Sunday 16 December 2018

Lessons from a week in the twilight zone

You learn a lot about life, culture and habits when hanging around a children's hospital, says Brendan O'Connor

Illustration by Tom Halliday
Illustration by Tom Halliday
Brendan O'Connor

Brendan O'Connor

One day before he left the HSE, the day after he got permission to exercise his share options as a director of a US healthcare company, Tony O'Brien announced the setting up of a culture unit in the HSE, which will be led by the head of the HSE Values in Action programme. On reading this, it was hard not to think of W1A, the sitcom about jargon-addled corporate dysfunction in the BBC, where the main character is the Head of Values, and one of the plotlines is the competition to fill the new post of Director of Better, with one of the characters noting that, "We do things well, but we could do them better than well".

Someone who works in the BBC told me that W1A is more of a documentary than a satire. And, indeed, we can all recognise aspects of our own organisations in there. The HSE is at pains to point out that the Culture Unit will be staffed from existing health service staff headcount, presumably conscious of the fact that the last thing anyone thinks the HSE needs is more managers.

Organisational culture, a notion that has been around for decades, has reached these shores and there are armies of consultants and change managers available to help you change your culture should you wish. The key phrase here is that culture eats strategy for breakfast.

In other words, you can have all the big-picture ideas you want, but you need to get the culture right. And, of course, culture is a nebulous thing, so there's plenty of room for jargon and waffle around it, and plenty of roles for cowboys and chancers who will fix your culture for you.

Having witnessed the CervicalCheck scandal so far, you would certainly say there is something rotten in the culture of the HSE. The amount of ass-covering, the lack of empathy, and the continued dissembling on this issue even when the organisation had been caught rotten, suggests a deeply toxic culture, a culture that was aimed at its own self-preservation rather than meeting the needs of patients or human beings. The inability to follow up on promises made about counselling and medical cards and childcare for victims of the scandal, even when the spotlight was on the HSE, suggested a culture that is so decayed that it couldn't even act quickly to save its own ass anymore, and that should be the most basic impulse of any culture, however rotten.

So without getting into one of those pieces where the writer has an encounter with the health service and tells you about how great the frontline staff are, I want to tell you about a glimpse into a few health-service subcultures I had in the past week.

Before we get to the main issue, I want to tell you about the subculture of parents of sick children. We visited this twilight world last week with my elder child and I learnt a lot. The first thing I learnt is that most families now are operating on a knife-edge, where if one thing goes wrong, or any unplanned event happens, the wheels fall off the wagon. Even if you only have two kids, once one of them needs to be in hospital, one parent needs to be there with them most of the time.

This will tend to be whoever is most dispensable in their work, whoever can try and take some time off.

The other parent will then function as a single working parent to the other child. Everyone goes into a survival mode. You and your spouse or partner become like ships passing in the night as you relieve each other in the hospital or at home, and favours are called in left, right and centre to plug the gaps.

You grab food - sandwiches in reality - when you can. And you usually eat while doing something else. You might even come home in the evening and stand at the counter unthinkingly eating some sandwich assembled from whatever is to hand, standing at the counter, before turning off the lights and heading to bed. Showers are grabbed when you can, and you will talk to your other half on the phone, or at the crossover junctions. You will mainly talk about medical issues.

After a few days of it, the rest of the world seems to be existing on another planet entirely. You are in your own grey world of just getting by. Your house is no longer a home, your family is just something to be managed.

It's doable for a few days or for a week. But the more people you encounter, the more you realise that many of the people involved in this subculture are in it for the long run. They are thinking in months of this rather than days. Their neglect of their other children and the guilt that goes with that has become chronic, their 'self-care' is long gone out the window, and they haven't had a proper night's sleep in months. But on they go, driven by love and desperation.

I thought a lot last week about John Murphy, the paediatrician who had checked out my second child before sending her home from Holles Street. We were both in some kind of a daze about Mary's Down syndrome and unsure what to do next, and Murphy tossed her around like you would any other baby, practically swung her around his head in that alarming way doctors do when they are assessing small babies, and then said: "OK. You've got a perfectly healthy child. Take her home and look after her, and she'll fit into the family fine, and just be glad you don't have a sick child, because that would completely disrupt the family."

I'll admit I didn't understand until later what he was saying, but that day, Murphy gave us the kick in the ass and the pat on the head we required to keep putting one foot in front of the other.

I'm not sure what a centralised culture tsar or a Director of Better would make of Murphy. Some people viewed him as slightly gruff and a bit too much of an individual. But that one intervention that day cut through a whole HSE culture that was ill-prepared for people in our position.

The more important thing I observed this past week was a culture in Temple Street that has become adept at dealing with the problems of sick and injured children and their parents. It was extraordinary to see the grace under pressure, and the humanity and patience demonstrated in difficult circumstances, with the added discomfort last week of everyone being slightly too hot in an old building.

I wondered if what I was observing was a culture, and in a sense it was, because there seemed to be a remarkable consistency to how things are dealt with. Everyone is remarkably calm, everybody has a really good bedside manner, goes by their first name, uses the child's name, doesn't bat an eyelid at anxiety (a lot of it in our child's case!), explains everything, shows the kids exactly what they are going to do, tells the truth but not in alarming terms, explains their thinking on everything, explains why they are doing what they are proposing to do and the thought processes and the process of elimination that got them there.

They also explain why they are not doing things, why they might not be sure. They are age appropriate with the kids, but not condescending. They put people at their ease, without lying unnecessarily. And they demonstrate humanity. A nurse with whom my kid clicked had finished work but asked would my daughter like her to wait and bring her up to theatre. They understand the importance of trust and chemistry with kids. And mostly their good humour is unflinching, even in what must be some awful situations, dealing with people who are at the end of their rope.

And no doubt there was some genius in the HSE or some great leader in Temple Street who inculcated this culture in the place. But the more I saw it, the more I realised that what I was witnessing was probably not a culture imposed by the same kind of people who we saw ass-covering around the CervicalCheck scandal. What I was witnessing was a simple thing. Good habits. Everyone had good habits clinically, in that they were clearly working off invisible checklists, and they had them interpersonally, in that they were unfailingly respectful and humane. And clearly these habits were the norm, even when you were tired, and even when you had just worked a long shift and had enough of other people's problems.

Clearly a common consensus has broken out in this place, that when dealing with vulnerable children and their often equally vulnerable parents, that there are certain habits required. And clearly this is contagious, spreading through the staff like a peer-pressure virus.

And, indeed, the model being pursued by the HSE is one called ViralChange, where: "Change and mobilisation of people are pull effects, a social contagion, a social movement, with the leadership engine in the grass roots and back-stage support from the Executive floor, not the other way around."

So that's only my experience, and it's only a snapshot, but it seems to me there is a germ of hope here for the rotten edifice that is the HSE.

That change will not be driven by the corporate managers of the world, but will be imposed on them by the true experts in organisational behaviour, those doctors and nurses who cultivate good habits. We can only hope a bit of this virus begins to trickle up to the top of the HSE to replace the rotten corporate culture that exists there.

Sunday Independent

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