Since the Francis report there has been much discussion about the need to disseminate “compassion” in the NHS. While there has been a great deal of moralistic rhetoric extolling the virtues of this noble and uniquely human quality, and its indispensible role in a caring health system, there is relatively little analysis of those organisational factors that might lead either to its flourishing or to its withering away.
I believe that the most effective measure to increase the degree of compassionate care towards patients would be for NHS staff themselves to feel more valued and nurtured by their organisations. The trouble is that the wider NHS culture has undergone a steady transformation in proportion to the extent of marketisation. There is a shift from a sense of belonging to part of a broader family in a cherished public service in which we take pride, to feeling more like disposable, anonymous employees of an indifferent corporate behemoth. There are various dimensions to this shift in culture. Firstly, NHS staff feel precarious in a way that was previously unheard of. Many are familiar with service reorganisations in which staff must “reapply” for their jobs. What is the underlying message? That your job is far from secure. Of course this feeling of potential job insecurity contributes to a pervasive free-floating anxiety. Secondly, the need for continual training, appraisal, performance management, revalidation, personal development, audit, targets, etc. creates an anxious atmosphere of always feeling that one is lagging behind and trying to catch up—that the goal of being designated “competent” is forever receding away on the horizon. Staff live with an apprehension that at any moment the hand of institutional authority might clap you on the shoulder and condemn your lack of up-to-date equality and diversity training, or woeful ignorance of your nearest fire exit.
Despite being well intentioned, NHS managers are unfortunately ensnared by rather bad systems that constrain and determine their behaviors. They are often forced to see clinical staff as specified skill sets and cost implications, and that’s how staff end up seeing themselves. If we are going to allow a productivity-obsessed NHS to drift further into the mire of call centre culture, then patients will be more likely to get a mechanical call centre experience. Staff who feel stressed, scrutinised, insecure, vulnerable, and generally demoralised will not have the emotional resources to open up hearts redolent with compassion. In claustrophobically stressful environments people tend to narrow their focus on their own immediate interests, and when people feel dehumanised they tend to act inhumanely.
It will be no use merely adding “compassion” to the swelling list of mandatory trainings without looking at the broader systems and experiences of staff. Surely all NHS employees want patients to feel valued, listened to, secure, and nurtured. However, if we are going to move collectively in the right direction we must begin by directing such positive regard to our staff.
Competing interests: None
Sean Roche is a consultant psychiatrist in north London, and a visiting research fellow in philosophy at King’s College London. Since completing his philosophy PhD in 2011 he has maintained a research interest in philosophical and political issues that are relevant to both psychiatry and medicine.