Why do we struggle with ‘caring’ in the NHS?

I think about this complex topic a lot because I frequently hear from, or meet with, staff and public who raise concerns about care quality. Francis links it to culture, but it remains difficult to understand ‘why’ we have a problem. Until we do understand this, solutions will continue to elude us.

We know that most hospital staff are competent and compassionate, and we know that staff who feel valued and supported will deliver good care. We also know from staff surveys that morale is low and that somehow, the system all too often acts to demotivate and disengage the staff who work within it.

Sometimes, the impact of this demoralisation overcomes individual professionalism, and care problems occur. Doctors, nurses, and managers can all reach this ‘tipping point’, and we need to think through why it occurs.

I suggest there are three overlapping, contributory factors…

The rise of managerialism

The introduction of managers into the NHS was never effectively sold to either staff or public. We know that ‘nature abhors a vacuum’ so, without a convincing narrative, front line culture filled the gap with reasons that were not always positive. Consequently, managers have always struggled to establish their legitimacy. Indeed, years later politicians still see the ‘reduce bureaucracy’ line at election time as a vote winner.

Targets and performance culture

Targets were introduced to address failings in access times, trolley waits outside A&E departments, and rising healthcare-acquired infections. All were priorities at the time but a narrative was again lacking which meant that, even today, most front line staff believe the 4hr target to be about politics rather than patient care. This created a ‘values divide’ between staff caring for patients, and managers tasked with delivering the target, that persists to this day.

Matters worsened as central performance management strengthened. The 4hr target in particular came to be seen as a measure of ‘good governance’ and therefore had to be delivered at all costs. Boards were now driven by different priorities than front line staff, with targets dominating however much they talked quality. Downward pressure meant that sometimes measures were implemented that ‘hit the target and missed the point’, further diminishing the authority of local management.

Growing pressure on hospitals

Hospitals have got hugely busier over the years, and the work is more demanding and more relentless. With shorter lengths of stay, a higher proportion of patients are very ill, requiring more intensive care and support. The communal day rooms of my junior doctor days, where most patients ate meals at table together, have gone because few patients are now well enough to use them.

While designed to provide acute care, hospitals have become the default option for the entire system. All other providers close at times, while hospitals remain open, even when full. Consequently, the elderly in particular are admitted because the support needed to allow them to cope at home is not available quickly enough – acute illness is often not the real reason.