It will take time to digest all the 290 recommendations of the Francis report on the failings at Stafford Hospital. Failings at the hospital were root and branch, from top to bottom of the NHS. For me, however, one recommendation stands out and it isn't one of the more legalistic or organisational ones. It is simply that there needs to be an increased focus on compassion in the recruitment, training and education of nurses, including an aptitude test for new recruits and regular checks of competence as is being rolled out for doctors.
The imperative to put patients needs back at the heart of decision making and care in the NHS was highlighted last year by Ann Clwyd's experience of the shameful way she and her dying husband were treated in hospital. It should inform us that something awful has gone badly wrong with health care provision.
The report is right to point to target driven decision making as being one source of the problem. It drives management to consider patients not as persons with individual needs but as statistics. But decisions have impact on persons and not an averaged statistic. I am an advocate of person-centred ethics because I believe that is the only way to build a framework for person-centred care.
This is not mere emotion; it is simply a realisation that people have hopes, fears, anxieties, loves, hates, desires; that the impact of decisions on patients is contextual and circumstantial. They have families and loved ones who care too, and they have particular needs that arise as a result. Yet, these are increasingly lost in the dry calculus of the utilitarian ethics of health care policy. Even the consideration of duty has become driven by calculation rather than imperative (Kant would turn in his grave). Ends become a justification for means regardless of the true meaning of outcome for those who matter, the patient or those in care. Patients become numbers.
We are of course interested in numbers. We tend to set targets by them. Quality is more difficult to measure than quantity. Well-being more difficult than wealth. But we should always look beyond the bare statistic and consider how a policy decision impacts real people and not an average. I have no real idea what an 'average person' looks like. I doubt if an 'average person' exists. You might be 'average' in some calculations but not in many others. The impact of being 'average' in any particular score most often depends on circumstances that are not average; housing, family, relationships, work, stress, but also personality.
A health care system simply charged with obedience to numbers is one that is more likely than not to ignore the individual needs of patients. If patients become a ward statistic to turn around as quickly as possible then nurses will have less time for real patient care. No time for emotional engagement. No time to ensure a continuity of care or of carers; care becomes impersonal; a monetised ingredient. And certainly poor pay, inadequate or non-existent training and low esteem in the privatised care system has produced a cocktail for potential and actual abuse and harm where the needs of the patient take second place in the profit margin.
None of this is to suggest that the majority of nurses and doctors enter their professions with any other than a caring ethos. Many nurses have expressed concern at the quality of care at their hospitals. Cuts in budgets and reorganisation are creating further problems at the font line of NHS care.
This is the warning given by the NHS Confederation in a report published last month. The NHS Confederation, a body representing all organisations that commission and provide NHS services, is worried that the current NHS reforms, by making the system more complicated, will increase still further the administrative burden on NHS front line staff.
Government ministers have argued that the £20 billion cut in the NHS budget would not affect front line services. Yet, between May 2010 and September 2012 whilst the number of managers was reduced by 18 per cent and the number of clerical and administrative staff declined by 10 per cent, a consequence has been an increased administrative load on doctors and nurses. If the administrative burden does not also fall, the report warns, there is a risk that front line staff will be diverted to form filling.
Reorganisation has compounded the problem. Commissioning is becoming more complex; for example, child health services are now commissioned by eight different parts of the system, including local authorities. Providers and commissioners will need to coordinate and build working relationships with more organisations than previously, which inevitably takes time and increases the administrative load. The number of commissioning organisations is also increasing; 211 clinical commissioning groups (CCGs) are set to replace 152 primary care trusts. There will also be a greater number of local bodies involved in providing health care, with health and wellbeing boards, local Healthwatch and more CCGs than there were primary care trusts.
There is already evidence that cuts in spending have driven some hospitals to dangerously low levels of staff, putting patient lives at risk. The Royal College of Nursing has identified 61,276 NHS posts which have either disappeared or are set to go as a result of cuts in spending and warn that the NHS is "sleep walking into a crisis." Nurses say that they "do not have enough staff to deliver good quality care. Demand for services is continuing to rise, however staffing levels are being slashed."
It is time the government abandoned the pretence that cuts in NHS budgets can be managed without impacting patient care. It is putting patients at risk. But it is also time we put the focus on quality and care, the patient experience, back at the forefront of NHS objectives.