Who cares? The crisis of kindness in the NHS

Created through the 2008 Health and Social Care Act, the UK’s Care Quality Commission (CQC) is responsible for inspecting and regulating the provision of health and social services. In short, as its title suggests, it’s meant to ensure that the care on offer is of the highest quality. That, at least, is the idea.

Since the CQC became operational in 2009, however, the reality has been somewhat different. In fact, under the auspices of the CQC, the caring professions have stumbled from one scandal to another. In 2011, for instance, an undercover BBC Panorama team filmed carers shouting at, and slapping, elderly patients at the Winterbourne View care home. Earlier this year, the Francis Report into the high mortality rate at Mid-Staffordshire NHS Foundation Trust hospitals reported that 200 to 300 deaths between 2005 and 2009 may have been caused by negligence. The report also uncovered appalling instances of neglect, from patients drinking water from vases to being left to lie in their own waste.

And now, following recent revelations that top-level CQC staff attempted to suppress the results of an investigation into the deaths of mothers and babies at Furness General Hospital, the CQC finds itself at the centre of a scandal.

Yet, the response to each scandal, even when it involves the regulator itself, has been uniform: a repeated call for more regulation and transparency in the healthcare sector.

Here are just a few of the latest proposals: establishing an Ofsted-style inspectorate for the medical profession; the publication of consultants’ success/failure rates on the NHS website; and the introduction of ‘new’ headboards on patients’ beds specifying a named nurse responsible for the particular patient and what the patient would like to be called.

The problem with such proposals is that they ignore the real problem here: the crisis of care itself.

If anything, the proposed ever-tighter regulation of those doing the caring – nurses, doctors, and so on – is likely to exacerbate this crisis of care. That’s because the act of caring depends upon the moral autonomy of the individual carer; it cannot be externally coerced or regulated into being. Caring for someone is not something that can be manufactured through a tick list of specific acts: a designated nurse’s name on board, check; call patient by stated name, check; patient fed within allotted time, check… and bingo, we have ‘good care’.

Advocates of regulatory ‘solutions’ fail to understand that if we want healthcare truly to be more compassionate and caring, then we need to assume that care is something of which everyone is capable. After all, at some point in our lives, we all need to receive and give care to someone, be they a baby or an elderly parent.

In liberal professions like health and social care, there are two components of care work. One is cognitive: a certain amount of knowledge is required to perform the work successfully. But the other component is practical: the care worker must exercise their own judgement when looking after particular patients in particular contexts.

Each act of care is meaningful, therefore, within an individual carer-patient relationship. An institution can make conditions favourable for such relationships to develop, but it cannot actually create care by decree. Good care work is not defined by being able to perform someone else’s idea of what ‘quality care’ looks like; it develops when an individual is able to conduct a relationship guided by a self-directed duty of care towards particular individuals.

For instance, in conditions where a person’s scope for acting and living their lives is drastically reduced due to age and/or illness, small acts, gestures and objects become all the more meaningful. An elderly lady fretting over a misplaced wedding ring may well not be concerned about the ring per se; rather, she might be upset because the ring symbolises over 50 years of her life. If a nurse or carer, eager to fulfil point four of a good-care action plan, responds with a polite but curt ‘never mind, it’ll turn up – you’ve got to eat lunch now’, is that really caring? Or would it be more caring to take time to acknowledge her worries and give her the option of spending time looking for the ring now and having lunch later? And if the nurse or worker failed to ensure the patient’s lunch was eaten within the allotted time, would her line manager mark the care worker down, or would there be an understanding that in this situation, with this patient, the right judgement call had been made?

Ultimately, care is underpinned by freedom, not regulation. Our own experiences as givers and receivers of care affirm the truth of philosopher Raymond Tallis’s aphorism: ‘A checkbox ticked is a kindness forgone.’

Alka Sehgal Cuthbert is reading for a PhD in the philosophy of education. She is a member of the Institute of Ideas Education Forum.