Anna Smajdor: Should we incentivise compassion in the NHS?

anna_smajdorIn response to the details of catastrophic failures in Mid Staffordshire NHS trust, David Cameron recently suggested that nurses’ pay should be dependent on their compassion. The idea that we should reinforce compassion in healthcare is seldom questioned, even if the means by which we attempt this is sometimes disputed. However, I suggest that the moral imperative to increase compassion in the health service is nowhere near as straightforward as many people suppose.

To explain such a counter intuitive view, it is necessary to consider the relationship between modern healthcare workers, the institutions in which they are employed, and the patients for whom they care. Compassion is what compels an individual to respond to another’s pain and distress. This is what is so shocking about Mid Staffordshire: how could doctors and nurses have disregarded the obvious suffering of the patients? Could it be because they were all morally flawed as individuals? This is what Cameron seems to imply: if we had employed better nurses, perhaps this could have been avoided.

But any individual doctor or nurse working in a large NHS hospital will be confronted with far more suffering than he or she can relieve alone. In these circumstances, compassion in and of itself cannot remedy the situation. Because of this, it is dangerous to rely on compassion as the motivation for accomplishing the tasks that are necessary to good modern healthcare. Resources, including numbers of staff, must be carefully balanced against the level of need to be met. This is not simply an issue of individual morality, but of institutional ethics.

Our modern approach to healthcare breaks down tasks into discrete components, which are carried out by many different individuals. One person may be responsible for emptying a ward’s bedpans, another for administering medication. These tasks are highly systematised, to ensure that as many patients’ needs are met with as little expenditure as possible, and compassion is not easily accommodated in such an environment. But good healthcare may still be possible, provided that the necessary tasks are being carried out efficiently and safely.

When this balance goes wrong, healthcare professionals will struggle and fail to meet their targetswhether or not they feel compassionand patients’ needs will go unmet. Things may go still more catastrophically wrong if the incentives and targets intended to ensure patients’ welfare, are skewed towards serving the institution’s own interests. If we focus our response to the Mid Staffordshire scandal on individuals’ failure to demonstrate compassion, we miss an important opportunity to think about institutions themselves, and their approach to target setting and resource management.

I would suggest that the most important priorities for the health service are ensuring patient safety, and trying to meet the needs of as many patients as possible. Incentivising compassion seems at best a circuitous way of achieving this—and at worst a rhetorical flourish that may feed into further sets of targets and priorities that detract from the central purpose of our health service.

Declaration of interests: I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.

Anna Smajdor is a lecturer in ethics at Norwich Medical School. She studied philosophy at Edinburgh University, and medical ethics at Imperial College, London.