After Francis, what is to be done? Should we employ new hospital staff, and improve the ratio of nurses to health care assistants? Invest in the development of a cadre of strong clinical leaders, equipped with the skills and vision to drive up quality? Abolish gagging clauses? Overhaul professional regulation? Or perhaps instigate a regime of tough external inspections, including unannounced spot-checks? Take nursing education out of universities, and return it in its entirety to the NHS via a new apprenticeship model? Or expand the role of universities by giving them some responsibility for the preparation of health care assistants? Should we draft people in from private companies to show frontline public sector staff how it should be done? How about increasing local accountability by requiring senior hospital managers to report directly to elected councillors or similar? Or might we look to science, by commissioning a research team to design and validate a robust measure of caring of a type which might be administered to all potential entrants to nursing, to newly qualified members of the profession, and to experienced staff at intervals thereafter? We could even link periodic re-registration to the securing of a minimum score.
Who is to say which of these (or any other) solutions, alone or in combination, is what the NHS needs? And how might we know if any selected course of action has ‘worked’? Truly the problems facing the health service are complex and intertwined, and proposed responses to them value-laden and open to challenge. In the event, February 7th’s Guardian led with the headline David Cameron’s prescription for NHS failings: target pay of nurses. The paper went on to say that the Prime Minister:
[…] wants nurses’ pay to be tied to how well they look after patients as part of changes to banish poor care in the NHS in response to the devastating findings of a report published on Wednesday into the Mid Staffordshire hospital scandal.
Well, that’s another ‘solution’, for sure. And how might we determine how well a nurse performs, and quantify this for the purposes of financial reward or sanction? In this version of what ought to be done we might need that researcher-designed measure of caring after all. But let’s think about this further: at what scale would performance and pay be linked? Should the salaries of all staff in a single hospital or organisation be bound together? Or might workers in a ward or team be grouped, each paid a sum reflecting some aggregated measure of performance or collective compassion? How about differentiating at the level of the individual practitioner? And what might the unintended consequences of each and all of these options be (because I can think of a few)?
So, as you will have gathered, I contest the idea of cash for compassionate care. I also thought that Chris Ham from The King’s Fund spoke sense when he wrote, in February 6th’s Independent, that Edicts from Whitehall are not enough. Dignity, quality and a culture of care cannot be driven solely by a deluge of initiatives from the top. If they could, we would by now have created the perfect health system.