Jeremy Hunt does not have an enviable job. Not only is he charged with putting into practice the radical NHS reforms that his predecessor steered tempestuously through Parliament (with scant support from the health professions), but now he has to respond to the fourth report into the horrific collapse of care at Mid Staffordshire NHS Trust in the last decade.
His proposals are fairly standard governmental responses – more regulation and legislation (including a legally-enforceable duty of candour on NHS institutions and professionals), some headline-grabbing proposals on nurse and healthcare assistant training, and some general lip service to creating a new, more compassionate NHS.
But Robert Francis’ report was far more wide ranging. He did not single out individual professionals or professions, or even a few institutions. His report’s 290 recommendations (surely too many and too in-depth to be taken seriously by politicians?) addressed pretty much every single institution and framework within the NHS and the health professions, and found them all wanting, if not actually complicit in the Mid Staffs scandal.
The government’s immediate response to the Francis Report was to appoint a new regulator / inspector for hospitals (to add to the two that already exist and which Francis suggested should be collapsed into one!). This week, they added a legal duty of candour – which, while a good idea in principle (especially outlawing the pernicious practice of NHS trusts slapping gagging orders on former employees and whistle-blowers) does raise concerns: in what way should we be candid and how can we be appropriately candid with potentially vulnerable and distressed patients and relatives? There is a fine line between candour and brutally insensitive truth-telling!
There are moves to bring in legislation to make individual managers and health professionals criminally liable in cases of poor care (which could easily lead to more defensive practice), and to bar managers and CEOs of failing trusts from being employed elsewhere in the NHS. And (yet another!) new rating system is being introduced to allow patients to assess how good their local hospital actually is (as a whole and department by department). So, when the Francis Report highlighted target culture and the push to qualify for ‘Foundation Trust’ status as two major causes for the failures at Mid Staffs, the government introduces another target for trusts to get hung up about achieving. Makes sense!
The other idea was to make all student nurses spend a year working as a care assistant in order to learn how to be compassionate and caring. It sounds commonsensical (a lot of student nurses and doctors do spend time working as care assistants before their training anyway), but whether it will make people more compassionate is open to question. Firstly, most of nurse training is about delivering basic care anyway, so this will merely add to what is already happening, and is in no way qualitatively different. Secondly, it depends where you work and with what kind of workplace culture – some of my experiences as a care assistant before and during my training were not conducive to learning compassionate care (I could tell horror stories of places I refused to work in again, but that is for another day!). And while registration and regulation of care assistants (another core proposal) sounds like a good idea, registration and regulation do not in themselves make one more caring. Being a degree nurse or a care assistant does not determine how caring you are – there are many other drivers behind what it takes to be truly compassionate.
At the heart of the recommendations in the Francis Report was not a call for more legislation, more regulation or cosmetic changes to training regimes to make health care more compassionate and caring. Instead, it called for a root and branch culture change in the NHS, and called for this to start from the bottom up, as well as for strong and visionary leadership.
I would go further. The health service that we have (like the government) is the one that we deserve. The NHS does not exist in a cultural vacuum – its values and culture are shaped by the cultural, social and political values of the wider society. If that society is so obsessed with individuality, youth, celebrity and material aspiration that it devalues the weak and the vulnerable, should we be surprised that this emerges in the institutions that care for such people? The need is not just for a change in NHS culture, but a change in our wider culture.
Tomorrow Christians will be celebrating the ultimate act of compassion – the God of heaven taking on human form to serve and teach fallen humanity, being cruelly put to death by the very people he came to save – but in that death, completing the very salvation he came to bring to us all. Laying aside all power, all rights and all privileges for the sake of others – that kind of cultural shift is one we so badly need in Britain today, and we could do no better than to look again to Jesus as a nation.