Why caregivers have stopped caring

A former nurse says that the mistreatment of patients at Mid-Staffs is a symptom of a bigger crisis of compassion.

Brid Hehir

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A couple of weeks ago, the long-awaited report into serious failings at an NHS institution, the Mid-Staffordshire Foundation Trust (Mid-Staffs), was finally published.

Compiled by Sir Robert Francis QC, the report comprised almost 2,000 pages and contained 290 recommendations, including a ban on gagging clauses, a duty of candour and a single sector-wide regulator. We are told that due to a lack of care at every level of Mid-Staffs, up to 1,200 more people died than might have been expected to between 2005 and 2008. In addition to the high mortality rate, patients there were also given incorrect medication, forced to drink water from flower vases, and ignored while lying in soiled and wet sheets. We are also told that many begged relatives not to leave them at the mercy of the staff. And no wonder. In one instance, a healthcare assistant is reported to have called a patient ‘a fat bastard’ when he asked for food.

Francis did not attribute blame to any one individual or organisation. Instead, his report identified a culture of fear prompted by cost-cutting exercises and the chasing of government-set targets as a major reason for the problems. This was compounded by a lack of care among nurses in particular, and staff in general.

Understandably, many were disappointed that care standards had fallen so low in a treasured institution. And many health professionals, especially nurses, are mortified that the duty of care patients are owed has been so callously disregarded.

Yet what happened at Mid-Staffs cannot be disentangled from today’s broader crisis of compassion. After all, it is generally accepted that Mid-Staffs is far from an isolated case – 20 other hospitals have already been named as providing sub-optimal care and having an unusually high death rate. Mid-Staffs was indicative of this widespread crisis of compassion.

A lack of compassion is clearly most evident in relation to the treatment of the elderly and those with learning disabilities. But it is not confined to these two categories of patient. Many patients in general experience a lack of care at the hands of putative caregivers when hospitalised or in receipt of other forms of health and social care. This is a new and worrying development.

Traditionally we, the caregivers, subscribed to values associated with our professions and expected in care settings. We were proud of our roles and respected for them. We knew what was expected of us based on our training, our peer group, and from the values widely held, even if frequently contested, in society. And although we provided very personal care we also learned how to retain a professional detachment, a necessary characteristic of caring practitioners.

Many of us belonged to professional bodies which upheld those values and expected us to maintain them. So we internalised these values and norms and held ourselves and others to account in practice. We become autonomous and moral caregivers.

We were dedicated to caring, often putting patients’ needs before our own, and as such we were performing a vocation (even if we were frequently taken for granted and had comparatively poor pay and conditions). We learned to be independent, moral agents. And crucially, although the care we provided was not then subject to measurement and target-setting, we knew intuitively what it was to provide good care. Likewise, we felt guilty when we couldn’t provide good care.

During the 1980s, things changed. As a consequence of society’s de-politicisation, the social world shrunk and fragmented. We became estranged from each other and focused our energies inward, resorting to individualistic as opposed to social ways of surviving. Consequently, we caregivers developed more of a relationship with management and the Department of Health than with our colleagues and neighbours. The unmediated influence of politicians, professionals, gurus and advisers grew dramatically. Health and social care professionals were as vulnerable to these changes as everybody else and our approach to care planning and delivery changed. Work became more demanding but less fulfilling. Whistleblowing (snitching) on colleagues was legally sanctioned and amotivation became the dominant trend. Unsurprisingly, time given to caring for patients was reduced. Some like the elderly, already devalued by society, were considered as health, economic and environmental burdens and therefore less deserving of care and support.

No amount of recommendations by Francis, the prime minister or the secretary of state for health can address this broader, societal problem. The NHS is failing, and failing badly. Focusing on particular aspects, such as the flaws of individual nurses and doctors, may appease some, but it will not address the deeper, underlying problem.

The much-discussed report recommendation, a ‘duty of candour’, will not help either. According to the Francis report, the duty of candour should become a statutory obligation on healthcare providers ‘who believe or suspect that treatment or care provided to a patient has caused death or serious injury to a patient’. If this is the case, the care provider has to ‘inform that patient or other duly authorised person as soon as is practicable of that fact and thereafter to provide such information and explanation as the patient reasonably may expect’.

This not only totally misunderstands the problem – it will compound it by encroaching on the fundamental condition necessary for any moral virtue: that an action is freely chosen. And this so-called duty of candour will also encourage distrust among caregivers. This has understandably raised a lot of concerns among practitioners who have learnt the hard way that external compulsion makes individuals less responsible for their actions rather than more responsible.

Francis also, patronisingly, said the necessary changes would only happen when NHS managers, clinicians and staff started to address the failings ‘rather than waiting to be told what to do from Whitehall, or by the top of the NHS’. But therein lies another problem – years of micro-management and interference have undermined managers’ autonomy, forcing them to be accountable to Whitehall and ignoring the people for whom they are meant to be responsible: patients and staff.

There is one positive that has emerged from this debacle: the top-down, target-driven culture remains deeply unpopular. Let’s hope those working in the caregiving professions develop this resistance to the damaging culture of the targets and top-down dictata. That might at least focus the discussion on the real problems besetting the NHS.

Brid Hehir is a former head of engagement and patient involvement and sessional nurse in the NHS in London.

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