Another week, another scandal, another institution on the ropes. Amidst the repeated abuse, everyone is wondering: what happened to the NHS?
What happened to compassion? Compassion for patients and for how we treat each other when things go wrong.
What is compassion, anyway?
A teaching hospital recently asked its staff to list what they meant by compassion. The commonest response by far was ‘being able to put yourself in the other person’s shoes’ - and empathy is, indeed, a good place to start the search for compassion.
But empathy is easy when faced with tragedy or pathos: the dying child or the suddenly bereaved. What about when you are cleaning up the third patient this morning to soil themselves? Then the barrier to empathy is what we feel: our own anger, disgust or frustration get in the way.
Compassion is far more than putting yourself in the other’s shoes. It is, crucially, the awareness of one’s own reactions. About leveraging the sudden thought “what must it feel like to receive care from someone who feels as fed up as I do right now?” into better care.
Here’s a story of compassionate care:
My stay on ward B2 was very good, but it was not always easy going. I had lows as well as highs.
“I kicked and hit staff in frustration, but they understood and over time I really [came to] love them all, especially my staff nurse JD, because she felt hurt by my behavior and that was the wakeup call I needed. The staff cared about me so much and my recovery. It helped me to recover; [it has] made me a better and stronger person. Thank you. [Patient Opinion 87869]
This story reveals some core elements for compassion: the ability to be alongside patients, to see beyond the present to the wider goal, to understand the deeper pain beyond the present behavior, to show acceptance whilst also setting limits. And being able to do all this with warmth and caring.
We know what it doesn’t look like
But perhaps it’s easier to see the negative outline of compassion, to recognise its cruel absence. Here is a story where staff are running on empty with no more to give:
My mother is left needing the toilet for hours and ends up wetting herself and they don't wipe her clean or change her sheet. This is not a one off, it's a daily thing.
“…Every day I have to take her clothes home to be washed due to the fact that they are wet with urine, from being left on the bed pan for hours. What a despicable thing. This is not a third world country. The staff I have met do not seem to be doing their jobs properly. It's so sad and upsetting. How can she be left in this state and people don't bat an eyelid?... Shame on the NHS. [Patient Opinion 84079]
Reading this, we see that compassion is more than just the presence of the empathy and insight. When compassion is absent, then we feel shame.
What happened at Stafford General Hospital and at Winterbourne View diminished us all. Acting without compassion corrupts the economy of care that lies at the heart of the NHS.
The response of the old regime
The old regime’s response to such failures is to place another 290 demands on the system, to criminalise ‘compassion failures’, and appoint a chief inspector.
But as our understanding of the neuroscience of compassion grows (for example through the work of Paul Gilbert we can begin to see why such ‘solutions’ are actively dysfunctional.
Compassion is always internally motivated and depends on staff’s sense of autonomy, meaning and flow (for more about the difference between internal and external motivation see: ‘Drive: the surprising truth about what motivates you’ by Dan Pink).
Trying to motivate it externally through targets, QoF points, or any other incentive is like offering to pay your mother-in-law for the dinner she has just cooked you. Wrong incentive, wrong situation.
The urge to audit compassion is equally misplaced: witness Alan Johnson’s suggestion when health secreatary that we should count the number of times nurses smile!
The neuroscience also says we tend to mirror each other’s behavior. Mirroring spreads behavior, good or bad, so over the last 20 years we have learnt to mirror the corporate behavior valued by the old regime: compassion became harder to practice, bullying a bit easier.
To reverse this and rebuild compassion we must ‘do unto others as you would have them do unto others’. So if we want clinicians to deal with the real and metaphorical shit on the front line, then they themselves must be treated with compassion.
Compassion begats compassion
So compassion tends to beget more compassion. What else? Well, behavior habituates around routines, so let’s find clinical routines that demand compassion for their completion.
Always dictating letters with the patient present compels a degree of sensitivity from clinicians, as patronising words fall away and words like ‘cancer’ or ‘personality disorder’ have to be explained.
And perhaps every doctor could go and greet their next patient in the waiting room and, if running more than ten minutes late, apologise for the delay so everyone waiting can hear.
When I first started doing this as a GP it had a profound effect on both me and the waiting room. No bad thing to have to do public penance several times an hour.
Finally, there is good evidence that humans are very quick at deciding who they want to trust so why don’t we put up 60 second videos of every clinician on NHS websites.
“I’m Paul Hodgkin, one of the GPs here, and I do a lot of work with people with mental health problems and with men’s health. I also see a lot of children but I tend to do less women’s health.” Seeing the videos and actively choosing begins to build trust before you even meet.
Of course, all these suggestions will cause clinicians to draw breath. That’s because the last and most important component of compassion is courage.
Apologising publicly five times every clinic is hard. Dictating letters with the patients means you have to take more care (in both senses of the word). Making a video of yourself makes you feel vulnerable.
But that is the point, isn’t it? Compassion is about taking the richer, more human, more rewarding, more challenging route. These routines, which I forced on myself as a GP, helped me to escape the easy, mundane, lazier ways that I tended to fall into.
To transcend the old regime we need organisations where integrity and compassion ‘run along the bottom of the valley’. At present, we have the reverse of this.
Acting with compassion is a struggle, often a heroic one, that involves repeatedly climbing to the top of mountains, negotiating narrow paths where only the most sure-footed feel comfortable, where the gravitational pull of ‘getting stuff done’ always threatens to bring us down.
The new regime, the one without more Francis Inquiries, will come from organisations that have used the burgeoning neuroscience of compassion to inform every relationship in health care.
Paul Hodgkin is chief executive of Patient Opinion, a website on which patients, service users, carers and staff can share their stories of care across the UK. Patient Opinion is a not-for-profit social enterprise based in Sheffield.
Until 2011 Paul also worked as a GP and has published widely including in the BMJ, British Journal of General Practice and the Guardian and the Independent. Follow him on Twitter @paulhodgkin.
Thank you for this great feedback.Paul Hodgkin 23 weeks ago
It is wonderful that you found the column helpful. And there are some great points.
The most hopeful thing is that compassion is moving from being a nice, ethical thing that we all knew was right in our hearts but which could easily be discounted in the press of being busy.
The building neuroscience is saying that compassion is also the pragmatic, cost-effective, evidence-based way to give the best care.
Of course none of us have internalised this much yet, and still less have systems been built to support this new understanding. But as these forces build then compassionate care built on great relationships will come to be seen as essential.
The results of my compassion self-assessmentimPatient4change 23 weeks ago
Another wonderful thought provoking piece Paul that made me reflect on how well I demonstrate compassion in my own role.
I think that the CQC would need to conduct a follow-up review with me as I often struggle to:
1. Have the courage to openly admit that there are many things that I don't understand in Health Informatics policy and its implementation in practice
2. Ask for and act on feedback from the people that I provide services for and from my peers
I always thought compassion was a soft issue for EHI to deal with. And yet in practice it's actually the hardest element to deliver in any Informatics service or project.
Excellent PieceJessieCunnett 24 weeks ago
Thanks Paul. A really useful article that puts things very clearly. It seems to me that many of the inquiries into health and social care failure have found that too much focus on systems and processes mean that people and compassion get left at the door whilst time energy and money is spent on feeding the beast.