Care: a higher calling?

Source: Paul Bateman

Everyone, it seems, has a view on care failings in our health services.

The other week I was in a taxi on the way to a conference about care as the headline news from the Francis report into failures of care in the Mid Staffordshire NHS Foundation Trust came across on the car radio. The taxi driver told me that we should “bring back Matron” (he had Hattie Jacques in mind).

At the conference we heard from a mother who fought to have her son’s complex care needs met. Care providers, she said, needed to listen more to families. Conference workshop leaders demonstrated the potential of simulation activities, the arts and critical thinking techniques to promote caring attitudes and behaviours in student health professionals.

The torrent of media coverage of Robert Francis QC’s report is now beginning to subside - but not before we’ve heard some people pin the blame for the failings in healthcare on universities for turning out nurses who are “too posh to wash” and producing professionals with degrees but without compassion. I am reminded of that old canard: “I’d rather have a competent bastard do my surgery than a bumbling humanist.”

The first Francis report, published in 2010, detailed the shocking distress and deaths of patients, the anguish of families and the prioritisation of organisational values over the quality of care and a culture of fear and bullying. The second casts its investigative net wider, setting out to examine the role of external organisations and agencies, asking why action was not taken sooner. It builds on the evidence given to the first inquiry, identifies lessons learned and makes 290 recommendations. The unravelling of the roles played by different agencies and senior hospital staff is revealing. Never in UK hospitals, it seems, has so much suffering by so many been endured and ignored by so many for so long.

What is particularly commendable about the Francis report is its quest for understanding and acknowledgement of the complexity of care - it does not reduce this to a narrow range of explanations and recommendations. As the report states, “It was not a single rogue healthcare professional who delivered poor care in Stafford, or a single manager who ignored patient safety, who caused the extensive failure which has been identified. There was a combination of factors, of deficiencies throughout the complexity that is the NHS, which produced the vacuum in which the running of the Trust was allowed to deteriorate.”

In order to negotiate the complexity of the NHS, the health professions, in my view, have never needed universities more. Of course we need health professionals who are both technically and ethically competent: those who can distinguish between a myocardial infarction and myasthenia gravis; between the symptoms of a urinary tract infection and dementia; and between psychosis and sclerosis. We need, too, those who can think critically about the quality of evidence and the range of values that currently compete for attention in a raft of codes, visions, charters and declarations.

This year marks the 20th anniversary of the journal Nursing Ethics and also of Joan Tronto’s landmark book Moral Boundaries: A Political Argument for an Ethic of Care. Research in nursing ethics informs us about nurses’ experience of moral distress, distress that is escalated by unethical organisational cultures and that contributes to nurses leaving the profession. The Francis report prompts us to engage with the darker side of human nature: the unmet needs, discussed by Tronto, that may contribute to negative attitudes or even rage towards care-receivers, the primitive defence mechanisms and industrialisation of healthcare that may drive practitioners towards brutality, coercion, perversity and disengagement (as discussed by John Ballatt and Penelope Campling in the book Intelligent Kindness: Reforming the Culture of Healthcare).

Tronto reminds us in Moral Boundaries of the need also to get political about care: “To recognise the value of care calls into question the structure of values in our society. Care is not a parochial concern of women, a type of secondary moral question or the work of the least well off in society. Care is a central concern of human life. It is time that we began to change our political and social institutions to reflect this truth.”

A key theme of the Francis report relates to the “culture of caring”. We need to engage with research that enables us to understand the complex mix of factors (individual, organisational and political) that promote or undermine caring cultures. Care is not a minority interest but rather an ethical practice that needs to be understood from historical, philosophical and empirical research perspectives. Care is not the preserve of “bumbling humanists” but rather a complex activity requiring the attention of the best minds and the most committed. It requires innovative pedagogic approaches such as those described at the conference and university support for students who report care concerns.

Universities are best placed to take the lead in response to the Francis report, creating space to bring all stakeholders and academics together, to share what we know about caring cultures and agree what we need to know and do to sustain caring practices.