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This week’s #107daysofaction has been about listening – or not – to families. Katherine Runswick-Cole blogged on Bettelheim and mother-blaming, Sara Ryan on speaking up for your family member, and Mark Neary gave us another chilling portrait of institutional deafness.  I’ve had similar concerns going round in my head for months and months now.

An acquaintance, whose child receives 1:1 health worker support in school to manage a life-threatening medical condition, last year gave permission for one-off participation in an educational activity which the child does not routinely access. The school’s trained risk assessor, with health-risk assessment input from the healthcare worker, devised a safe way of delivering the activity to the child on that occasion, using 3:1 support.

The healthcare worker was subsequently disciplined by the Trust for not preventing the activity.  Healthcare managers visited the parent at home and tried to get agreement that proper parental permission had not been given for the activity.  The parent repeatedly asserted that permission was in fact given, but felt that the managers’ attitude and language implied the parent was lying to protect a worker to whom the family had become ‘too close’.  The managers then declared that even if given, the permission was invalid because it was in an improper format and from a parent insufficiently informed to understand the ramifications.  The parent was incensed:  “Are they trying to say I was too ignorant to give permission, or just too stupid?”

What seems to have riled the heid high yins of the Trust, is that an ‘unqualified’ parent and a lowly healthcare assistant trespassed on their fiefdom by daring to take part in decision-making with school staff, but without deferring to, and involving, the almighty expertise of the health management.  Things which tend to support the idea that management took a hissy fit include the conduct of the disciplinary investigation and the disciplinary panel.  An ‘independent’ member of management – i.e. a manager out of the worker’s direct line of reporting – was charged with investigating and reporting on the incident, but:

– Did not follow agreed procedure;
– Did not consider the legal and practical responsibilities of, and limitations on, the health worker in school;
– Failed to seek evidence from the school staff and school management;
– Did not refer to, never mind place any weight on, the parent’s responses to the managers;
– Cited the one clause in the worker’s contract that could be construed as requiring supervisory oversight during risk-assessment, while ignoring several others that mandated routine independent risk-assessment and joint working with education staff;
– Ignored the provisions of the child’s care plan, which required the worker to risk-assess;
– Accepted, without any supporting evidence, management assertions that there was a risk referral system (there wasn’t, and never had been);
– Refused to accept, despite supporting evidence, that permission had been given and suitable risk-mitigation put in place;
– Took no account of customary practice; and
– Did not seek to check that delegation, training and supervision had been set up and delivered as claimed by management (they weren’t, and hadn’t been for some time).

In spite of all its faults and omissions, the worker was found on the basis of the investigation report to have committed gross misconduct and the severest sanctions were applied.

The worker, together with the Union representative, did huge amounts of work to find evidence to refute the allegations.  Some of the school’s other healthcare workers had been interviewed by the investigator.  All mentioned that the worker was known to have a high reputation, but each agreed, with some or with marked reluctance, that the worker’s conduct might be blameworthy in the scenario as described by the interviewer.  When the Union rep contacted the co-workers to ask if they would be prepared to give evidence in person about the qualities of the worker and their understanding of the scenario, they all refused.  All seemed to be fearful about what might happen to them if they spoke up.  The Union rep then contacted the parent, and on hearing what was happening, the parent volunteered to act as witness for worker, to state that valid permission had been given for the activity.  The Union rep – also a Trust employee – subsequently mentioned having been the recipient of pointed remarks from managers on the subject of being overzealous in trying to find staff witnesses, although according to the rep, no pressure to appear had been put on anyone – they had merely been asked, and any refusals accepted at face value.

At the hearing, the parent was told, dismissively, by member of the disciplinary panel that even valid parental permission and school risk-assessments or management plans did not override the health worker’s duty to determine suitable activities and prevent ‘unsuitable’ ones.  The parent was stunned and asked the panel, “When did Trust personnel take over my responsibilities?  When did my child become a looked-after child?”  The only response was huffing and eye-rolling.  The school staff who had also volunteered to come, as witnesses to the risk-assessment procedure, seem to have been similarly rudely treated; apparently there was much fury and a few tears of outrage in the anteroom after evidence had been given.

In the end, it was the school’s risk assessment trainer – a very senior healthcare professional who is now an independent consultant to settings that care for children with complex medical needs, and who, like the education staff, had volunteered as a witness – who gave the evidence for the worker that tore to shreds the allegations, the management’s supposed superior risk-assessment capability, and the way the healthcare workers were managed and (un)supported when working with the child in school.

Once all the substantive allegations had been disposed of, the management seriously considered changing the accusation and disciplining the worker for ‘risking the Trust’s reputation’.  The parent threatened to go to Press and allow the public to judge precisely who had put Trust’s reputation at risk, pointing out that it was the child who had been at significant risk, and from the actions of the Trust, not the worker.  After disciplinary proceedings were begun, and the worker removed from duty, the parent had been left without trained cover for lengthy periods of time and on several occasions had had to stay awake to the point of dangerous exhaustion, in order to provide the round-the-clock observation and care that the child must have.

After all this malarkey, family is now so distrustful of health service management that it is embarking on the personal budget route for the child’s future care. And an excellent healthcare worker – the most capable, conscientious and trustworthy, says the parent, of all who have ever cared for the child; one who cares not just for, but about the child – has been off work for the best part of a year.

I wonder if that ‘not just for, but about’ is the nub of the problem.  ‘Caring for’ is a professional activity: seen as regulated, neutral, dispassionate, cerebral, theoretically-based, rational, considered and orderly.  ‘Caring about’ is unprofessional: therefore unregulated, involved, emotional, visceral, practically-based, instinctive, reactive and messy.  It can’t be reduced to spreadsheets and tick-boxes, it can’t be fitted in to predetermined slots.  It spills over, like life, like laughter.  It doesn’t respect professional pomposity and it threatens professional power.

As such, it is dangerous for professionals to listen to the voices of those who ‘care about’ – mostly, but not exclusively, family – unless they are prepared to give up their power and thereby risk their professional status and, potentially, the income that derives from it.  Even worse is to suggest that other professionals besides one’s self should listen, as that threatens whole swathes of professionalism.  The safe thing to do, professionally, in a status-defined field of work, is generally to keep schtum oneself, and suppress anybody else who looks ready to speak.

Selective hearing and elective mutism work fine as defences for power, until power comes up against someone who has so little of it that they have no stake, no interest in maintaining the power structure and are happy to kick the supports away.  Striving to maintain the appearance of power then becomes less a method of defence and more one of shooting yourself in the foot.

The parent in the story above is going to walk away from the power-game with the budget-ball, leaving a reduced service that will probably, eventually, need a reduced number of managers.

The health worker was so pulverised by the spitefulness of the way the disciplinary was handled, and the threat that over a decade’s dedicated work would be utterly obliterated by what was basically managerial arse-covering, that all the energy and thought that had previously gone into work was redirected to building a defence case.  The results must be deeply uncomfortable for all in the Trust hierarchy.  What’s more, when that worker is back in post, it is pounds to pennies that they are not only going to do everything by the book, but they are going to allow zero leeway for management to do things other than by the book.  In future, says the parent, that worker is going to be stamping, hard, on any toe that comes even a fraction out of line.

The school staff are not answerable to the Trust, and resented the implied attempt to impugn their conduct in their own areas of professional responsibility.  It was the school that initially alerted the risk-assessment consultant, by calling them in to double-check that education staff had in fact done things properly.  The consultant wasn’t prepared to have their training smeared-by-implication either, so volunteered for witness duty.  Although a health professional, the consultant now works outwith the NHS, so had no inhibitions of loyalty to the Trust to prevent them from doing a thorough demolition job on the execrable management case.

Everybody knows that sooner or later, the tactic of sticking one’s fingers in one’s ears and humming loudly is bound to fail.  Eventually, the elective deaf-mute will have to listen, and have to answer for their actions.  Much better to start off by listening carefully, so that you actually hear what is being communicated; and by speaking up whenever (but only if) you’ve got something worth saying.