The lost compassion of nursing? Making sense of the Francis report

The debate on Robert Francis’ report on the Stafford Hospital disaster is likely to be the last crucial opportunity voters in England will have to fully understand what is being done to their health service, and to consider better alternatives. It would be nice if the debate could be rational, informed and evidence-based. But so far the signs are not very good. Contrary to what most commentators have said, Francis actually put his finger on the fundamental problem – we’ll get back to that in a minute – but he avoided explicitly blaming any one cause or person. This has encouraged commentators of all persuasions to see his report as endorsing their pre-existing personal convictions, reinforced by anecdotes (their own, their friends’, or those of high-profile individuals, such as Anne Clwyd’s account of the wretched treatment of her dying husband). 

On the Today programme in January John Humphrys saw the problem as down to the bad behaviour of individual nurses, and called on the new Chief Nursing Officer for England, Jane Cummings, to agree. Shouldn’t bad nurses be sacked? Cummings might have drawn Humphrys’ attention to the fact that NHS hospitals in England had just been found to be dangerously overcrowded, operating at close to 100% bed occupancy (even before the usual ‘winter beds crisis’), while nursing posts are being cut in the name of ‘efficiency savings’. But she did’nt seem to be a woman to fight the nurses’ corner. She responded by saying she was launching a campaign for nurses to live up to six ‘Cs’ - Care, Compassion, Competence, Communication, Courage and Commitment. It’s not hard to imagine overworked nurses adding a seventh ‘C’ to the list.

For the TV businessman Gerry Robinson, interviewed by the BBC, it was obvious that the problem is bad managers. But in his revealing 2006 TV series, ‘Can Gerry Robinson Fix the NHS?’,about a hospital which certainly seemed to suffer from a weak chief executive: he discovered a deeper problem – the perverse financial logic of the internal market. After weeks of intelligent effort he found a way to greatly increase the productivity of the hospital’s surgical theatres, only to be told that the PCT couldn’t pay for more operations to be performed. At that point his fixing capacity seemed to come to a full stop.

Sir David Nicholson was the man in charge of the Strategic Health Authority overseeing the Mid-Staffordshire trust while its patients were dying unnecessarily and is Chief Executive of the NHS and of the incoming National Commissioning Board. He has brushed aside the suggestion that he should resign by saying that he feels he is the man to put things right. His response to the Francis report has been to make a video in which he wrings his hands and calls on everyone to behave better.

For most people the problem is fundamentally moral: we must simply stop accepting that sick people in hospital – man of them old and no longer attractive, sometimes confused and occasionally difficult – are treated worse than we treat our pets. It is a problem of culture. Deborah Orr, an acute and progressive critic of public policy, sees it as due to a failure to respect and reward those who do the dirty work that society needs done, including much of the hands-on work of nursing care.But how are we to change a culture that fails to do this? She doesn’t say.

The prime minister did have an answer, the default public-school response, perhaps – more discipline, to be imposed by a new Chief Inspector of hospitals. This is not actually a bad idea: hospitals, like factories, building sites, restaurants and schools, do need inspecting, and the Care Quality Commission is not adequately equipped to do it. Whether the new Chief Inspector will be given the number of high-level specialist staff and other resources needed to do the job remains to be seen. It also remains to be seen whether hospital inspectors will be like the old school inspectors who aimed to help teachers do better, or like Ofsted inspectors who aim to frighten them into improvement. I suspect Cameron sees it operating more on Ofsted lines. He sees nursing as a job like any job in a company that operates in a business environment – which indeed NHS hospitals now do.

The trouble with relying on inspection, however, is that while it should be able to stop the worst failures of care, it won’t ensure good care. As Michael Power showed in The Audit Society, when public services are reshaped into businesses and set to earn a surplus you can no longer trust staff to do their best simply because they love their work and want to do their best for the public: now you have to monitor and audit their work and reward and punish them according to set criteria. But where something as complex, and also qualitative, as nursing is concerned, criteria for really good care can’t be laid down. What results is a focus on providing a paper trail to prove that the prescribed minimum standards have been complied with – a task which then becomes a major consumer of nurses’ time. And the work culture gradually adapts to the audit culture. People tend to do what the inspectors will check up on, but not necessarily more, especially if there is insufficient time for both.

Appointing a chief inspector also means rejecting the one proposal in the Francis report which points in the opposite direction, and which does go to the heart of what is wrong, as Professor Calum Paton has well noted. Francis proposed that the roles of Monitor and the Care Quality Commission should be combined in a single organisation. He saw that meeting the bottom line demanded by the financial regulator will always take precedence over the quality of care so long as the financial regulator is not also responsible for the impact on quality. But this proposal points to the real problem – the determination to convert NHS hospitals into businesses – which is why it has been rejected out of hand by Jeremy Hunt, the Health Secretary.

And this is the nub: instead of empty pleas for nurses to be more compassionate and caring, and for managers to be less pusillanimous and more efficient, we need honest attention paid to the elephant in the room: the conversion of the English NHS from a universal public service to a profit-driven healthcare market, with all that implies for the incentive structure of its staff. Perfect organisations, whether public or private, do not exist in the real world. Behind a great deal of commentary on the NHS lies an unacknowledged fantasy of a perfect service. In this fantasy the NHS’s 400,000 nurses (50,000 of whom are from overseas) should all be equable, cheerful, caring people, who are never depressed or have family problems and never get numbingly tired or become careless or simply indifferent. However understaffed they are, and for however many years their salaries remain frozen, their compassion and commitment should never flag. Similarly with managers. Regardless of what is happening to their hospital’s income, as private providers cherry-pick their more profitable services and 4% of their budget is annually siphoned off under the so-called Nicholson Challenge, they will somehow always ensure that staff levels remain adequate.

The reality is that the NHS has been broken up into a system of competing businesses (foundation trusts) with uneven endowments of capital, and variable levels of administrative skill and commercial acumen on the part of their managements. NHS nurses too have an average mix of competences and are working in hospitals at close to 100% capacity (the clinically recommended level is closer to 80%) while budgets are being relentlessly cut. The costs are being borne by both them and their patients. The mid-Staffordshire story is no more (and no less) than an acute result of this, the impact of impending competition transmitted  to NHS hospitals in the form of a desperate drive to meet the financial criteria for foundation trust status, under very poor leadership at every level. Hunt says there could be more Mid-Staffs. He is right. The contradictory demands his government is making on the NHS will produce them wherever the local mix of excessive debt and sufficiently poor management and other local faultlines makes hospitals unable to cope.

None of this should be taken as minimising the gravity of what happened at the Stafford Hospital, and may also have happened at some of the other NHS hospitals now being investigated – and has notoriously also happened to NHS patients being treated in some private hospitals, such as Winterbourne View. But what must strike anyone who attends any of the meetings taking place all over England as hospital services are closed, and other services are transferred to commercial providers, is that local people who take the trouble to find out what is going on have no difficulty seeing what the problem is. The impact of profit targets on care quality is no mystery to them, and the official line taken by NHS management who come to address these meetings, echoing that of ministers, is so clearly calculated to avoid acknowledging the problem that it is positively embarrassing, if not insulting.

Discussion of the Francis report will be a wasted opportunity if it doesn’t match the level of understanding of ordinary people who use the health service. The report should prompt a sustained effort on everyone’s part to look at the evidence and to think seriously of better alternatives to the present ideology-driven course. We could do worse than start by taking a closer look across the borders at what is happening in Scotland and Wales, which have declined to throw their health services into the market maelstrom. We will not find perfection there either, but we might find some thought-provoking differences and a useful starting point for a comparative and evidence-based public debate.