This week I gave a research seminar in my department, the Centre for Language, Culture & Communication at Imperial College London, in which I synthesised some of the ‘lessons learned’ in the course of my research and how this has informed my teaching. It was streamed live, and Julian Lecoeur from ProlificTV has kindly made a recording available here.
In an interview for the Oldie magazine, oncologist Prof. Karol Sikora has recommended being as nice as possible to those that treat your health conditions. “If someone is particularly helpful be appreciative – everybody likes positive feedback,” he told John Sutherland. Sikora is promoting his new book The Street-wise Patient’s Guide to Surviving Cancer in which he advises patients to charm their doctors if they hope to persuade them that they are worth ruinously expensive cancer drugs. NHS staff are “dedicated and remarkably caring”, he said, “and they naturally respond well to pleasant patients.” His advice,though to “tell someone they have a lovely smile,” might come across as a bit obsequious though, not to mention downright creepy in some situations. Best, I think, compliment people on their actions rather than their appearance. But he’s probably right in saying, “The lower down the food chain you are the less you get thanks in the NHS – that’s where the unsung heroes are to be found.” Sikora advises getting a ‘small gift’ for the receptionist: a bunch of flowers, bottle of wine or box of chocolates. This, he says, will make all the difference in prioritising your case. “Don’t be too generous,” he says, for this will embarrass everybody.
Sikora’s book is undoubtedly a ‘consumers’ guide’. It characterises cancer as an ‘industry’ and provides advice on how to maximise personal gain from a system geared to the general good. There is a fine line between genuine gratitude though and blatant bribery, and I suspect staff at all levels are able to tell the difference.
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I recently paid a visit to the University College London Hospital (UCLH) archives in Euston to discuss gratitude and see some of the archive’s holdings. Annie Lindsay and Penny McMahon have charge of a vast amount of material. Some fascinating highlights are on public display in UCLH’s highly recommended heritage trail. Annie and Penny gave me an insight into the kinds of documents that are preserved. Patronage, of course, is well documented, and this has an enduring legacy in a number of wards in hospitals being named for their donors. Complaints are also kept on record although, interestingly, Annie pointed out that in the past this largely depended on the diligence of the superintendent in charge. I was shown a formal complaints form from 1890. Complaints were often lodged by the patient’s sponsor on their behalf if it was felt that treatment was not up to the expected standards that the sponsor had paid for. Does paying for treatment at the point of delivery make complaints more common, I wonder?
We also discussed how gratitude is given and received today. Social media is important at UCLH and tweets saying ‘thank you’ are printed in the staff magazine. Patients expressing gratitude in this way is clearly valued and noticed. There is also a ‘good deed feed’ on the staff intranet for saying ‘thank you’ to colleagues.
The UCLH archive has a great collection of photos. The pic on the right is one of staff participating in festive shenanigans to help raise money for the hospital.
A few weeks ago I had the opportunity to present some of my work on the gratitude expressed in the Frimley correspondence to GP trainers and trainees from West Middlesex Hospital, whose two days away were delightfully themed around ‘happiness’. It was a nice way to hear some stories of gratitude from the frontline.
We had a lively discussion about whether patients are morally obliged to feel grateful. Lots of the delegates were uncomfortable about the word ‘moral’, although most agreed that patients had lots to be grateful for. The overwhelming majority felt that patients should be grateful for the NHS in general, rather than specific practitioners. This sits uncomfortably with some of the literature (e.g. Simmons, 1979, Moral Principles and Political Obligations) in which it is argued that there are difficulties with expressing gratitude to an institution, especially if the individuals that form it are merely carrying out their duties. Most of those joining in the discussion thought that gratitude was owing to the NHS because patients got a lot more out of it than they put in. Some invoked comparisons with other parts of the world, making the case that access to the NHS is a privilege and definitely something for which to be grateful.
When it came to receiving gratitude, the most memorable gifts or cards came from patients from whom it was unexpected. An example was given of a man that had to be sectioned and was incredibly angry at the time, so a card saying ‘thank you’ a few weeks later was particularly touching. Homemade food as a currency of gratitude was also prominent, especially amongst the Asian community. Receiving gifts was confirmed as a particularly tricky issue for doctors with high potential to cause offence by refusing gifts, but sometimes it’s tricky to tell whether gifts do indeed come with strings attached.
Cards displayed on the 
ward, chocolates in the common room… but there is an increasing trend to use Facebook as a collective noticeboard to proclaim gratitude. Showing Thanks is a recently established webpage for conveying gratitude to healthcare professionals involved in maternity care and childbirth. Mothers have been posting their stories on this Facebook site and then Rachel Ellie Gardner has taken it upon herself to let healthcare trusts know when a member of their staff has been thanked.
Anecdotally, we know that staff involved in obstetrics get a lot of gratitude. Even if a birth has been dramatic (and, let’s face it, most births have elements of trauma), the outcome is usually happy. The thanks logged so far are revealing of what women value as being worthy of gratitude. These tend to be making time in spite of being busy, compassionate touch (like giving a hug or holding someone’s hand), being supportive of choices, and being reassuring. Even when the outcome was tragic, women have still thanked healthcare teams for being kind and supportive.
My reading lately has taken me into the realm of the ethics of gratitude. A conundrum when considering gratitude in healthcare is that patients are not obliged to be grateful. After all, healthcare providers are paid to do a job of work in an institution which is funded by taxpayers. Therefore the care provided is a duty rather than a benefit. Alan Goldman (1980, The Moral Foundations of Professional Ethics, Totawa, NJ, Rowman and Littlefield), for example, argues that citizens have no debt of gratitude to the state because they collectively pay for public goods through taxes. This suggests the relationship between citizen and state resembles a commercial relationship (one does not feel gratitude to a store for selling you goods). However, it is clear that many patients do not see healthcare in this way. I think this is partly because there is a collective social resistance to political pressures to commercialise the NHS, but also because the benefit of healthcare is psychically distant from the funding of it through tax. Overwhelmingly though, gratitude is a culturally mediated, social action that takes place between people who have a shared emotional connection. Gratitude becomes an instinctive response to what we might generally call ‘humanity’ demonstrated that goes beyond obligatory professionalism.
Walker (1988, Political obligation and the argument from gratitude, Philosophy and Public Affairs 18: 359–64) argues that even if you have ‘paid’ for a service, gratitude may be warranted if the quality of the service is exceptional and the manner in which it is provided is special. This is borne out by the stories being told on sites like Showing Thanks.
These amazingly creative cupcakes were made by the aunt of a young tonsillectomy patient for the surgical ward and theatre team. It meant a great deal to the staff. Dr Ruj Roplekar, who was one of the recipients, said, ‘I was delighted that someone had shown that degree of appreciation for all those involved in the care of someone she loved.’ When Ruj posted this image on Facebook, it was interesting to see that one of her fellow medics urged her to save the photo as evidence for the ARCP of the ISCP (that’s Annual Review of Competence Progression for the Intercollegiate Surgical Curricular Programme). Indeed, thank you cards and other ‘evidence’ of patients’ appreciation are considered when competency is being reviewed. All the more reason to say ‘thank you’ creatively when good care has been received.
An article on the Guardian’s ‘Comment is free’ website is attracting a lot of attention. Within two days of posting, it has been ‘shared’ on social media nearly 27,000 times and attracted 650 comments. The article is a first-person account of experiencing a miscarriage. The couple received excellent, sympathetic care, undermined somewhat by an automated text the next day asking, ‘How likely are you to recommend our A&E department to your friends and family if they needed similar care or treatment?’ The text presented a 5-point Lickert scale and asked respondents to text back 1 to 5 on the basis of how likely there were to recommend that A&E. This also happened with a follow-up scan at a different NHS site.
The couple felt the texts were ‘crass and inappropriate’. They did not want to be part of someone’s piechart being lauded at a meeting for improving ‘customer satisfaction’ (again the economic language that has proved so potently divisive given the debates about privitisation in the NHS). Instead it was the sincere, human interchange which this couple saw as their meaningful feedback: ‘We had thanked the excellent doctor who witnessed our anguished hope, who entered into that space with us at the start of a long night in A&E and held our hands when our nightmare became reality. I can’t speak highly enough of her … That’s the place for feedback: face to face, sincere thoughts and feelings expressed from one human to another.’ It seems the intimacy of the expression of gratitude was violated by the imposition of a faceless, administrative measure by text. But the comment, ‘I cannot speak highly enough of her’, is revealing. It suggests that language is unequal to the task of praise in this instance, thus the negative framing: ‘I cannot speak.’ That the article has been written at all is a way of expressing gratitude, even if it is by way of condemning the feedback system.
The measure, known as the Friends and Family Test (FFT) was announced by the Prime Minister in 2012 and is gradually being rolled out across all NHS services. Various healthcare trusts publish their results on their websites, and NHS England aggregates the results here. Defenders of it see it as a cost-effective way of improving services: the statistical measures are published so that some services are ‘named and shamed’ presumably so they will try harder. The feedback does allow for comments which is presumably what really delivers value in terms of suggestions for improvements or singles out particular individuals or practices for praise. Do these positive comments get fed back to staff? I hope so.
The framing of the ‘would you recommend?’ question is not appropriate for A&E. No one ‘recommends’ a trip to A&E: it should be a place of last resort. One can’t imagine googling the stats before deciding on the A&E at which to turn up, or instructing an ambulance driver to head for a distant A&E department that has a higher FFT score. So how could soliciting feedback be done better?
Presumably there is some admin involved in which phone numbers need to be transferred to the system which sends out the text. If there is joined-up thinking here, someone would make a judgement call about what method of soliciting feedback would be best, or whether it would be appropriate at all. Might this be open to corruption with Trusts cherry-picking patients to survey whom they think will give positive feedback? Perhaps, but an audited system in which decisions about whom to survey are transparent would be preferable to the one-size-fits-all approach. In this case, it would have been far kinder for someone to ring the couple to ask if there was any further support they needed, and gently asking an open-ended question about their experience of A&E. If the Lickert scale must be brought into play, framing it with an apology for the bureaucratic style might minimise the potential offensiveness. “I apologise for seeming to reduce your experience to a number, but the government requires us to collect this data. Could I ask you, on a scale of 1 to 5…?” And if the couple did single out individuals for praise, my first priority would be to let them know that that his/her efforts had been appreciated and it was fed into their staff feedback.
Rina Dave has found a wonderful way to celebrate the healthcare professionals and her friends and family who are supporting her through he treatment for cancer. She has created large-scale photographs of caregivers, each personalised by an ‘accoutrement’ that gives a glimpse of their personalities. Read more about the exhibition, on display from 17 to 30 November 2014 in the main entrance of Imperial College.
I have been reading an influential essay by Arjun Appadurai, ‘Introduction: commodities and the politics of value’ from Appadurai, A. (ed.) (1986) The Social Life of Things: Commodities in Cultural Perspective. Cambridge: CUP, pp. 3–63.
Although focused on ‘commodities’ which implies an economic context that is missing (overly at least) from the NHS context, points in the essay have made me think about how one might frame a critical study of gratitude and the giving of gifts to healthcare professionals.
It is not customary to give gifts in the NHS (although this needs further research). Most anthropological studies of gift-giving are focused on the trajectory of gifts within relatively isolated, small-scale societies. Whilst a hospital environment, or a GP practice, could be viewed as analogous to a non-capitalist society (at least at the patient-facing end), gifts are meant to be ‘terminal’ (or ‘enclaved commodities’) rather than circulating. There may be very interesting things to say about how gifts are usually consumables or have a short shelf life. According to some studies (cited in this excellent article by Spence on patients bearing gifts), chocolates and wine are most often given. These are ‘luxury’ items that are relatively low priced and thus less potentially threatening to the professional/private boundary than more personal gifts.
Gifts given at Christmas are customary, and possibly more acceptable because they form part of rituals surrounding celebration and one need not be suspicious of ulterior motives on behalf of the giver. In an article for the RCGP’s The New Generalist publication in 2005 (quoted here), de Zulueta describes a range of reasons why patients give gifts, including:
Anthropological studies are woefully inadequate when it comes to addressing motives for giving, yet assumptions made about motive is what drives policies about gift giving, including widespread advice not to accept any gifts at all. ‘Gifts’ also see to be treated as a homogeneous category regardless of the giver, so that gifts from patients are treated as if they are the same as gifts from pharmaceutical companies (which are unlikely to be stimulated by genuine gratitude – the most ‘sincere’ motivation for gift giving – and inevitably carry a whiff of moral taint).
My hunch is that the nature of gift giving in the NHS has changed in response to the way healthcare is organised. I predict that the rise of teams responsible for care has meant that fewer patients identify a single individual as being particularly worthy of gratitude. Gifts that can be shared are likely to continue to predominate (chocolates especially). I think (hope!) that a greater awareness of religious sensibilities of healthcare providers make a gift of wine a less popular choice (about 10,000 workers in the NHS are Muslim and eschew alcohol).
The role of patronage is important here too. Gifts from patients are often channelled though charities associated with hospitals or particular fund-raising initiatives. This separates the gift and any possibility of it contributing to individual gain. Initiatives like the ‘giving tree’ at the Brompton Hospital helps to bridge the gap between the impersonal cash contribution and the expression of gratitude to individuals or teams within the hospital.
Appadurai’s essay examines ‘instruments of value’ and reminds us that status participates in the economics of exchange. League tables, and specific ranking of individuals, could be seen as a rather insidious form of what Appadurai calls ‘tournaments of value’, involving status, rank, fame, reputation and ‘central tokens of value in the society in question’ (in the NHS, that could be analogous to ‘patient safety’): ‘Tournaments of value are complex period events that are removed in some culturally well-defined way from the routines of economic life. Participation in them is likely to be both a privilege of those in power and an instrument of status contest between them.’ The worrying aspect is that league tables treat people and skills as commodities, whose worth can be quantified by simplistic measures. In the context of concerns about the privatisation of the NHS, the use of league tables is held up as an example of transparency and accountability, and in the interests of patient choice (however illusory that may be), whereas the rhetoric of the hierarchy which is entrenched in the very notion of ranking reinforces the metanarrative of the NHS as a ‘market’ in which value is distilled into a set of indicators reminiscent of the trading floor.
Perhaps the most salient take-home message from Appadurai’s essay is that politics govern the contexts of value-based exchanges: ‘not all parties share the same interests in any specific regime of value.’ It is those interests that are woefully understudied.
This is a lovely story of how patients queued for hours to thank Dr Richard Hughes on his retirement. An ‘event’ such as retirement provides a focal point for gratitude – it seems a shame that many doctors receive a show of appreciation only at the end of their careers. One of the characteristics of the way we express gratitude, in Western societies at least, is that it often signifies the ‘closure’ of a particular transaction. (The word ‘transaction’ here seems freighted with economic meaning, rather unfortunately, but the rhetoric of gratitude is saturated with economic metaphors.) This closing shapes the framing of the act of gratitude as a ‘reward’ for past service: in terminis res, as it were, rather than in medias res.
Here is a round-up of news coverage of this story:
Daily Mail: The GP everyone in Britain wishes they had
Daily Mirror: Patients queue FOUR HOURS to thank GP retiring after 32 years serving community
Telegraph: Dr Richard Hughes: ‘I saw them through the best and worst times’ and A great family doctor is a treasure beyond price
The Times: Doctor’s prescription for a better health service
How frustrating must it be for the Hanway Medical Practice where Dr Hughes worked, to have received poor ratings (at time of writing) on the NHS Choices page for Ratings and reviews. Interestingly, in response to a complaint about difficulties in booking an emergency appointment, the practice manager invokes a comment received by the practice website:
The Practice regularly receives positive feedback from patients about the ability to get same day appointments and the helpfulness of staff; this is a written comment that was received via the Practice Website on the same day as the above comment ‘ Just wanted to express my thanks at the excellent service yet again from your staff. Have had to book 2 emergency appointments within the last week for my husband and your staff were friendly and helpful and my husband was seen both days by lunchtime’.
Gratitude is often expressed privately, but frustrated complainants are keen to use the public platforms provided by institutions further up the hierarchy (NHS Choices, rather than, or as well as, the practice’s ‘customer satisfaction survey’ on the website.
Take-home points: