Austerity and Professionalism: Being a Good Healthcare Professional in Bad Conditions

Health Care Analysis https://doi.org/10.1007/s10728-019-00372-y ORIGINAL ARTICLE Austerity and Professionalism: Being a Good Healthcare Professional in Bad Conditions John Owens1 · Guddi Singh1 · Alan Cribb1 © The Author(s) 2019 Abstract In this paper we argue that austerity creates working conditions that can under‑ mine professionalism in healthcare. We characterise austerity in terms of over‑ lapping economic, social and ethical dimensions and explain how these can pose significant challenges for healthcare professionals. Amongst other things, austerity is detrimental to healthcare practice because it creates shortages of material and staff resources, negatively affects relationships and institutional cultures, and cre‑ ates increased burdens and pressures for staff, not least as a result of deteriorating public health conditions. After discussing the multiple dimensions of austerity, we consider the challenges it creates for professional ethics in healthcare. We highlight three mechanisms—intensification of work, practitioner isolation, and organisa‑ tional alienation—which pose acute problems for healthcare professionals work‑ ing under conditions of austerity. These mechanisms can turn ‘routine moral stress’ into moral distress and, at the same time, make poor care much more likely. While professionalism clearly depends on individual capabilities and behaviours, it also depends upon a complex sets of social conditions being established and maintained. The problems caused by austerity reveal a need to broaden the scope of professional ethics so that it includes the responsibilities of ‘role constructors’ and not just ‘role occupiers’. Austerity therefore presents opportunities for health professionals and associated ‘role constructors’ to contribute to a reimagining of future models of healthcare professionalism. Keywords Austerity · Ethics · Healthcare · Moral distress · Moral stress · Professionalism * John Owens 1 Centre for Public Policy Research, King’s College London, Waterloo Bridge Wing, Franklin‑Wilkins Building, Waterloo Road, London SE1 9NH, UK 13 Vol.:(0123456789) Health Care Analysis Introduction This paper examines how the regime of fiscal austerity seen in the UK since 2010 has created working conditions for healthcare professionals that pose significant challenges for professional ethics. In part, this is because shortages of material and staff resources at a time of simultaneous cuts to complementary public services and deteriorating public health conditions mean that professionals are often working in overstretched and stressful conditions. But, in addition, austerity can be seen as part of a broader neoliberal political-economic culture that has imposed stricter manage‑ rial controls, raising the stakes for professionals while holding them more personally accountable for errors. Such conditions risk professionals feeling over-burdened, isolated from colleagues and alienated from their institutions and professional iden‑ tities. In this way, austerity can turn the moral stresses routinely associated with healthcare work into experiences of moral distress. Austerity therefore generates significant ethical challenges for healthcare professionals as ‘role occupiers’, as well as for figures who act as ‘role constructors’. We begin by briefly drawing on the recent case of Dr. Hadiza Bawa-Garba to illustrate the severe problems faced by healthcare professionals working in highly stressful and overstretched conditions. Healthcare Professionalism Under Stress: The Case of Dr. Bawa‑Garba Dr. Hadiza Bawa-Garba is a paediatrician who was found guilty of manslaughter by gross negligence after the death from septic shock of Jack Adcock, a 6-year-old boy with Down’s syndrome, in 2015. We draw on the internal Investigation Report to present details of the case [1]. In doing so we are not taking a position on the full complexities of this particular case (i.e. we are not arguing that this is a clear-cut and direct example of the negative impact that austerity can have on paediatric profes‑ sionalism), but we are suggesting that this example clearly illustrates the dangers that overburdened and highly demanding clinical practice can have for medical pro‑ fessionals, especially under managerial regimes that enforce strict personal account‑ ability. The high profile of this case has led many doctors to identify with and reflect on the conditions in which Dr. Bawa-Garba was working and to question whether something similar could happen to them. On 18th February 2011, Jack Adcock was admitted to Leicester Royal Infirmary Children’s Assessment Unit (CAU) unresponsive and limp. Relevant to his underly‑ ing Down’s Syndrome, Jack had previously had an operation to repair a significant congenital cardiac anomaly, and was being managed on a blood pressure medica‑ tion called Enalapril. Dr. Bawa-Garba—a high-flying doctor with an unblemished record—was the paediatric registrar that day. As her paediatric consultant was absent, staff shortages meant that Dr. Bawa-Garba was requested to cover the CAU as well as her own ward duties and was responsible for Jack’s care. The hospital was stretched in other ways too: IT failures disrupted test results; nursing shortages meant inappropriate use of agency staff for patients such as Jack; and insufficient 13 Health Care Analysis equipment created avoidable delays. Dr. Bawa-Garba worked for 12 hours that day without a break. Jack was treated, initially, for gastroenteritis and dehydration and, after sig‑ nificant delay, with antibiotics for pneumonia (later confirmed to be the cause of death). Pressure to discharge patients from the ward meant constant rearrangement of patients. Later that evening Jack’s mother administered an unprescribed dose of Enalapril. When Jack developed septic shock with organ failure and suffered a cardiac arrest an hour later, resuscitation was hampered by the mistaken belief that he was a different patient. Despite resumed efforts, Jack was pronounced dead at 9.21 pm. Dr. Bawa-Garba was convicted for gross negligence manslaughter and struck off from the GMC medical register on 25th January 2018. She was reinstated in August 2018 after a successful appeal drew attention to the numerous extenuating circum‑ stances she faced that day. Whether or not the Bawa-Garba case is a direct result of austerity is, of course, contestable. Jack Adcock’s death certainly took place at a time when many Trusts were facing real terms cuts in funding and Bawa-Garba was working in a context of staff shortages. However, the mistakes that took place and the contributing problems associated with staffing, resources and ward culture have been attributed to a num‑ ber of other factors [1]. Thus whilst attributing direct causation between resource pressures and the mistakes that led to Jack’s death is extremely difficult, the case does highlight the difficulties that many health professionals face when operating in ov (...truncated)