Services which try to go beyond caring

I had the great pleasure listening yesterday to the NHS blogger Roy Lilley demolishing the vacuous research by Portsmouth University for Panorama on the PM programme yesterday (40 mins in).

The research suggests that there is around £5bn a year lost to fraud in the NHS every year, and another £2bn lost to financial errors.  But there is a irritating circularity about the argument that appears to have gone over the heads of BBC producers.

It suggests that we don't know how much fraud there is in the NHS, but can perhaps estimate it by looking at fraud in other health systems in other countries.  The result is that, for an organisation the size of the NHS, it would be around £5bn.

That is potentially interesting.  But then to be shocked at the high figure is really taking the story round full circle, since it is only an estimate based on other countries.  Quite how they manage to weave a Panorama report around this is beyond me.

And so the redoubtable Lilley explained on PM, much the irritation of the man behind the study.

From my point of view, the real losses we need to worry about in the NHS are those that fall into the nether world between fraud and financial errors - the manipulation of definitions used in gaming payment targets and treatment categories.  The amount of energy that goes into this in the border between providers and commissioners make my hair stand on end.

I mention this really because I wanted to write about Roy Lilley, who is a phenomenon, so well-read in NHS circles that he is now almost a national treasure, like Alan Bennett.

Not everyone agrees with him and he certainly flusters people in and around the many conflicting top posts and overlapping agencies in the NHS.  But he manages both to be trenchant and thoughtful at the same time.  A rare thing.

This morning he wrote about the word 'compassion' and the real meaning of the word, before it became an NHS management slogan, and how it is, strictly speaking, too much to expect compassion from ordinary mortals.  This is what he said:

"Can we cultivate compassion? Probably not. You can create an atmosphere of calm, you can encourage people who love their job to do their job. You can create the time and space for good people doing good things, to do even better things. Change, instability, unpredictability and volatility are the enemies of calm and constancy. Both of which are the foundation of a good workplace."

Quite right.  But there is another problem here that Roy only hints at.  Care and compassion may be the right stance for someone taken into hospital, but the vast majority of the money spent by the NHS goes on continuing chronic conditions - eczema, back paid, depression, diabetes - for which compassion is not really appropriate.

I know charities which have also realised that, if they really want to help support people to turn their lives around, they don't want to employ compassionate people - or, if they are compassionate, they will have to leave their compassion with their coats at work.

They need something far more hard-headed than that.  In the early days of time banks, many of the people we employed to run them were so compassionate they ended up trying to do all the mutual support themselves - when the whole purpose was to find ways of encouraging people who are always volunteered to that they can find a new role in life.

It is worse than this.  For too long, our public services have been supposed to be about oozing care, wearing down the staff, until care got abolished in favour of targets.  

When all the time, it might have been more effective for them to use their position as frontline public service staff, not to be more compassionate, but to provide an equal relationship that can challenge and support people to live their own lives.

Relationships, yes: people need those.  But it isn't the need that's important - the relationships are potentially a means to an end, so that frontline staff are no longer just wallowing in what people need - they are also asking them what they can do, and to challenge them to be the heroes of their own life.

The emphasis on compassion has led to public services that emphasise a corrosive dependence.  We need a more equal relationship with people.  That may require compassion in its broadest sense, but it requires something quite different which services are only now beginning to think about.

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