You can’t mandate compassionBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8509 (Published 18 December 2012) Cite this as: BMJ 2012;345:e8509
- Nigel Hawkes, freelance journalist, London
He’s said it twice, so I think it may be worth listening. In his mandate to the NHS Commissioning Board, the health secretary for England, Jeremy Hunt, indicated that he wanted to put the care back into caring. Then, in a remarkably sharp speech to the annual conference of the healthcare think tank the King’s Fund at the end of November, he made the same point but with even greater force. “In places that should be devoted to patients, where compassion should be uppermost, we find its very opposite: a coldness, resentment, indifference, even contempt,” he said. I can’t remember a health secretary speaking so plainly for a very long time, if ever.
The chief nurse, Jane Cummings, has since weighed in with her list of C words, though understandably she didn’t quite call them that. Care, compassion, courage, communication, commitment, and competence are the “six Cs” that she wants to see forming the pillars of nursing practice.
Both these interventions got a good press. Cynics may suggest that the Department of Health is simply making ready its defences in advance of the publication of the Francis report into failures of care at Mid Staffordshire NHS Foundation Trust, now expected next month. (Parenthetically, why do inquiries led by judges and QCs take so long? Had Brian Leveson delivered his report on the misbehaviour of the press when the issue was still smouldering, he would no doubt have got his way, and statutory regulation would have followed. Had Francis moved more quickly, his recommendations could have helped shape the NHS in the wake of the Health and Social Care Act. As it is, he’s already taken far longer to deliver his report on a small but murky corner of the NHS than William Beveridge took, in wartime, to devise the blueprint for the whole institution and much else besides.)
The passage of time will enable the guilty to argue that things have since changed for the better and that the proposed actions are no longer needed. However, even if that defence does lie behind the department’s compassion drive, it does not invalidate it. My guess is that by his words Hunt has set the tone for his entire term as health secretary, however long that may be. It’s one that clearly distinguishes him from his predecessor, wrong foots the opposition, and appeals to those whose experience of the NHS is not one of unblemished rapture.
The trouble is that you can’t mandate compassion, even if you put it in the NHS Mandate. It’s unclear under the terms of the Health and Social Care Act that Hunt can mandate anything any longer, though he may not yet realise that. In his King’s Fund speech he promised to create ratings for hospitals and care homes in the manner of Ofsted’s ratings for schools, but he set his ambitions higher than the old “star ratings” run by the Commission for Health Improvement from 2001 to 2004. He demanded an “easy to understand, independent, and expert assessment of how well somewhere is doing relative to its peers,” with clear, simple results, greater certainty that poor results were identified early, and no increase in bureaucracy. A doddle, then. Jennifer Dixon of the Nuffield Trust has been given until the end of March next year to come up with the answer.
It’s clear why star ratings are disdained. They preceded the Mid Staffordshire troubles, so reinventing them provides no defence against Francis. But finding something that ticks all Hunt’s boxes will give Dixon plenty of sleepless nights. As for compassion, Hunt is placing a lot of faith in the “friends and family” test, to be rolled out across the NHS next year. Patients treated in hospital (but not in primary care) will be asked to fill in a form and indicate, as if to friends and family, whether they would recommend the hospital as a place to be treated. It’s got some value as a measure of patient experience, but I suspect that it will prove a blunt instrument. Like the measurements of national wellbeing to which the prime minister is so attached, friends and family test results won’t change much over time. The proportion of people who report either good or very good wellbeing hovers around the 70% mark and has done for decades, come rain, come shine. I suspect that the friends and family test will behave in the same way.
There are many reasons why care is less compassionate than it ought to be. Nurses, and the way they are trained, have taken the bulk of the criticism, but the way medicine is practised has also contributed to a loss of compassion. For every condition there is a guideline to follow, a reward for doing so scrupulously, and a penalty for falling short. Patients matter less as individuals than they do as units in a scheme with a public health objective in mind. Though well intentioned, this is alienating. Anybody who has been “treated to target” for high cholesterol, blood pressure, or blood glucose—and that seems to include almost everybody over 55—will know what I mean. And now general practices have been told by the National Institute for Health and Clinical Excellence to screen all adults for their exercise habits, urging greater efforts on the sluggish and admonishing the idle. That’s fighting talk! If I want a lifestyle coach (I don’t), I’ll find my own.
Among Hunt’s other obsessions is the power of IT to transform healthcare: consultations on Skype, the rollout of telehealth, embracing the smartphone, you know the kind of thing. The rhetoric advances like “a bow-wave of guff” as one blogger put it on the NHS Network website. But the same (anonymous) blogger pointed out that for every patient who is liberated from the drudgery of trips to the local surgery or outpatient clinic there is another slipping into depression through lack of human contact or with a worsening condition that is out of the range of clinical intuition. Telehealth may save money and reduce admissions (or may not, the evidence is equivocal), but it is not compassionate.
Cite this as: BMJ 2012;345:e8509