terça-feira, 23 de julho de 2013

The failure of care in England's hospitals

NHS-speak and the failure of care in England's hospitals

Is compassion being crowded out of the NHS by the language and values of consumer capitalism?
The NHS is in the uncomfortable glare of the political spotlight. The high mortality rates of Mid Staffordshire NHS Trust, maternity ward deaths in Furness General Hospital, and last week a report led by Professor Sir Bruce Keogh that up to 3,400 patients may have died needlessly last year at 21 major hospitals run by 14 NHS trusts.
Commentators have linked these concerns not just to insufficient funding levels but to the ‘culture’ of the NHS. The lack of transparency and the gagging-contracts have, rightly, been decried in the media.
But there has also been talk of the malfunctioning of values and attitudes amongst clinical staff contributing to this culture and ultimately to failures in care. One solution proposed is ‘compassion training’ for nurses.
But this individualised approach is both misguided and unjust. To focus on teaching groups of individuals about compassion, as if they alone were responsible, is a smoke-screen for much wider issues about resources and structure. These are just aspects of ‘culture’: and they cannot be treated in isolation.
If there is, among some, such ‘compassion failure’, might it not in fact be caused by the very ‘culture’ in which they have to work, day in day out? In other words are the problems of secrecy, gagging, neglect and disregard actually brought about by the institutional values and the day-to-day mentality fostered by the NHS under consumer capitalism?
Values in debate 
Research into values suggests that we have a number of different sides to our identity. Two, competing sides are our ‘consumer’ and ‘civic’ sides. In day-to-day life, this means that we respond very differently to a ‘market’ object than to a ‘public’ one. This is because we have very different mental associations with each: one is about money, efficiency, and individual gain; the other is about social and collective good and shared resources. Such structured associations are known as cognitive frames.
The first frame is related to values of power, wealth and self-interest; the latter to values of universalism, social justice and community -- and these values are in direct opposition to each other. This means that when we are thinking about one, we find it very difficult to think about the other: market and consumer thinking actively discourages community and compassion thinking. Michael Sandel has called this the ‘corrosive effect’ of markets [1]. In behavioural economics it is known as ‘motivational crowding out' [2].
Social psychology research has shown that participation in a market situation made participants 30% more likely to be willing to allow a mouse to die, for instance.[3] People persuaded to join a car share scheme on economic merits were less likely to recycle afterwards than those persuaded to join for community reasons [4]. Once residents in Switzerland were offered monetary compensation for a toxic waste site to be placed near their communities, they were 50% less likely to agree to it than when it was presented simply as acting in the interests of the community, without compensation [5]. A financial incentive changes the object in question from something of civic worth to a simple market object that could be traded for convenience.
In one study, participants were given tasks framed either as Consumer tasks or Citizen tasks – either by simply changing the title of the task at hand, or by showing participants related words or images. The tasks were identical other than this framing. The Consumer groups were more likely to be attracted to materialistic values, such as wealth, image and success, more competitive, less social, less likely to want to volunteer, less likely to co-operate with other participants, and less likely to conserve water. They also felt more anxious [6]. Similarly, people asked to think about a business decision will give very different considerations then when asked about an ethical decision [7].                         
Other experiments demonstrate that engaging with people’s awareness of money leads them to be less helpful [8], reflecting the empirical evidence that the valuing of financial success is almost perfectly opposed to community feeling. Similarly, when people think about achievement values – related to competition – they perform better when asked to complete a puzzle, but are also less willing to give unpaid help: again reflecting the opposition of these values [9].
And the effects don’t stop there. Research also shows that our materialistic, economics-focussed side is also associated with short-term thinking. When asked to describe factors considered in solving a problem within an organisation, people focused on the ‘consumer’ identity were more likely to think How can I benefit the most? How will this make money? What can we gain from this now? What impact will this have on my reputation? Those focused on the ‘civic’ side considered not only money and reputation, but also: Is this morally right? Is this in line with our principles? What effect will this have on our employees? What are the long-term implications? [10].
The studies we mention above were mostly carried out in an artificial setting. But the key finding is valid – that words matter, because they directly trigger associated ideas, feelings, attitudes, and values.
Framing the NHS
Current discourse around the NHS is unquestionably commercially-focussed.  The ‘Friends and Family Test’, for example, smacks of consumer-choice mentality; ‘targets’ are the focus of business, not care.
To take another example, take the following text from an NHS website relating to the mental health sector (surely the least funded and most neglected in the system):
NHS Career Planner for Nurses
The Community Mental Health Nurse works autonomously in assessing patients, planning and implementing evidence based mental health care in a community setting. Nurses in this role will :
·   ensure care promotes the independence and autonomy of the service user.
·   work collaboratively across sectors and agencies.
·  manage a clinical caseload and work in partnership with other professionals, service users, families and carers.
·  contribute to service development.
·  act as a resource for information on local initiatives facilitating access for service users, families and carers;
·  supervise and provide line management for registered and non-registered staff. 
The detail of the wording tells its own story. Only once are patients referred to, and then it is to make them the objects of ‘assessing’ – an activity that does not necessarily evoke ideas of interaction with a human being (especially if other wording in the rest of the text encourages depersonalisation). And indeed, the rest of the advert refers to ‘the service user’ and to ‘services’.
There is no indication here that mental health nurses care for the sick, distressed, and suicidal: they ‘plan and implement evidence based health care’ for ‘users’. Of course care should be evidence-based – but again the point is that the wording backgrounds caring for real people and foregrounds an impersonal process of ‘implementing’ that could just as well be in a commercial setting. You may say it’s obvious: anyone reading the ad would know nurses deal with ill people. And yet the choice of wording is actually ‘crowding out’ our social concern and focusing us on what we usually associate with consumer and commercial activities.
Consider the tasks highlighted in the bullet points. Only the first one is about patients - sorry, ‘service users’ - and is couched in pseudo-sociological jargon (what is the would-be nurse to make of the difference between ‘independence’ or ‘autonomy’?). Then we are directed to the ‘service’ and its employees – ‘working across sectors and agencies’, ‘managing a case load’, ‘service development’, being a ‘resource’, ‘supervising’, and providing ‘line-management’.
These are the structures and functions of a commercial company. Are these activities what you typically think of nurses as being employed for? There are no words evoking activity directly serving some of the most needy people in modern society. This selective wording focuses on managerial functions and dehumanised processing.
Once one accepts that the words matter, one has to accept that they evoke ideas and images of business activity – cognitions that the research suggest have nothing to do with care or compassion. Imagine working in an environment where you are swimming in this kind of word soup, constantly primed with words to do with efficiency, cost-cutting, treating people as things to be processed as fast as possible, all in a style of language that is identical to that of a financial services company, supermarket, or hotel chain.
This is the key point: the values of the business management world are not those that we associate with healthcare, and they can swamp concern for other people, and the behaviours this normally motivates.
Consumer values in the NHS: what’s the effect? 
Given the research, we suggest that the actual language of the commercial world that is used throughout the NHS has the insidious effect of stimulating values of material self-interest and actually inhibiting values of care and compassion.
What is this likely to do to support for universal healthcare?
This discourse is likely to eventually weaken public support for ring-fenced NHS budgets, and strengthen support for reforms that are individualised and market-based: the route, indeed, that we appear to be taking. And the corollary will be consumerised, self-focussed, privatisation.
What is this likely to do to how we think about healthcare?
Establishing consumer or commercial relationships between healthcare practitioners and sick members of the public is likely to drastically corrupt the professional caring relationship.
What is this likely to do to healthcare practice? 
Besides the tragic examples being leapt upon by opportunistic business and political actors, the creeping commercialisation is already incentivising perverse thinking: the Competition Commission is likely to block the merger of two hospitals in Dorset because it will negatively impact consumer choice. As the Chief Executives of these hospitals said;
“We are bitterly disappointed that the interests of competition are being put before the interests of patients, their care, welfare and safety.” [11]
And yet such prioritisation is precisely what we would expect from the continued propagation of these values. We believe this deserves further detailed investigation. The evidence already seems intuitively strong – even obvious – but it could be made stronger by a larger-scale study that can demonstrate the verbal environment that the NHS lives in and the effects it can have on values and thus on practice—the kind of thought, talk and behaviour that may have led to mortalities in Mid Staffs, Barrow in Furness and, it now, appears many other hospitals throughout our NHS.

[1] Sandel, M. J. (2000). What money can't buy: the moral limits of markets.Tanner Lectures on Human Values21, 87-122. 
[2] Frey, B. S., & Oberholzer-Gee, F. (1997). The cost of price incentives: An empirical analysis of motivation crowding-out. The American economic review,87(4), 746-755. 
[3] Falk, A., & Szech, N. (2013). Morals and Markets. science340(6133), 707-711. 
[4] Evans, L., Maio, G. R., Corner, A., Hodgetts, C. J., Ahmed, S., & Hahn, U. (2012). Self-interest and pro-environmental behaviour. Nature Climate Change,3(2), 122-125. 
[5] Frey, B. and Oberholzer-Gee, F. (1997). The cost of price incentives: An empirical analysis of motivational crowding-out. The American Economic Review, 87 (4): 746-55. 
[6] Bauer, M. A., Wilkie, J. E., Kim, J. K., & Bodenhausen, G. V. (2012). Cuing Consumerism Situational Materialism Undermines Personal and Social Well-Being. Psychological science23(5), 517-523. 
[7] Tenbrunsel, A. E., & Messick, D. M. (1999). Sanctioning systems, decision frames, and cooperation. Administrative Science Quarterly44(4), 684-707. 
[8] Burgoyne and Lea, 2006; Vohs et al., 2006
[9] Maio et al., 2009, cited from Common Cause: The Case for Working with our Cultural Value, 2010.
[10] Illies, J. J., & Reiter-Palmon, R. (2007). Responding Destructively in Leadership Situations: The Role of Personal Values and Problem Construction.Journal of Business Ethics82(1) 
[11] Daily Echo. A bitter pill: Commission blocks Bournemouth and Poole hospital merger - on day NHS chief warns centralisation is vital for future of services. Available at: http://www.bournemouthecho.co.uk/news/10544000.A_bitter_pill__Commission_blocks_Bournemouth_and_Poole_hospital_merger___on_day_NHS_chief_warns_centralisation_is_vital_for_future_of_services/Accessed on: July 16th, 2013.

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