TUCKED away deep within
the Government's 82-page response to the inquiry into the
Staffordshire hospital scandal, unnoticed and unreported, was a
section entitled "The Emotional Labour of Care".
It appeared out of place
in a report dedicated to finding answers to one of the most brutal
and shameful episodes in the history of the health service.
Yet there it was, a
challenge to journalists such as me, focused as we were on asking
why hospital staff appeared to have lost the ability to care for
the frail and the vulnerable.
"The Emotional Labour of
Care" was an acknowledgement, albeit all too brief, of the
emotional demands placed on doctors, nurses, and health-care
assistants, assailed hour by hour, day after day, by human beings
in their greatest hour of need.
The term "burn-out" was
absent; instead, mandarins at the Department of Health told NHS
managers that: "Teams need to be given time and space to reflect on
the challenging and emotional impact of health and care work."
The report highlighted
the part played by what are known as "Schwartz Rounds" in
hospitals, and at the Royal Free London NHS Foundation Trust in
particular, where they have taken place each month since October
2009. It is a simple concept: clinical and non-clinical staff from
all backgrounds and levels meet for an hour over breakfast or
lunch, to talk about the impact that their work has on their
feelings and emotions.
It is not about solving
problems, but a time for reflection, and a safe place to voice
feelings that are not often shared: frustration, anger, guilt,
sadness, joy, gratitude, and pride.
Joanna Goodrich, from the
King's Fund health think-tank, said: "Sitting in on Rounds all over
the country, I have been moved, time and again, by the commitment
of staff, and humbled by their stories of how they have gone the
extra mile for their patients, and seen what it has cost them."
The eastern-region
director of the Royal College of Nursing, Karen Webb, would
probably agree. As the Health Secretary, Jeremy Hunt, prepared to
deliver his response, she tweeted: "As a nurse teacher, ward
sister, and unit manager I only ever came across one
uncompassionate (sic) student nurse for thousands. And the
student was removed."
HOW do we square these
sentiments with the general picture that emerged in the Francis
report into the Mid Staffordshire NHS Foundation Trust, and myriad
horror stories about failings in care in other hospitals that
followed the report's publication in February? Among the senior
executives whose job it is to run the NHS, there is deep concern at
the loss of public confidence in a health service that has been an
object of national pride since it was formed in 1948.
Until recently, they had
found comfort in patient surveys that routinely found a high level
of satisfaction among the majority of patients, who appeared immune
to earlier alarms, such as the Bristol heart scandal in the early
1990s, the Alder Hey organs scandal, and the major outbreak of
Clostridium difficile, which killed 90 patients at
Maidstone and Tunbridge Wells between 2004 and 2006.
But with Mid
Staffordshire there appears to have been a seismic shift in
perceptions. The reputation of nurses, in particular, has suffered
immeasurably: a generation ago they were popularly known as
"angels", and families were willing to join rallies in support of
their demands for better pay; today, they are viewed with
suspicion.
RANK-and-file NHS staff
have been deeply affected by the Francis report. Many do not
recognise the health service that the chairman, Robert Francis QC,
describes, but know that it is futile to speak out in the face of
such devastating evidence. They feel let down by NHS leaders, from
the Department of Health through to the Royal Colleges, for being
too willing to buy in to the "lacking in compassion" agenda.
Indeed, on the morning
that Mr Hunt delivered his response to the Francis report,
newspapers - my own included - reported that aspiring nurses would
be expected to spend one year as health-care assistants, washing
and feeding hospital patients, to test their commitment to caring
for frail and vulnerable patients before beginning their training
in earnest.
The proposal was
well-received, even though it appeared to overlook the fact that
all student nurses already split their time between the classroom
and hospital wards; and many, if not all, work closely with
patients.
This is what the Liberal
Democrat peer Lord Willis of Knaresborough had to say about young
nurses, when he presented his report into the future of nursing
training and education last year: "We have been both humbled and
excited by the enormous dedication, intellect, compassion, and
altruism that shone through the many submissions and
presentations.
"Indeed, the message was
the same wherever the commission took evidence throughout the UK -
the desire to provide tomorrow's nurses with the very best
opportunities to offer the very best care. Nowhere was this more
apparent than when we met nursing students, whose ability to
articulate their ambitions, and their desire to nurse, was
awe-inspiring."
Lord Willis concluded
that there was no evidence that having degree-standard nurses had
had any impact on their ability to demonstrate care and
compassion.
Of course, the NHS is not
just about nurses: it is also about GPs, consultants, hospital
porters, clerical staff, and ambulance drivers. The health service
employs an extraordinarily diverse workforce of 1.4 million people,
and its values and frailties must be representative of the country
as a whole. If there really is a crisis of compassion in the NHS,
it must reflect poorly on the nation that it serves.
It is still the case that
many doctors and nurses come from families with a tradition of
public service. Yet if it is true that they have been inspired by a
parent who was a GP, a surgeon, or a paediatrician, the health
service they work for is a very different organisation, and the
challenges they face are complex.
In a typical hospital, on
a typical day, about 40 per cent of the patients are likely to be
elderly and suffering from dementia. They cannot feed themselves,
and must be bathed and changed. Their skin is like tissue and their
bones are like porcelain; so that even the most basic care requires
exceptional skill.
Often, patients show
signs of long-term neglect and malnutrition when they are brought
to hospital, and, while their broken hips may heal, their minds
will not.
A single nurse or
health-care assistant may be expected to care for a dozen elderly
patients in this way. The work is intense, back-breaking,
relentless, and, let's be honest, demoralising. Many patients are
kept in hospital beyond their clinical requirements, because there
is nowhere else for them to go. And when they do leave, their place
is quickly taken by another elderly patient with the same complex
needs.
A GP may have just ten or
15 minutes to spend with a patient whom he or she may be meeting
for the first time, and may never see again. There is no
relationship with the patient, other than the notes put in front of
the GP.
With luck, the symptoms
may be obvious, and the diagnosis simple; the chances are, however,
that the symptoms will be generalised and unclear, and the patient
may have difficulty explaining how he or she feels. The clock is
ticking, the queue outside the door getting longer. A prescription
is written, or a referral made. The appointment is over, but both
patient and doctor know that neither has been served well.
And while so much of the
focus of compassionate care is on the treatment of elderly
patients, it must not be forgotten that Britain is in the midst of
a prolonged baby boom. This is putting a strain on midwifery
services and paediatric care.
Children born today are
more likely to have complex health needs, and to come from a home
that is culturally and ethnically diverse, often with a single
parent. Families are more likely to move and to break up, making it
difficult for health and social services to provide appropriate and
consistent treatment.
SOCIETY has changed, and
the health service has not kept up. It is still mostly organised
around hospitals that were designed and built to care for illnesses
that no longer trouble us, or accidents in factories that have long
since closed.
Today's NHS is
preoccupied with the problems of old age, and long-term conditions
such as diabetes, heart disease, and cancer; but its structures
have not evolved to help doctors and nurses provide the treatment
that patients require. The system is set up to fail, and its
frontline staff are being held responsible. Because, of course, the
way the system fails is that overburdened or under-supported staff
become demoralised; they cut corners and cover each others' backs,
creating an environment in which patients suffer neglect or
mistreatment.
That is not to excuse the
appalling events at Stafford Hospital. Individual clinicians
responsible for the abuse of patients should obviously be held to
account.
But it is too simplistic
to accuse today's health workers of no longer caring for their
patients. Even the fabled matron of old would struggle to bring
order to this dysfunctional service.
Certainly, the NHS needs
to put patients back at the centre of everything it does. But it
also must pay far more attention to that Emotional Labour of
Care.
Martin Barrow is health editor of The
Times.