NHS organisations and the professionals who staff them are under tremendous pressure. The University of Manchester’s Professor Leo McCann has been working closely with NHS paramedics in England over the last five years, learning about the changes they have gone through as professionals and the pressures that ambulance trusts face as organisations. In this blog, he asks at what point do our NHS staff finally ‘break’? How do they persist, and is there room for optimism?

• The paramedic profession has moved from a manual occupation (first aid and transportation) to a clinical role involving pre-hospital and unplanned primary care duties. These developments potentially offset frustrations and constraints that paramedics have faced for decades.
• But ambulance services still face considerable issues over burnout, stress, conflict, and severe operational pressure. Numerous reports attest to a staff mental health crisis, unsupportive management and entrenched cultures of bullying and blame.
• Missed response targets don’t necessarily mean poor standards of care. NHS workers provide highly effective care to patients every day. A clinically-advanced system free at the point of use is a powerful reminder of what society can achieve, and what the public expects and supports.
• There are certain ways in which the general public can help. The public should be better educated about health, well-being, and the care systems we have. Basic first aid could be taught more broadly in schools, universities and workplaces, from infection control to hands-only CPR and the use of automated external defibrillators.

Is this NHS at breaking point?

Stories of the NHS’s desperate struggles are rarely out of the news. Writings often include metaphors of ‘breaking point’ or ‘cliff edge’, implying the struggles are terminal. Certainly the health service faces severe problems, with the situation in Accident and Emergency departments and ambulance services especially acute. News media and ‘fly on the wall’ documentaries portray interminable trolley waits, continual ambulance diverts and hopelessly breached waiting targets. Several recent stories have described dedicated professionals leaving the health occupations that they have devoted their lives to. Here we have the personal breaking point; when it just gets too much people understandably leave their organisations or even change careers.

There are dozens of pieces like this, such as newspaper stories on burnt-out doctors, and a high-quality blog series entitled ‘Broken Paramedic’. Personal stories such as these convey important messages to politicians and NHS leaders about the impacts of their policies. There is no doubt that working life in emergency healthcare is physically and emotionally exhausting and the writings about breakage and crisis express powerful, uncomfortable truths.

Important as they are, they also beg a question: amid all this strain and conflict how can professionals remain optimistic? Why do people come back for more? What is it about work – perhaps especially high-pressure, public service work – that drives people to continue to devote the best part of their lives to ‘make the broken machine work’?

Researching the emergency healthcare world

Over the last five years, I have been working closely with NHS paramedics in England, learning about the changes they have gone through as professionals and the intense pressures that ambulance trusts face as organisations. Exhaustion and strain were regular themes. One highly-experienced paramedic and middle manager asked me to consider ‘at what point do we break them?’ His phrasing was instructive: the assumption was made that we break them, ‘we’ being the organisation itself – the management, the system. Indeed this has been a major finding of my work. It is not necessarily the intrinsic elements of high-pressure emergency work that are traumatic (although of course certain incidents can be extremely challenging). As I have discussed on this blog before, a central problem is the organisational battles, the sense of being undervalued, the feelings of resentment and sometimes embarrassment about how dysfunctional organisational systems and chronic shortages can undermine services provided to the public.

But on my travels with ambulance services I also came across other perspectives. ‘Please don’t only report our miserablist stories’ requested an emergency medical technician at a shabby old ambulance station somewhere far from HQ. ‘We can moan for England’ was a phrase I heard almost everywhere. Many of the ambulance workers’ complaints about their organisation were valid. But there was an interesting cultural angle to it. Paramedics and technicians would also reflect on ‘the moaning’ itself, describing it as habitual, a remnant of the ‘canteen culture’, part of the territory and not to be taken completely seriously. The metaphors could be colourful: one ambulance crew in particular was described as ‘a comedy double act’, and another paramedic described what he called ‘the baboon pack’; certain crews on station would form almost a closed circle to share stories, gossip and complaints.

One of my informants spoke at length about the pointlessness of ‘the moaning’:

‘the constant moaning is a problem. It’s cultural, it’s like a stuck record. Sometimes, yes you are exhausted, it’s hard, it’s bloody hard, but the constant whinging and moaning just makes it worse. You are wasting energy, dragging everyone else down, too. Sometimes I join in, other times I’m like, right that’s enough, this isn’t helping you or anyone else.’

Optimism is a strategy

So what exactly is happening? To what extent are these people and organisations really ‘broken’? Is there value – as Noam Chomsky believes – in being optimistic because the alternative is hopelessness? What grounds are there for optimism? In common with workplaces in general, the picture is mixed and contradictory. Ambulance services, like many other uniformed occupations such as nursing and policing, have ‘professionalized’ in recent years. In terms of clinical expertise the paramedic profession has taken great strides recently, moving from a manual occupation limited to first aid and transportation to a complex clinical role involving a wide range of pre-hospital and unplanned primary care duties. Within certain boundaries, paramedics are encouraged to be increasingly autonomous and in many cases can treat patients at scene or at home removing the need for onward transport and probable hospital admission. A recent change in the law allows Advanced Paramedics to prescribe certain drugs. The Health Care and Professional Council has recently recommended that university degrees should now be the only entry point for the registration of new paramedics.

These are major developments that potentially offset the frustrations and constraints that paramedics have faced for decades. The role is potentially opened up for increased discretion, autonomy and a more expansive career trajectory. In general the paramedic role enjoys wide public support and interest, as attested to by almost nightly ‘reality’ TV and supportive viewer comments. Paramedics’ own writings have also been influential, such as Liz Harris’ article in The Guardian that somehow managed to turn that pointless and intrusive question ‘what’s the worst thing you’ve seen?’ into something humane and wise. Paramedic science degrees are in high demand. In an era of automation, gig economy and ‘bullshit jobs’ , the promise of a meaningful, identifiable role where one can help the public in its hour of need is an attractive one.

A search for balance

And yet, ambulance services still very much slot into the narrative of burnout, stress and breakage. Numerous reports attest to a staff mental health crisis, unsupportive management and entrenched cultures of bullying and blame. Missed targets and operational delays are common, with 2017 the worst year ever for waiting times across NHS England. Although life out on the road can be very rewarding, NHS trusts face considerable challenges in coping with shortages, restoring trust and enabling more supportive cultures and behaviours.

But we shouldn’t lose sight of the daily successes. Missed response targets don’t necessarily mean poor standards of care. NHS workers typically provide highly effective, compassionate care to patients every day. The fact that a clinically-advanced system free at the point of use exists at all is a powerful reminder of what society can achieve, and what the public expects and supports. A&E work embodies the NHS ethos of treatment being available to all based on clinical need, regardless of patients’ ability to pay. In today’s neoliberal environment, when everything is priced and everything is ‘competitive’, that in itself is a radical democratic achievement.

The NHS needs more funding; there can be no doubt about that. Optimism seems misplaced and naïve when confronted by governments that want to ‘open up’ health services to competition and can’t see past ‘efficiency savings.’ But there are small steps that can be taken in the everyday – outside of the political worlds of policy and funding. One glaringly obvious issue is to better educate the public about health, well-being, and the care systems we have. It is remarkable how little health knowledge is available among communities. Basic training in hygiene and first aid should be taught more broadly in schools, universities and workplaces, from infection control to hands-only CPR and the use of AEDs. Many people wrongly interchange the terms ‘cardiac arrest’ and ‘heart attack’. Official guidance from the Resuscitation Council UK states that AEDs can be used safely by ordinary members of the public, but this is not widely known. The whole system needs much more support – not just in terms of increased government funding to address the chronic shortages – but also in terms of better understanding from the public, and a more inclusive managerial culture. Management behaviours need to continue changing to become more appreciative of front-line realities.

Chomsky’s optimism rests on the possibilities for self-organising, of making everyday changes and interventions possibly outside of ‘the system’. Even in a constrained funding environment there is always some scope for this – the College of Paramedics relies heavily on the voluntary, self-organisation of its dedicated members. Paramedic Rob Moore’s ever-optimistic ‘blue-light happy’ Twitter account is a great reflection of self-organising.

What can we do as citizens and users of our health service? NHS trusts are public bodies (at least for now). Become a member. Go to a meeting. Maybe sign on for CPR training. Make room and think ahead when a blue-light vehicle is thundering up in your rear-view mirror. Educate yourself about self-care. If you or your family receive good treatment from an ambulance crew, an A&E nurse or a consultant, consider writing them a thank-you letter. I can guarantee it will make their day. Learn about the work of The Ambulance Staff Charity (TASC) or the various Air Ambulance services around the country (all of which are charities). Follow your ambulance trust on Twitter (or at least follow Rob Moore). They need your support. It is here where Chomsky’s optimism strategy makes the most sense, with its philosophical roots in mutual aid and solidarity. There is always more that we can all do to make lifeworlds that bit more tolerable and humane. Amid all the breakage in modern society, optimism is a strategy we should all try to pursue.