The Francis Report should form a landmark in the quest to address deeply damaging flaws in the health service – and begin to turn compassion from a 'hurrah word' into a concept cemented at the heart of healthcare design, says Professor Paul Crawford
One of the key elements of the Francis Report into the appalling treatment of patients by Mid-Staffordshire NHS Trust is its foregrounding of systemic failure and the need for responsible management. We can only hope this marks a long-overdue shift in emphasis in the quest to address fundamental and deeply damaging flaws within the health service.
The stock response to the question of compassion depletion – acting with coldness, cruelty or uninterest in the suffering of others – has been far too simplistic for too long. The customary reaction is that the fault must lie entirely with the nurse rather than with the production-line cold clinics and threat cultures in which health systems in high-income societies all too frequently ask their practitioners to work.
As a result, the term "compassion" has come to be used rhetorically or uncritically, often as a kind of "hurrah word" that is connatural with or defines nursing. In fact, compassion is a highly complex and under-researched concept that we might best attempt to capture in a list of adjectives: kind, warm, loving, affectionate, caring, sensitive, helpful, considerate, sympathetic, comforting, reassuring, soothing, attentive and so on.
It is tempting to reflect how wonderful it would be if every nurse could be imbued with these qualities, but this, again, is to massively over-simplify both the problem and the solution. Compassion is not just for nurses: it is for all the professionals who work in the NHS and, indeed, for all those who manage it.
Moreover, compassion does not reside solely in our moral ambit: it is generated by compassionate environments. This is why we need to cement it at the very heart of the design of the healthcare system – across place, process and person – instead of limiting it to individuals and, as has repeatedly been the case, presenting it as a dilemma that the nursing profession alone should tackle.
Growing calls for "compassionate design" have been born out of an increasing body of work centred on the role of dignity and compassion in healthcare and how these phenomena can be measured and enhanced. The King's Fund's Point of Care initiative raised concerns about the NHS's target culture and the way in which relational work and interaction habitually default to the least qualified members of staff.
Peter Carter, general secretary of the Royal College of Nursing, has argued that a major contributory factor to the poor care of older people is a care assistant workforce that is not properly trained. Francis has now added to the mounting disquiet by laying bare the catastrophic extent to which compassion has been overlooked in favour of financial objectives and a desire to hear only good news.
Even now, there are those who maintain that effectiveness and efficiency are paramount, yet the reality is that the current bent for a factory-style NHS causes untold harm to patients and practitioners alike. The conveyor belt mentality it ineluctably cultivates in staff is so prominent that it is not unusual to hear nurses speaking like supervisors at a car plant. The atmosphere is deleterious for all concerned.
Kari Martinsen, a Norwegian professor of nursing science, poses a straightforward question in her book Care and Vulnerability: "Does the hospital, with its rooms, corridors and interiors, invite people to dwell in its midst?" She posits that nurses should not have to contend with surroundings that are "painful to be in" or "rooms with shameful architecture". Later, presaging some Francis observations, she warns: "People must always come before numbers. Statistics, benchmarks and action plans are tools, not ends in themselves. This is what must be remembered by all those who design and implement policy for the NHS."
We ignore at our peril the emerging message that the genuine transformation of hospitals and care homes into compassionate spaces will not occur merely through practitioners applying the right attributes like some kind of miracle cream. The development of a more compassionate NHS will need to go much deeper than mandating angelic nurses or setting up new box-ticking initiatives to be poured in as a skill through linear or values-based curricula.
What we have to see, particularly in light of the Francis Report, is a significant and essential change in both government policy and NHS organisation – a change focused on how services and processes can maximise the likelihood of compassionate relationships from and among nurses and other clinical and non-clinical staff. The rule of the clock or the excuse of being "far too busy" should not blind us to opportunities to encourage meaningful engagement that will ultimately benefit not just patients but practitioners.
We should all demand that our NHS not be turned into a production line. As a starting point, the government, policymakers and managers of healthcare organisations could do worse than spend some time reading up on the psychology of threat and its aftermath. Patients should not have to be treated amid threat cultures that lead to compassion fatigue and moral slide – and, equally, practitioners should not have to work in them. We all deserve better than that.
Professor Paul Crawford holds the world's first chair in health humanities and is the founder/ director of the International Health Humanities Network (www.healthhumanities.org) and a founder of the Madness and Literature Network (www.madnessandliterature.org)
This article first appeared in Public Servant magazine