Conundrum 4
Using Status Wisely

Rob could see the discussion heading in a direction he didn’t want. The GPs had been so adamant that the problems lay in the discharge process from the hospital, but now that they had the opportunity to tell them so they were backing down. Instead of insisting that the consultants ensured their teams cooperated with the agreed protocol, planning the discharge on admission, they were agreeing with them that what was needed were more discharge liaison nurses. Instead of achieving significant savings in the course of providing better care, they were about to commit the PCT to even higher spending – without any evidence of the benefits of the investment. How had this happened?

At a recent meeting for all the people involved in the clinical pathway, the ward nurses had reported that the consultants weren’t monitoring their junior doctors’ observation of the protocol, even when the problems this caused were pointed out to them. It was a pity that none of the hospital medics (consultants nor juniors) could be there to hear this, and that was why today’s meeting had been arranged. An opportunity for the GPs who had been present to talk clinician-to-clinician with their hospital colleagues.

When they had been asked why they didn’t tackle the consultants and ask them to take a more active role, the ward nurses were uncomfortable. They had tried, they said, to discuss it with the junior doctors, but they always complained of being too busy, and somehow at ward rounds the moment never seemed quite right to raise it. They had talked about it with their manager, they said, but to no avail. She had a huge amount on her plate too of course, what with all the preparation for the Foundation Trust application.

Somehow or other Rob knew they had to get that Length of Stay down. Getting the discharge processes right would both reduce costs and help them maintain their success on access targets. Not to mention the better outcomes and patient satisfaction. It was important damn it! And the GPs knew it. What were they doing?!

Question
What is happening and what can Rob do to encourage the discussion in the direction he wants it to take?

Commentary 4

The situation we have here is one where a group of professionals with a legitimate view, strongly held and articulated forcefully when on their own, fall silent (or become wholly amenable to a view they have rejected when on their own), when they come face to face with the people whose behaviour they are finding problematic. Does this sound extraordinary? Not to most people working in health care, in health care this is not at all uncommon.

Why is this the case and what can be done about it by people like Rob, observing it?

Sometimes it is to do with daunting surroundings, particularly if the meeting is on ‘the turf’ of the other ‘camp’ (who feel very much at home there).

Sometimes it can result from forceful or domineering behaviour on the part of one or more members of the other group.

Sometimes new information is introduced and the previously agreed view now seems less valuable or relevant.

But often it is a result of a difference in status between the groups.

Status is widely felt within health care organisations but much less often explicitly discussed nor addressed. Indeed to talk of some groups holding higher status than others can be seen as politically incorrect. That is because of a misunderstanding about the nature of status.

Status is a regard conferred by society at large which has no correlation with moral worth or likeability, and which influences the way individuals and groups relate to each other. Members of low status groups find it difficult to express their views to those of higher status groups, and people can respond differently to information or behaviours coming from individuals of different status.

Status is not a bad thing, it enables individuals and groups, drawing on their specialist knowledge base and their professional experience, to insist on action they believe to be in the best interests of their patients or the wider public, in the knowledge that if it came to a battle between them and organisational managers then the press and public (and hence politicians) will often back them.

It becomes destructive however when the status is ‘carried over’ into discussions about issues where that knowledge base and experience are not relevant, or when it is used to further the interests of the professional group rather than their clients.

Status can pervade interactions in health care – both positively and destructively. So it is worth understanding what gives rise to higher and lower status, predicting in advance of any meeting what the status differences are likely to be, and making sure that they are only used appropriately.

That is what Rob, in our vignette, has not done.

Sociologists have considered status and status differences for nearly a century, and processes of ‘professionalisation’ and ‘deprofessionalisation’ and ‘proletarianisation’ have been mooted. Issues of gender and salary are often suggested by lay observers (although they quickly see that these are often the result of status rather than its cause – although they can further reinforce it). But the suggestion that seems to explain the dynamics within health care most accurately is that of Jamous and Pellouille who talk of a technicality / indeterminacy ratio. By this they mean that the nature of the knowledge base held by a profession is an important factor – the harder, more definitive, more technical that knowledge base is then the higher their status is likely to be. So professions (or specialisations within professions) that can say ‘yes’, ‘no’, ‘0.375%’, are likely to heave higher status than those whose vocabulary is dominated by ‘it depends’, ‘let’s wait and see’.

However if the knowledge base is so technical that it can be codified, then this group can be replaced by guidelines or a computer, so the degree to which it must be interpreted differently from one patient to another is also relevant. The highest status health care professions will have a highly definitive knowledge base and this interpretive ability.

If we apply the technicality / indeterminacy ration in this case what do we find?

It will depend on the specialty of the hospital consultants but on the whole they will have a more technical knowledge base, within a more limited range, than their GP colleagues. They will also be applying it with the necessary interpretation and thus will hold, within society, a higher status. They themselves will feel this, so will others interacting with them. For this status to be used ethically (in accord with the reason it is granted) then they should ensure that it is used wisely and well, in decisions that require their knowledge base and professional judgement. However because we so rarely discuss status it is unlikely they will have considered these boundaries.

Rob can therefore expect that his GPs (and indeed he himself) will tend to defer to the consultants. And he should take steps to prevent this happening when it is inappropriate.

He can, during the discussion, paraphrase (reframe) statements made by the consultants in which they appear to insist about a decision that does not draw on their knowledge base, and express these as preferences. He can support the GPs in fully articulating their case.

He will be most useful if he can persuade both sides to describe the service they would like patients to receive, the problems they have with the current situation and with any of the proposed solutions, and encourage them jointly to devise a solution that addresses all of these. In other words, he should encourage everyone to ‘sell’ the problem (as they see it) itself, rather than to sell their solution to it.

He will find himself more able to do this if he has prepared for the meeting emotionally as well as familiarising himself with the issues under discussion. Visualising the meeting beforehand will help enormously. If he can imagine the behaviours likely to occur during the meeting, notice his own emotional responses, and then practice changing those responses to ones where he is calm, able to listen carefully, think clearly, keep the aims of the meeting in mind, help others to do the same, etc. then he will be much more able to do so during the meeting itself.

And it isn’t only down to Rob, any of the members of the meeting could do the same. So if these dynamics are making life difficult for you, then you can try this yourself.

Please send any comments and suggestions to
conundrum@reallylearning.com