Smuggling compassion into care: Is the NHS destined for system D?

The National Health Service (NHS) in the United Kingdom holds a special place in the hearts of the British public, and is considered to be a beacon of safe and good practice, offering free care at the point of need, based on a comprehensive system of taxes, and costing less per head than health-care systems in other countries. Indeed, the NHS has been so successful as an international brand (Davis et al., 2015) that other countries, in and outwith the Commonwealth, have adopted many of its values, behaviours and practices. It has even had an impact by the export of British legislation when it comes to mental health law (although in many countries legislation is still absent or not always compatible with human rights instruments). However, our export of the NHS brand, practices and values is now in question.

The reality is that Nye Bevan’s original vision of an NHS that would eradicate illness has not been realised. Greater demands on acute and chronic care, a growing population of older people living longer with disabilities, and societal and economic changes all add up to a system under strain. The costs of services have risen because of a larger workforce of highly trained, and therefore expensive, professionals and costly new medications and new technologies. The National Institute of Clinical Excellence seeks to provide cost-effectiveness analyses that sanction the use of some and not other services. The purpose of this justifiable rationing of technologies and interventions is to give value to society and to balance this with individual patient gains. Can we afford a state-supported system of comprehensive health care? The strain on services is unrelenting as we seek more cost-effective interventions with less overall spend, while needing to protect quality and safety – a process that is also insidiously undermining professionalism and motivation, which are arguably our most important commodities and agencies of patient care.

At the same time, the nature of professionalism is changing: it increasingly involves greater accountability through regulation, life-long learning, revalidation and a contract culture of commissioner-providers splits, in which medical practice has become a routine application of known technologies – a job, rather than a life-long vocation with self-governance and altruistic principles as a prevailing ethos (Dixon-Woods et al., 2011). Consequently, there is less attention to the art and science of psychiatry, not helped by the separation of university and clinical organisations so that most clinicians do not research or teach – in the conventional sense – and end up providing continuous care bereft of the reflection and quality improvement through audit and scholarship that is supposed to be central to, and distinguishing of, the expertise that doctors offer. This erosion of autonomy and expertise by the maverick use of research data, was recently evident in the United Kingdom with the politicisation of the NHS, as the government claimed that weekend deaths were excessive and implied that this was caused by absent doctors. The real ambition was to reduce the weekend pay costs of doctors, in pursuit of which the government imposed a new contract resulting in subsequent dispute and strike actions. We know that there are not excessive deaths at weekends in psychiatric hospitals; nonetheless, given the national conditions for junior doctors, psychiatric trainees will also face the new terms and conditions (Patel et al., 2016). These events have led to the demoralisation of staff, loss of trust and the cancellation of many routine NHS care episodes. The medical professions are now expected to be cheaper, quicker, less trained and less specialist – just good enough rather than the most experienced or most skilled. What does this mean for patient care, as quality cannot be sustained?

Advances in neuroscience and genomics offer hope for more effective treatment of those who currently do not reach their aspirations for recovery. Alongside these advances, psychiatrists and mental health practitioners across all disciplinary divides have seen enormous improvements in the quality and scientific basis of care over the last few decades, especially in the organisation and delivery of mental health care around patients’ priorities. For example, in the United Kingdom, the National Service Framework was a revolutionary consolidator of deinstitutionalisation and closure of the large asylums by scaling up and skilling up community mental health services. This included specialist teams for early intervention, assertive outreach, home treatment and specialist dual diagnosis and complex case teams, for example, for people with homelessness or cultural complications in their care. Despite these marvellous advances, the era of austerity and recession has seen sweeping cuts to remove such teams and additional welfare supports, housing projects and social care, resulting in scandalous care experiences, increasing suicide rates and laments over the poverty of care for young vulnerable people.

In spite of the celebration of NHS services, and exports of NHS ethos and practices, in the United Kingdom, we have now hit a decision point: can Bevan’s comprehensive coverage, free at the point of delivery, an indicator to Bevan of a civilised society, continue? Professionals want to care, but they are not being allowed to do so. The increasing unthinking application of guidelines, without complex integration of multiple sources of evidence for each patient, and the demand on services, and lack of capacity are all driving less clinical contact, and more time spent on governance, training, IT systems and policies that focus on providing time-limited interventions for the most ill.

Even when interventions work, they are not comprehensively provided. The gradual erosion of professionalism, intended to guard patient safety against rare episodes of dangerous doctors, has led to less agency and commitment to scholarly clinical practice, and these losses also affect person-centred, humane, ethical and value-based care. These qualities of Bevan’s vision now seem romantic hopes that are difficult to quantify and thus prioritise; it takes time to care and to do the right thing.

The recent Mental Health Task Force report in the United Kingdom calls for a new era of mental health care to be a social campaign. And yes, social activism, social capital, anti-stigma actions and more mental heath promotion and prevention away from health systems are all important. Yet people will still develop mental illnesses, and social campaigns will not help them. Studies of shared decision making with patients, and the culture of care, show that person-centred, compassionate professionals struggle in an emergent uncaring and compassionless culture of care driven by proxy targets of service performance to inform contractual reviews rather than true patient outcomes (Farrelly et al., 2016).

Both patients and professionals have to be resilient if they are to protect their humanity and to ensure aggressive prevention and work-life balances are secured, while trying to avoid burnout and compassion fatigue. Who can retain compassion in their practice, and at what cost? As compassion time is not viewed as a productive use of resources, it seems that compassion must be smuggled into the consulting room through time found or extended hours worked. Compassion requires emotional connection, role exchange, empathy, experimentation and exploration of people’s world views and experiences, their perspectives on what troubles them beyond the illness label, and a shift of the professional gaze to the person’s location in a social world of relationships and a life-course legacy of risks which include genetics and life events, and current contextual impacts. A remarkable positive consequence is that the practitioner feels that they can perform their professional role with their full range of skills, and without a conveyor-belt culture of processing and outcome measurement, before and after unthinking intervention. The sense that the system we work in is not socially inclusive, and transmits inequity, as only the most able remain engaged and effective consumers, erodes the ethos of professionals. The skill of exploring the personal biographies and narratives of patients requires flexible and reflexive awareness by professionals of their own histories, and therefore connection with the true self rather than alienation from one’s ethos and values.

The notion of smuggling ideas, of commodities, of geopolitical and imperial conquests, of romantic piracy all come together to reveal that smuggling is a pretty ordinary part of the informal economy of organisations and societies (Harvey, 2016). All organisations have creative spaces in which people negotiate and resolve shortages of resources, conflicting interests and avoid scrutiny in order to realise what is not attended to or seen as important in formal economies and structures, alternatively known as System D. Should compassion be relegated to the System D in NHS practice, or health care in any country? Surely not.