Soaring with eagles or swimming with sharks? Aviation, banking and healthcare

"So, I should sell my shares in solar?"

When Steven Shorrock (@StevenShorrock),  Safety Development Project Leader at EUROCONTROL, spoke at ASPiH 2015, he mused aloud whether the conference organisers might have been better to invite a speaker from the banking sector than from air traffic control. He recommended reading "Swimming with sharks" for an insight into the former and these are my thoughts after reading it.

The book, "Swimming with sharks", published in 2015, is based on interviews with about 200 people who worked or recently worked in banking in London. The author, Joris Luyendijk, discusses the financial crash of 2008, which almost brought the developed world to its knees, as well as other scandals such as Libor trading, laundering of drugs money, assisting tax evasion and the fall of Lehman Brothers. The real substance of the book lies in the personal accounts of the people working in banking and their thoughts about the sector. There are definite similarities between healthcare and banking but also some important differences... 

Similarities

Safety

In banking, compliance officers are meant to keep an eye on the traders and ensure that trades did not expose the bank to too much risk. However, as Luyendijk states: "...it is very difficult to put a number on a loss you have averted by saying no..." A football analogy may be apt. The goalkeeper is remembered less for the many saves than for the single goal which lost her team the game. In healthcare a similar effect may be seen with those who work in "patient safety" including simulation-based training. Because safety is a "dynamic, non-event", interventions aimed at improving safety may be seen by both front-line staff and hospital board members as costly and time-consuming with little return on investment. 

Culture and sub-cultures

Although there is much talk in the NHS of changing "the culture". Shorrock suggested that healthcare may be more similar to banking in this respect too, with a plethora of "sub-cultures" rather than one over-arching culture. "Swimming with sharks" details a few of these sub-cultures. The  dog-eat-dog world of the front office traders compared to the investment bankers in asset management, who are encouraged to make slow, deliberate moves. Luyendijk says that banks like to portray themselves as organisations organised like an army or an airport, but in fact they are "clusters of islands in the fog, staffed by mercenaries" (p.145). It may be suggested that the culture(s) of hospitals can approximate those of aviation, although distinct in terms of values and behaviours the over-arching goal is the same. When hospitals fail, their cultures resemble those of banks, each sub-culture putting its own interests first resulting in a disconnect between frontline staff and the Board.

"Culture" is also high on the investigation list of a Holmes-like consultant who helps banks prevent and detect rogue trading (p.145). Luyendijk quotes him: "Is this a place where somebody can raise his hand and say I made a mistake?" In healthcare too the culture of a specific department or ward will give you an insight into how safe it is for patients. Dysfunctional teams are unlikely to be safe teams.

Lastly, one of the interviewees states: "It's not the people who are bad: it's the culture..." The same may be said of healthcare. Individuals are expected to adapt to, adopt and accept the given culture within a unit, department or ward. Luyendijk, in his recommendations at the end of the book, says: "One thing I believe does not help is to reduce the problems with global finance down to individual character flaws... if you blame all the scandals as well as the crash on individuals you imply that the system itself is fine, all we need to do is to smoke out the crooks..." This "bad apple" theory is well-addressed by Sidney Dekker and others. In fact the system/culture encourages certain types of behaviour and without changing the fundamental causes we are unlikely to see long-lasting change.

Hierarchies and silos

Luyendijk refers to Gillian Tett, a Financial Times journalist, who argues that "the number-one problem in investment and megabanks is that everyone works in 'silos'". A compliance officer Luyendijk interviewed says: "We need to get rid of the idea of "the bank". That term implies a unity of action and purpose, as if there's an all-encompassing view driving the bank. There is no such thing. What we have is a collection of individuals in positions of power. Each of them manages his or her own world." The same personalities can be found in healthcare, with the clinical lead or general manager who looks after "their world" without reference to the needs of the wider organisation.

Complexity

Some financial products have become so complex that very few people, even inside the bank, actually understand what they represent or how risky they are. "Even the risk and compliance people who were supposed to be our internal checks and balances... We had to teach them how to monitor us" (p.132). One of the causes of the crash of 2008 was that the complex financial products on offer, collateralised debt obligations (CDOs), although AAA-rated by ratings agencies, were filled with mortgages which people were not going to be able to repay. A similar level of complexity operates in healthcare. A Board which is not pro-active in understanding the everyday workings of the hospital risks thinking the place is much safer than it actually is. In addition, decisions made by the board (with the best of intentions) may have significant, unexpected implications on the shop floor.

Lack of funding in IT

Handwriting: Lantus 8 Units misread as 80 Units

"Your readers would be shocked if they realised just how crap the IT organisation is in many banks..." (p.141). The same is true in healthcare. Whether it is "the biggest IT failure ever seen" costing £10 billion of UK taxpayers' money or the fact that most hospital drug charts are still hand-written, IT investment in healthcare is lacking. This means that, as in banking, many systems don't "speak" to each other, multiple passwords are required for multiple systems and patients' notes are still folders where pages may go missing. The potential for errors is phenomenal.

Short-termism

In part because of the risk of instant dismissal (see below, under Differences) bankers often have a short-term outlook (p.154). In the NHS, acceptance of a post is often "for life", particularly at the patient-facing end. However there are perhaps similarities with NHS board members where turnover is much more rapid. This means that the long-term effects of some decisions are not made obvious to board members who have moved on.

Speaking up

A number of interviewees spoke of the futility of speaking up when witnessing poor practice. "I'd lose my job never to find a new one anywhere in the City. Meanwhile nothing would have changed" (p.188) The same can be said of healthcare, the fate of Stephen Bolsin, who spoke up about the Bristol heart surgery deaths, is not unique.

Differences

Focus

The focus of bankers and banks is to make money. Bankers want to make money for themselves and, in a meritocratic system, are rewarded for how much money they make for the bank. Public healthcare, as is generally found in the NHS (although the the English NHS seems to be on the road to privatisation) instead seems to be more focused on not losing money rather than trying to make a profit. This means that the majority of healthcare workers do not have a vested interest in increasing throughput or reducing costs.

Dismissal

In banking, dismissals are unexpected and immediate. To prevent the newly unemployed trader from damaging the bank, all network access is revoked and they are escorted from the building. In healthcare it is much more difficult to dismiss employees, even when their behaviour seems obviously unacceptable. Although at first glance it may seem preferable to be able to instantly dismiss "bad apples" or under performers, the effect this has on banking is not negligible. Bank employees may have much less loyalty to their bank and therefore may care little what effect their risk-taking has on "their" bank (e.g. Nick Leeson and Barings Bank)

Professionalism

The "professional" doctor vs the "professional" banker

In the City, the biggest compliment is 'professional'. "It means you do not let emotions get in the way of the work, let alone moral beliefs" (p.107). A recurring theme in Swimming with Sharks is that bankers are not immoral, but rather amoral. As long as an action is legal it is irrelevant whether it is "right" or "wrong". In healthcare the word "professional" may still mean a number of different things to different people, but what it most certainly does not mean is "amoral".

Final thoughts

Was Steven Shorrock right? Is healthcare more like banking than aviation? In effect it can be like both. At its best, healthcare resembles aviation with its focus on safety and a desire to ensure that the passenger/patient gets to his destination/home in one piece. At its worst, healthcare resembles banking, with a climate of fear (p. 95), amorality, back-stabbing and a focus on money and targets (cf. Mid-Staffs). It is up to all of us to decide what kind of ward, department and hospital we want to work in. In particular it is the job of hospital leadership to foster a safety culture and sell the idea of "the hospital" or "the healthcare centre" that staff can be loyal to and work together for. Hospital leaders must also speak truth to power by making it clear that the current cost-cutting across the NHS cannot be making the organisation safer. It is the job of politicians to provide the funding required and to protect the nascent safety culture against accusations of "blunders" as more adverse events are reported.

As for banking, Luyendijk makes a convincing argument that nothing substantial has changed. The basic weaknesses which almost brought the developed world to a standstill in 2008 remain in place. Unfortunately the political willpower to make the required root and branch reform is lacking.

Acknowledgments: 

"Swimming with sharks" does not make a single reference to healthcare or human factors. I am unlikely to have read it without Steven Shorrock's recommendation for which I am grateful.