On compassion, markets and ethics of care

‘Compassionate care must be at the centre of everything the NHS does’ proclaims the Government's response to the Francis Report on the failures of care in the Mid-Staffordshire NHS Trust. Amongst many sensible recommendations, the most catchy and impressive is the one requiring ‘96% of senior leaders and all ministers at the Department of Health to have gained frontline experience in health and social care settings by the end of the year’. It still remains to be seen what this means in practice. The duty of candour is vital too although it applies to health care institutions as a whole and not the individual health professionals. Other important initiatives involve ensuring that healthcare assistants and social care support workers have the right fundamental training and skills in order to give personal care to patients and service users. However, the Francis report recommendations relating to registration and training of healthcare assistants were not accepted by the government and it appears from its response that they have put in place a very weak mechanism for requiring that they have the relevant training. Thus it will be entirely legal to practice as a healthcare assistant without having the ‘Care Certificate’. Various arrangements to monitor the implementation of the Francis Report’s 290 recommendations are also needed. But the government is not proposing that it, itself, will ensure this happens, or makes new funds available for it. This is particularly important since NHS hospitals, facing intense pressures to keep costs down, are now relying on unregulated and poorly paid healthcare assistants and other ‘auxiliary workers’ to provide the care formerly delivered by professionally trained and regulated nurses. Yet, since most of the areas identified as being in need of improvement are about embedding a ‘caring organisational culture across the health system’, promoting appropriate leadership and reinforcing values, it is doubtful whether relying on surveillance, bureaucratisation and instrumentality can achieve any of these if the root causes are ignored.

Organisational research confirms that when explicit targets are coupled with strong incentives (and/or disincentives), people will strive to meet them, often even at the expense of common sense. This can sometimes lead to them violating socially accepted norms such as leaving dying patients ‘to starve, soiled and in pain’ and undermining the fundamental ethical principles underpinning care-giving. In order to understand why this happens we must move beyond simplistic frames taken from economics, pointing at self-interest as a rational decision making process and single key driver of human behaviour. Sociology and social psychology can offer more profound insights here. Max Weber, foresaw almost a century ago, how the mechanisation of production, the rise of mass markets and the impersonal bureaucratic structures implemented to increase productivity, could lead to the dissolution of personal responsibility. Such conditions, he argued, could lead to people being treated as objects, or as mere cogs in the wheels of organisations. The Mid Staffordshire NHS Trust failures in rudimentary aspects of care are among many such examples.

At Mid Staffs demonstrating ‘financial health’ was a necessary precondition for achieving foundation trust status, and the staffing requirements needed to provide adequate patient care, and arguably the patients themselves, were ultimately seen as ‘getting in the way’ of achieving the hospital’s strategic goal. The Francis Report provides a damning indictment of such an approach: ‘While the system as a whole appeared to pay lip service to the need not to compromise services and their quality, it is remarkable how little attention was paid to the potential impact of proposed savings on quality and safety’. But how could managers or even the frontline staff distance themselves from the obvious task of providing care to the point of criminal negligence? Some recent research suggests how almost anyone might engage in unethical behaviour, thanks to a complicated and socially reinforced mix of individual and organisational factors having to do with mental framing, perceptions and unconscious motives. Yet though moral responsibility for any action rests ultimately with the individual, the widespread failing in care standards cannot be simply attributed to callous and uncaring staff. Indeed, the findings from the Francis Report confirm the absence of ‘a sufficient sense of collective responsibility or engagement for ensuring that quality care was delivered at every level’. Managers and organisations are critical to the creation of an ethical environment but the overall policy framework in which they operate is even more important.

The question now is: will the measures proposed by the government offer an  effective way of ensuring that nurses and doctors treat their patients with compassion given that they will be introduced at a time when new competitive pressures are being introduced to the health service? This is highly unlikely. In fact, as the market is introduced into public health services, commissioners facing severe financial pressure, may seek to negotiate cheaper contracts under the guise of ‘value for money’, which could lead to a decline in standards of care. For example, the contract to provide NHS community health services in Suffolk which was won by Serco as the lowest cost bidder has led to significant concerns about ‘potential patient safety and quality issues’ after the company failed to meet key performance targets and shed 130 staff. Thus the recent experience of private providers in the newly created NHS market does not inspire optimism. Indeed the problems with introducing markets in health care are well-established in the voluminous literature on this topic, and there is a worrisome lack of clarity as to whether the government’s recommendations for promoting compassionate care will apply in equal measure to the private sector providers who are now encouraged to bid for the NHS contracts.

Until recently, codes of ethics along with the lengthy socialisation process into the norms and values of the profession offered some safeguard against egregious misbehaviour by health care staff, notwithstanding some highly publicised exceptions. But these codes of ethics become difficult to adhere to when resources are squeezed. Recent research found high workloads to be the most commonly identified cause of patient neglect. The incidents of dangerously low levels of nursing staff are routinely under reported and often come to light when a crisis erupts.

Regulating aspects of behaviour that are difficult to measure and assumed to be lacking such as compassion reveals the absence of a clear understanding of its nature and causes. The culture of litigation and blame is not likely to bring the desired improvements in care. As Kathy Meade, clinical negligence solicitor explains: ‘Being exhausted, undervalued and under-supported with a high ratio of patients to staff can make it difficult to provide the care people are entitled to expect’. Thus while continuous professional training, proposed in the government’s response to Francis Report, is an essential precondition for an adequate level of care and in order to prevent the abominable excesses witnessed in the Staffordshire hospital, this cannot be achieved without adequate resources. After all, the downsizing of already drastically reduced frontline staff in order to achieve a £10 million saving needed to enable the hospital to acquire a foundation trust status, was one of the main, if not the key cause behind the failure of care. Such pressures are to become ever more pronounced under a regime which requires the NHS and individual hospitals to produce savings of 4% per year in the next five years. The government’s recommendations in response to the Francis Report are not likely to address the root causes of the problem – such as financial constraints and targets – but are instead focusing on regulating staff and managers individual behaviour.