Being the secretary of state for health must be both a wonderful and a frustrating job. You have the glorious NHS to look after. Every day you are witness to the audacious claim that we are good enough to provide, for each person, as decent and healthy a life as science can, regardless of individual wealth. You see both acts of heroism and quiet, attentive kindness: from the paramedic saving lives, to the nurse in a dementia room helping someone remember, in comfort.
But then there are the frustrations. Getting things changed in the NHS must be difficult. Planning and providing care in the NHS is not contained within one body: it is complex and multifaceted.
So, how far can national policy seek to influence the way the system operates between health organisations while also moderate what happens within organisations? It’s all very well having a vision of the care we want to see for our relatives, to have a view of what an individual episode of care should feel like at a human level. But how can we build a system which delivers this all the time, every time, on an industrial scale? If you want to see an NHS that treats people really well, not just makes them better, but, with kindness, makes them feel better – how can that be done?
In their 2011 book, Intelligent Kindness, John Ballatt and Penelope Campling unpick the forces that might cause health care professionals to treat their patients not only poorly, but unkindly. They focus on the quality of relationships between individuals saying:
“Kindness challenges us to be self-aware and takes us to the heart of relationships where things can be messy, difficult and painful .Kindness is natural – we see it all around us. It drives people to pay attention to each other.”
So what gets in the way of kindness? In the first place, the work of health professionals is extremely difficult. It is both technically complex and emotionally wrought given the pressure from emergencies and risks if mistakes are made. Also, there is the physical distress that can come from the practical difficulties of lifting, cleaning, and otherwise manipulating human beings, and human material. It’s a common understanding that professionals can sometimes cope often by creating distance, by not engaging, with the people they are treating.
So, the challenge is to influence what goes on inside teams within the NHS to, provide a structure and culture where kindness can be supported and allowed to thrive.
Ballatt and Campling also find that there are structural reasons that can work against kindness. Fragmentation in health services disassociates health staff from seeing the whole person. In other words, where a team of people providing a service are narrowly focused on one particular task, they are unable to look beyond the job in hand to the individual’s broader health. Not only this, but tension might arise between different parts of the health service, as one team can perceive patients to have been ‘dumped’ on them by others – though all are equally under pressure.
There are financial barriers to kindness too. Individual organisations that provide healthcare services have to balance their desire to provide excellent healthcare with their need to remain financially sustainable. Demographic change is increasing demand for hospital services – there has been a 37 per cent increase in the number of emergency admissions in the past decade alone – yet we could save money, and provide a better service by preventing hospital admission. However, in a system where hospital income is linked to activity there is not much financial incentive for hospitals to engineer this though.
Hospital staff might want to prevent admissions, knowing that supportive care in the home is the kindest way to treat patients, but if in the end this means less income for their service (when all services are fighting for income in a time of austerity), this will create conflict between human instincts and system incentives. And why worry about growing apples that fall in someone else’s garden? Why battle to make a change when another organisation will reap the benefits, by making more money or greater savings, leaving your service underfunded.
Now, despite these incentives, many staff do worry about these problems. They are not interested in people being or staying in hospital unnecessarily. But if their good intentions are frustrated by the financial incentives, this is a recipe for kind, caring people to feel constrained and frustrated. Wouldn’t we be better going with the grain of what doctors and nurses and patients feel is right, and seeking to address these reverse incentives?
The question is, what kind of mechanism could do this? Clearly the public finances will remain extremely tight over the medium term, and this makes transition hard. The trick for the NHS is to develop a funding system which releases the innate motivation of frontline clinicians to care. To be kind.
If we want to genuinely support kindness – and the caring, determined professional NHS staff – we have to make our politics and our policy work to support this, and not against it.