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Have the angels lost their wings?

19 April 2013

NHS staff are accused of acting without compassion. The story is more complex, says Martin Barrow

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.

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