Compassion and cost-effectiveness can work together

“Compassion” was undoubtedly one of the healthcare buzzwords of 2013. A year of negative headlines, chief among them those arising from the scandal in Mid Staffordshire, spoke of a system in which production-line attitudes and procedure-driven philosophies have condemned the fundamental notion of humanity to shell shocked afterthought.

‘The box ticking, target heavy environments in which practitioners are frequently obliged to work are rarely mentioned when blame is being apportioned’

It’s perhaps revealing that the vast majority of discussions concerning compassion in the NHS continue to champion it as essential to the nursing profession while neglecting to contemplate its relevance anywhere else.

The near-automatic response to what has come to be known as “compassion depletion” is that the fault must rest with the nurse. The box ticking, target heavy environments in which practitioners are frequently obliged to work are rarely mentioned when blame is being apportioned.

Ascribing culpability

Ascribing culpability to a single group and contriving to encumber its members with sole responsibility for righting the wrong is easy. It’s also blinkered and thoroughly disingenuous.

The fact is that compassion should be utterly central to place, process and person. It should be a focus for not just those who work within the NHS but those who manage its services. It should be intrinsic to any healthcare system’s design, fostering surroundings in which patient and practitioner alike are encouraged to engage for shared benefit.

It’s a vital issue – one that’s illustrative of a wider need for an altogether more inclusive and outward-facing approach. We’re crying out for a move beyond the purely medical, for the discarding of the culture of the car factory bedevilling the NHS and for the simple realisation that healthcare practice can be a richer experience for all if there’s scope for originality, improvisation and, maybe most importantly, humanity.

We need only cast a despairing glance at the field of mental healthcare to grasp the urgency of the situation. The social side of mental health has never amounted to more than the sum of its parts, crippled by a self-defeating tendency to pigeon-hole rather than collate and the perverse prizing of fragmentation over integration. With meaningful progress and coherence lacking for years, neurological, pharmacological and individual psychological theories have maintained their crushing dominance. The basic idea that mental healthcare is about more than medicine remains all but ignored. Even the huge overlap with physical health continues to be overlooked.

The result? Some government ministers have judged community care a failure. Service users’ and carers’ trust in professional care has been badly damaged. Public scepticism about the effectiveness of mental health services has intensified. The remedial efforts now required are massive and will have to be undertaken, lest we forget, in a climate in which many of the organisations currently tasked with advancing mental healthcare are cutting services and staff to keep pace with harsh financial realities.

Ultimately, it boils down to a matter of both mindset and resource. It’s not unreasonable to expect compassion to flourish where pressure is diminished and for practitioners to find themselves less inclined to be cold, less disposed towards disinterest, if somehow granted more time to think, talk and empathise.

Mental health challenge

Interestingly, NHS England recently declared its intention to put mental health at the “core of virtually everything the NHS does”. In tandem, the newly appointed chair of the Parity of Esteem Board, Lord Victor Adebowale, has repeatedly shown a willingness to embrace less mainstream solutions to the challenges confronting mental healthcare and seems acutely aware of the enormous potential inherent in the participation of communities.

‘As non-professionals and communities take a step towards the frontline of primary care, so the traditional order can take a much needed step back’

This offers no mean promise, because what’s really needed is a full-blown paradigm shift towards non-professional and public means of augmenting wellbeing. And for this to happen we’ll have to at last abandon the long-held belief that treating people with health issues – both mental and physical – unavoidably demands an appointment with a health and social care professional.

To some this might sound like an epochal rejection of the NHS and other professional providers. It isn’t. Rather, it’s the basis for an essential and utilitarian deployment of the assets available to us. In short, genuine parity of esteem would be most effectively attained through much more forthright engagement with the informal care community.

We all recognise, after all, that a steady move from inpatient care to care in the community has been under way for several decades. As broadcaster Andrew Marr remarked last year in recounting the aftermath of his stroke, acknowledgment of the true scale of that move is now well overdue. The NHS isn’t comprised of around 1.3m staff: about 7m informal carers provide its near-invisible backbone.

Moreover, this isn’t, as we frequently hear, a “shadow workforce” that’s second to professional carers. It lies at the very hub of the health and social care of the nation, which is why there could be massive real-world benefit in policies that “officially” reposition it centre stage.

More interaction required

For this to happen, of course, more interaction between informal and statutory carers is absolutely crucial. Such engagement has be rooted in understanding and accountability and would need to include education and training opportunities, appropriate support and arrangements under which informal carers are entitled to respite and a national minimum of time off.

‘The future of the NHS itself might just hinge on our ability to make compassion and cost-effectiveness go hand in hand’

But this isn’t just about rescuing informal carers from the periphery and ensuring they’re able to cope as they come to constitute an ever greater element of our health and social care workforce. It’s also about relieving the frequently intolerable pressures that are heaped on those already ensconced at the accepted heart of the NHS. As non-professionals and communities take a step towards the frontline of primary care, so the traditional order can take a much needed step back.

This transformation is bound to be difficult. We should be under no illusions about that. Equally, though, there should be no doubt that current approaches are woefully unsustainable. With demographic, fiscal and policy timebombs ticking ever louder, the future of the NHS itself – and with it the fate of those who work within it and those for whom it cares – might just hinge on our ability to make compassion and cost-effectiveness go hand in hand.

Paul Crawford is a professor of health humanities at Nottingham University, the founder and director of the International Health Humanities Network and director of the Centre for Social Futures at the Institute of Mental Health