Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Let’s value and encourage problem raisers

BMJ 2019; 367 doi: (Published 11 December 2019) Cite this as: BMJ 2019;367:l6871
  1. David Oliver
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic

Ara Darzi, surgeon and former health minister, has stated that “we can only be sure to improve what we can actually measure.”1 I would add that we can tackle problems in healthcare delivery only if we openly name them. We can implement solutions only if we describe and understand problems fully.

Bad news shouldn’t be suppressed. Reporting it may lead to good news, as services improve and staff feel supported and involved. Sceptics asking awkward “what if?” questions are an asset if we don’t reflexively dismiss them as laggards and unbelievers.

I’ve been dismayed recently by comments I’ve heard at conferences or read in articles from clinical leadership and quality improvement enthusiasts suggesting that doctors shouldn’t speak out within their organisations, or in public, about the downsides and stresses of working in the NHS because this focuses excessively on problems instead of constructive solutions.

This attitude reminds me of the NHS England chair, David Prior—a frequent critic of medical culture—saying in 2013 that doctors were “silent” over care quality and were “bitching from the sidelines.”2 It’s one step away from the zealotry of the positive thinking culture described in Barbara Ehrenreich’s book Smile or Die3—a culture that tends to blame people or teams for their own misfortune if they’re not positive enough.

I’d be the first to acknowledge the huge range of service innovations and improvements driven by local teams and service leaders throughout the NHS, often in the face of serious funding and workforce shortfalls and the pressing crises of demand and capacity. And some extraordinary turnaround stories and success have been born from adversity. It’s a fine line to tread between campaigning, advocacy, and positive messages to attract practitioners in.

A relentless narrative of burnt-out clinicians working in overwhelmed, depleted services—suffering moral distress from an unmanageable workload, high public expectations, and politicised performance pressures—is hardly likely to draw applicants in. People with wide career choices might run a mile at the prospect.

Those of us working in services have the potential to make local improvements to patient care and the staff experience, and there’s a risk that too much negativity leads us to think that we can’t change the landscape and must simply accept the conditions we’re given.45

Potentially, however, the people who are labelled as too negative are those who rightly flag up the risks of service changes, the need for evidence based evaluation, or the importance of considering logistics and learning from the failure of similar initiatives. Their refusal to be carried along on a tide of optimistic enthusiasm for change is often vindicated later. The prophets of doom turn out to be prophets of realistic, tempered expectation and advocates for risk assessment and logistics.

It’s surely vital that healthcare professionals are allowed to highlight serious staffing shortages, a lack of capacity, poor IT systems, unrealistic expectations, or unhelpful policies, targets, or processes. They should be encouraged to do so and shouldn’t be disparaged when they do. And, if they are in fact burnt out, depressed, or distressed, labelling them as negative looks horribly ill judged.

You can’t solve a problem if you don’t describe it first.



View Abstract