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Matt Morgan: Sitting on the bin

BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2767 (Published 16 November 2021) Cite this as: BMJ 2021;375:n2767
  1. Matt Morgan, consultant in intensive care medicine
  1. University Hospital of Wales
  1. mmorgan{at}bmj.com
    Follow Matt on Twitter @dr_mattmorgan

I remember the first time I sat on a bin. I was a medical student, squeezed into an undersized consultation room. Despite it being a family planning clinic, no one had planned for having more than one chair. Rather than offering to stand each time another family entered, I accepted my fate and sat on a bin for three hours. I can’t say that it helped my learning experience, and I still have a faint line on my rear.

As the NHS enters into a busy winter, many healthcare workers are once again sitting on bins—both literally and metaphorically. Handover rooms are filled with too many people and not enough chairs. Intensive care unit beds are filled with patients and not enough nurses. GPs struggle with bulging patient lists. People on waiting lists are kept waiting. Our healthcare infrastructure is creaking under the ultramarathon of the pandemic, with overworked staff and undertreated patients. This is not through lack of care, attention, or insight but often through the sheer difficulty of the task at hand.

Do you regularly sit on a bin? Eat lunch on your lap? Speak to patients in a stock room? Or find that lower nursing ratios or a lack of medical cover have become a daily feature?

What we must resist is organisational acceptance of this as a new normal. My children regularly demonstrate the power of the hedonistic treadmill, when they get so excited about a new toy. The drive to the shop is filled with joy. There is elation when the wrapper is peeled off. Pleasure for a day or so. Then it becomes the new normal.

Humans adapt amazingly quickly to new highs—but also to new lows. Instead of the hedonistic treadmill, healthcare is at risk from the “masochistic rower.” Despite your strokes pulling you forwards, the tide takes you backwards. And you soon accept this new low. Poor care becomes normal despite the staff rowing harder and harder.

In people, this tendency to adapt is actually a design feature. The hedonistic treadmill keeps us eager for new challenges and change. The masochistic rower allows us to overcome difficult life events. But organisations need to be very careful when they continually reject poor standards, even when little can be done about them. Having this insight is hard.

Standard setting can help, and calibration against others can unblind you to what “good” looks like. But a broken healthcare system doesn’t simply break, like a wooden ruler. It bends, distorts, and loses its flexibility. It curves away from what was once good. Recognising the break and then responding to it is hard—but that is what our government and healthcare leaders must now do.

Acknowledgments

Thanks to Dr Hingston for the ruler analogy after a particularly long night shift.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Matt Morgan is an honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination

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