, but I was having far too much fun to actually learn anything. MD should have imposed a bit more discipline, thinks my older self.
    Anyway…happy days. I met Boris Pasternak’s sister as well.

    The picture at the top of the piece was taken in March 1978 at Villiers Park, Oxfordshire. A sixteen year-old GA (back row, third from left) poses next to Mary Dejevsky (back row, second from left).

  6. Hi GrumblingAppendix

    I think the white paper, “Equity and Excellence: Liberating the NHS”, published in July 2010 is one of the most insidious gambits of all.

    While ostensibly moving the NHS from a system of distant, to local, control sounds like a big win for consumers and professionals, it restricts control by both. Yes, local communities will be empowered to make decisions, but they will have to live in budgets far more constrained than in the past.

    The problem, which I write about a great deal (, is the loss in insurance risk management efficiency that comes with aggregating many risks at a distant level. Smaller insurers manage risk far less efficiently than large insurers. This, in turn, means that smaller insurers have lower probabilities of earning profits, much lower probabilities of avoding losses, dramatically lower probabilities of avoiding catastrophic losses and offer lower benefits than large insurers.

    Regional trusts, as small insurers, cannot match the ability of the NHS to adjust to years in which local health issues are dramatically higher than average. The budget of a local trust can easily be exceeded if a severe flu season occurs even though another trust may be relatively unaffected. The NHS would simply divert resources where needed – but regional trusts cannot do that because their budgets do not allow for such flexibility.

    While appearing to invest control to local residents and professionals, the reality is the local trusts must enforce a higher level of scarcity than would exist with centralized risk management.

    Most of my work addresses capitation-like health care finance mechanisms, but the disaggregation of insurance risks suggested in the White Paper accomplishes essentially the same end.


  7. Thank you for your comments. England is a small and relatively homogeneous country, and the idea that different geographical areas have different health priorities is routinely overstated in order to make ‘increased choice’ and ‘locally decided priorities’ look like positive benefits rather than simply the engines of an ideologically motivated drive to fragment the NHS.
    In the short term, central funding would underwrite any unanticipated expenditure of individual Trusts, but hospitals with unsustainable debts would become targets for takeover and eventual closure and reduction in services. In terms of standard of services offered, there is a case to be made for concentration, but hospital closure is unpopular with local populations – so in this sense, current policy, even though it is telling people it can give them greater control, seems unable to deliver.

    • Thanks for the thoughts – sadly the disaggregation of insurance risks will inevitably lead to some poor performing hospitals and some hospitals that appear to be stellar performers.

      I am intrigued about the issue of homogeneity though. Are the regional trusts homogeneous with regard to age? I’d have thought that there would be communities that had significantly higher portions of aged people or starter families, where one might have to choose between immunization programs and geriatric services, between gerontologists and pediatricians? Or perhaps distinctions between mining regions and urban areas in terms of respiratory illness? I gather that your sense is that such variations are not significant issues for regional trusts?

      In the US insurance risk transfers led to a massive takeovers of hospitals by large health care corporations (i.e. HCA and Tenet) as every year the poorest performing public and independent hospitals, due to financial failings largely beyond their control, became acquisition targets. Same thing for physician’s practices. If, for example, a fee for service system insurer switches over to capitation, it virtually guarantees that half a dozen out of 100 hospitals that assume the insurance risks for their patients’ hospital care, will fail catastrophically.

      That leads to belt tightening which often exacerbates the situation as dissatisfied staff leave, further weakening the hospital’s core service capacity. Some health care finance executives saw these situations as tremendous opportunities. The hospital runs into financial difficulty, so you blame the physicians and nurses for being inefficient, cut their legs out from under them and replace them with lesser qualified staff, and just keep the pressure on until the only staff that are working there are so concerned about keeping their own jobs that they won’t question administration.

      Sadly, despite a background in math, statistics, insurance and ratemaking and reserving – it still took me over 20 years to understand my gut reaction to health maintenance organizations and managed care organizations. But when you deal with the mathematics, statistics and economics it is almost exquisitely ugly and depraved.


  8. Thanks for your comments. I think there is a great deal the UK can learn from the US experience – much of it unfortunately in the form of a cautionary tale.
    England – because this is about England, not the other home nations, one of which may vote for full independence later this year – obviously does have some regional population variations. For example, the South Coast is a popular retirement destination, so large elderly populations are often gathered there. But local hospitals have traditionally offered a wide range of services. This is almost certainly going to change – and there are sound clinical reasons why it has to happen: the one you’ll hear quoted most often is how London, by concentrating stroke services into a few centres of excellence, has now become ‘the best place in Europe to have a stroke’.
    Unfortunately, local electorates hate losing services at their hospitals, either because they don’t like to travel to the next town (the distances would be laughable by US standards) or because they fear their town would lose its identity if it lost its hospital. For these reasons, supporting hospital closure has become political suicide.
    I am NOT a supporter of the Health and Social Care Act 2012, but some weeding-out of services needs to happen. The conditions created by the Act will probably accelerate the process. The tragedy is that good clinical argument has been muddled by politics.

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