When Robert Francis published his report on the ‘systemic failings’ identified in Mid-Staffordshire in 2013 the report was a damning indictment of management practices and unsafe staffing policies. But is also raised concerns about a lack of compassion on the part of ward staff, and spoke of concerns that patients were not treated with dignity and respect. Part of the government response was to amend the NHS constitution and values, particularly emphasising values relating to dignity, respect and compassion; it was redrafted to include a list of NHS Values around putting patients first, valuing every person, a commitment to quality care, striving to improve lives, inclusion and compassion. This emphasis on compassion and dignity works to background the systemic failings in the NHS and functions to point the finger of blame at health professions.
Since this 2013 report, there has since been a push towards ‘compassionate care’ in the NHS. NHS staff are now required to undertake training to increase their levels of ‘compassion’. Universities commissioned by the NHS to train health professionals are now required to adopt ‘Values Based Recruitment’:
In some regions this is being enforced through a checklist with which trainers at interview give each candidate a score for each of the NHS values (e.g. valuing patients, improving lives, showing compassion, etc).
This idea that compassion as an individual tangible quality, which is either present or absent in that person, is contrary to the available evidence. Both nurses and doctors tend to begin their training with good levels of compassion but this diminishes either during the course of training or in the early years after qualifying. Something interferes with levels of compassion through the process of becoming a health professional.
One likely culprit is the work environment itself. In a survey of 12 European countries plus the USA, England had the second highest rate of burnout in nurses at 42%. Compare this to Greece which had the highest rate (78%), the Netherlands which had the lowest (10%) and the USA at 34%. Similarly, in 2015 43% of doctors reported low morale (a figure which is increasing) and 39% reported frequently feeling “drained, exhausted, overloaded, tired, low and lacking energy”. In spite of a wealth of evidence concerning the need for a whole system approach to improve compassionate care, health care workers are pressured to meet expectations of both the general public and other professionals to demonstrate compassion despite increasing work pressures and a real time reduction in levels of funding, new accountability frameworks and so on.
With the current emphasis on recruiting and ‘training’ staff to be more compassionate, little focus has been placed on barriers (both structural and interpersonal) that undermine staff compassion. A study of frontline staff working on dementia wards found that staff have intuitive ways of responding compassionately. But the realities of the workplace, such as styles of management and unsympathetic structures, often prevent them doing so. A focus on compassion training and Values Based Recruitment therefore seems misguided without a parallel commitment to removing barriers to compassion.
Responses that seek to remove the structural barriers to compassionate care are clearly needed. At the very least this must mean a commitment to safe staffing levels, as called for in the Francis report. It could also mean creating more opportunities for regular peer supervision and support. What is required is compassionate management and leadership with an eye to the system as a whole, which models and enables the compassion that healthcare staff are expected to demonstrate.
The focus on measuring the compassion of possible NHS employees, via a Values Based Recruitment process, bears little resemblance to the recommendations Francis made. His report emphasised the ‘systemic failings’ in Mid-Staffordshire. In this sense, the NHS system is woven into the very political and social fabric of the United Kingdom. The system stretches as far as the Secretary of State for Health and includes high level structures such as the Department of Health and NHS England, commissioners, training bodies, professional bodies, staff as well as patients and carers. It appears that the imperatives encapsulated in Values Based Recruitment do the opposite of addressing systemic failings, instead focussing on individual professionals as though they are potential future failures (i.e. if they struggle to display empathy in threatening environments). Meanwhile at the top of the system, the Secretary of State for Health is attempting to impose a contract on junior doctors which demonstrates a fundamental lack of corporate compassion, putting patient safety at risk in a way that sounds very much like the failings identified by Francis.
About the authors: Syd Hiskey is a Consultant Clinical Psychologist working for the North Essex Partnership University NHS Foundation Trust. His clinical interests include the neuropsychology assessment of dementia and post-diagnostic psychological treatment, as well as compassion focused therapy for people with severe and enduring mental health problems. His research interests include post-traumatic stress disorder (and post-traumatic growth phenomena), and compassion in a therapeutic context. Susan McPherson blogged previously on Cost of Living here.