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Subject:

Re: Voice, etc.

From:

Kenneth Thompson <[log in to unmask]>

Reply-To:

[log in to unmask]

Date:

Fri, 27 May 2011 16:26:36 +0000

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Hi Marin et al 
I am really sorry to press on this. I guess it depends on what you mean by care.  
There is a kind of oceanic, spiritual care. There is a kind of care in doing what we do as well as we can. And there is actually caring about another person.  
 
I think we can expect the first two kinds of care. The third is emotionally engaging in a way that no one can keep it up all the time. In fact, caring too much can become a kind of pathology of self neglect.  
 
Ken 
Sent from my Verizon Wireless BlackBerry 
 
-----Original Message----- 
From: "Gemmill-Toyama, Marin (CMS/CSP)" <[log in to unmask]> 
Sender: Anglo-American Health Policy Network <[log in to unmask]> 
Date: Fri, 27 May 2011 10:34:04  
To: <[log in to unmask]> 
Reply-to: "Gemmill-Toyama, Marin (CMS/CSP)" <[log in to unmask]> 
Subject: Re: Voice, etc. 
 
Hi all, 
 
I would agree that empathy might be too much to expect from providers, but perhaps a middle ground of care could be met. Simply caring for the patient's well-being and other providers' well-being is what I mean by that. For instance, if a physician treats a nurse as if she is a lower-class provider, should we expect the nurse to then turn around and treat the patient with dignity? Providers work under constraints (e.g. time), so we can't expect them to be fully empathic, but they can care enough to treat others with respect and dignity. 
 
Personally, I believe the little things make an enormous difference in human interactions. I spent 4 days in the hospital in London in 2004, and the food was horrible. But honestly, I didn't have much of an appetite, so that didn't bother me. It was the treatment of the nurses that made all the difference in the world. I remember waking up from surgery to a gentle Irish nurse saying I might feel a little ill, would I like something to take the nausea away? The nurse telling me that she wouldn't send me away until they figured out what was wrong with me was so comforting. Contrast that with the first emergency room I visited where the nurse briskly told me that I had a "tummy bug" and sent me away without listening. Another nurse barked that I needed to get ready to go home right after my surgery when I could barely walk from the bed to the bathroom much less make it out to the curb to get a taxi. Tone of voice, looking people in the eyes, taking a few extra seconds to listen - these are simple but profound things that make a difference. 
 
We aren't always taught "emotional intelligence" skills in education - we're often expected to pick up these skills on our own. Yet, many people don't have a clue how their words and actions have an impact on others. 
 
Marin 
 
-----Original Message----- 
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Kenneth Thompson 
Sent: Friday, May 27, 2011 10:17 AM 
To: [log in to unmask] 
Subject: Re: Voice, etc. 
 
Hello Tom et al 
 
Tom- I think you have put your finger on something important. You can't rely on empathy to fuel care day in and day out. Mundane pressures just overwhelm it from time to time. 
It actually takes effort and focus to "keep up the appearances"- at least until its the default position of habit. (Like acquiring and then keeping "a stiff upper lip" while "muddling through"- but think of the disney smile instead. Being a good host and guest friendly is work!! 
 
Ken 
:) 
Sent from my Verizon Wireless BlackBerry 
 
-----Original Message----- 
From: Tom Foubister <[log in to unmask]> 
Sender: Anglo-American Health Policy Network <[log in to unmask]> 
Date: Fri, 27 May 2011 00:41:17 
To: <[log in to unmask]> 
Reply-to: [log in to unmask] 
Subject: Re: Voice, etc. 
 
Ali, I'm not sure empathy has much to do with any of this. I doubt empathy can be sustained working on a ward - I also doubt that it would be very useful. It's entirely possible to treat people with dignity without this having to rest on empathy. Empathy may - somehow - take you into a health profession, but I don't think that given the reality of health care it will keep you there. 
 
Adam - I'm not sure the management solution, although I sympathise with it, will work - for the (bad) reason that it hasn't worked so far. It would be good to know why it hasn't. Perhaps someone with experience on the board of a hospital (Alan?) can shed light on this. 
 
The NHS is a good health care system. The major thing wrong with it is that too many (and even a small proportion is too many) patients are treated in a way which fails to accord them dignity, and sometimes is simply cruel. I too have heard damning tales about nurses. I know few people who have spent time in hospital, but each has had such a tale - none on the scale of those reported by the care quality commission (and in previous reports in previous years, particular in respect of care homes a few years ago). Just small scale things which are nevertheless utterly shocking. 
 
What are we to make of this? There is a real problem here. The small scale stuff clearly readily becomes the large scale stuff in the right setting (i.e. care for older people). 
 
Clearly one problem is the resources problem - too many patients, too few staff. But the resources problem does not explain the small scale stuff (and small scale stuff's becoming larger scale stuff in the right setting), so there is more to it than resources. 
 
It seems to me that the problem is that in some settings, it becomes normal to treat the job of nursing in the way that people the world over (justifiably) treat their jobs - a job to be done, talk to friends or 'shirk' (awful word learnt in a health economics course) whenever possible, look forward to going home and forget about work. This may not be damaging overall (even if the boss would disagree) in most normal work settings, but in health care it is. So what to do? 
 
I don't know, but one thing I would venture (and this is only one part of this) is that the position (I don't know how else to say it) of the nurse has to change if the move to incorporate professionalism into nurse education is to be fully effective. When you take the archetypal professions - doctor, engineer, lawyer - there is an equality among them; they do not stratify themselves into a hierarchy. Put a nurse next to a doctor and something very different happens. Where this is the case, how can real professionalism be sustained? The work done by educators over recent years to ensure that professionalism is central to the education of nurses (as it is to doctors) is undone. Professionalism, to be meaningful, must assume equality between professionals. 
 
This does not mean that nurses and doctors must have, or pretend to have, the same knowledge and skills. But it does mean that there should not be unmerited deference (i.e. deference to a doctor because and only because they are a doctor). How to move in this direction? Again, I'm not sure. But further efforts to make effective team working central to health care delivery would probably help. And team work should not mean, as it currently too often does, that every team has to be led by a doctor, and that the doctor talk to the junior doctors on the team but ignore nurses on the team, and so on. 
 
So I guess the point is that to have people treat other people with dignity, without having to rely on empathy or the manager looking over your shoulder, you need to ensure that they work in an environment which accords them dignity themselves - and where nurses are concerned, the dignity inherent in professionalism. 
 
Just a thought, anyway. 
 
Tom 
________________________________ 
 
From: Anglo-American Health Policy Network on behalf of Ali Shukor 
Sent: Thu 26/05/2011 23:23 
To: [log in to unmask] 
Subject: Re: Voice, etc. 
 
 
My dear Adam, the people of the East are certainly no more empathetic than the West, especially in this globalized village we live in. I would dare to say that the East has regressed immensely, and has much to learn from West, which has a debt to repay in morality. I have seen for myself how Iraqis, Arabs and Kurds, have changed as people over the past 30 years. As for Enthoven's free market, the more I study it, the less free it seems, and the more peacefully violent its philosophical underpinnings appear. 
 
As for building the institutional framework to promote humanity and empathy, we know how to do it - as Navarro so beautifully said in "What we mean by social determinants of health", it's not a scientific question, it's political. Good reading is the introduction to "political wolves and economic sheep: the sustainability of public health insurance in Canada" by Bob Evans, entitled "Ingenuity - sustaining ourselves in an unfriendly world": http://www.radcliffe-oxford.com/books/samplechapter/7017/07-maynard-5462c100rdz.pdf 
 
My apologies to all on this wonderful listserve for cluttering their inboxes, due to my lack of empathy. My last email for a while, I promise. 
 
Kind regards, 
Ali 
 
 
On Thu, May 26, 2011 at 5:59 PM, Adam Oliver <[log in to unmask]> wrote: 
 
 
        Ali 
 
 
 
        On a philosophical level, you might be right. I don't know. Are people of the East intrinsically more empathetic than people of the West? I doubt it. People are people, it seems to me. My main concern in this dialogue, though, is more immediate and practical. I wouldn't argue that people who work in health care services lack empathy. Probably, they are more empathetic than others on average, through self selection. But for some reason, health care delivery, perhaps the world over, is often unacceptable. Now, we could try to instill in people from a young age a greater sense of empathy, but how long will that take to have an effect on health care delivery? Twenty years? A hundred years? Never? Ideally, we need to reduce the amount of horror now (or soon). A way of doing this might be to have greater accountability (better management, spot checks etc) in hospital wards. I called this fear before. Perhaps that was the wrong word. Enthoven, by the way, wasn't promoting fear. Quite the reverse - he believes in the free market. But I think the market (free or otherwise) probably doesn't instill the necessary incentives to improve health care delivery on the ground. If you are a doctor or a nurse or a porter or a caterer in the health service, and you know that if you don't do your job to a reasonable standard you will face consequences, then you might be better motivated not to let someone die or lie in agony from bed sores, or dehydration, or despair. I suppose all of us have to accept that we will one day die. But we shouldn't accept that we have to die like that. 
 
 
 
 
________________________________ 
 
 
        From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Ali Shukor 
        Sent: 26 May 2011 22:25 
 
 
 
        To: [log in to unmask] 
        Subject: Re: Voice, etc. 
 
 
 
 
 
        Many thanks, Adam. The key ingredient perhaps isn't compassion, but its prerequisite, empathy. We Easterners have our own scientific schools aimed at 'manufacturing' empathy - for example, us Kurds try to attain this knowledge through Sufism, through the writings of our teachers such as Rumi, Khayyam and Hafez - who were also the scientific polymaths of their time. I can see our 'enlightened' academics snickering right now... 
 
 
        Luckily, the West need not become a population of whirling dervishes - it's pathetic enough to see them seek peace of mind and body through their corrupted version of "Yoga". The West has its own teachers and ways. You all know them well. For example, Kant in his 1784 essay "Answering the Question: What Is Enlightenment?" tried to explain that "enlightenment is man's emergence from his self-incurred immaturity", and tried to show ways out of our hubristic immaturity. 
 
 
 
        Our modern universities can play a major role. That wonderful Ian McWhinney of the University of Western Ontario explained how in a beautiful convocation address to medical graduates: http://www.uwo.ca/fammed/ian/convoaddress.htm. I can say, as a current student, that our formal curricula are very far away from such a vision. 
 
 
 
        I was always taught that fear is a result of duality - a duality resulting from a lack of empathy - and that the threat fear is derived from is nothing but a blunt tool used by those who lack the intellect to create an environment of understanding and knowledge. An unsurprising tool promoted by that 'intellectual' Enthoven; for wasn't he the US Secretary of Defense for 'Systems Analysis' under that murderous McNamara - that same McNamara that escalated the Vietnam War; that same McNamara who instituted 'system analysis in public policy', now known as the "discipline" of "policy analysis"? RAND can go on trying to socially engineer humanity - all they will manage to do is engineer a stupid, blunt, totalitarian system, as Huxley so beautifully wrote. It scares me that Enthoven has so much say on how we are to promote 'modern' health and wellbeing. 
 
 
 
        Kind regards, 
 
        Ali 
 
 
 
 
 
        On Thu, May 26, 2011 at 4:24 PM, Adam Oliver <[log in to unmask]> wrote: 
 
        Ali 
 
 
 
        You may be right, but as a policy maker, how do you manufacturer compassion? Maybe you either have it, or you don't. It has to be admitted that dealing with patients is often very difficult, and it requires a special kind of person to handle them properly, without any other form of 'control' in place. When I finished my undergraduate degree, I worked as a hospital porter for a few months. Some of the porters loved dealing with the patients, most were pretty much indifferent (it was just a job to them), and a few were very obnoxious towards the patients (if they thought they could get away with it). 
 
 
 
        I've noticed a few times that many nurses jump to attention when they think that a figure of authority (e.g. a doctor) is around. Otherwise, often not so much. Maybe Gwyn Bevan is right. Maybe 'threat' is the best way to improve health services. I remember Alain Enthoven in a meeting once ridiculing Nye Bevan's famous phrase that whenever and wherever a bedpan falls on the floor, its sound should ring around Whitehall (or something like that). Enthoven misunderstood the quote I think (he took it too literally). But I think we all, metaphorically, and perhaps especially those who sit in Whitehall (or their equivalents), ought to be straining our ears to the sounds of those pans. Judging by the stories that people have written to me today alone (and I wish people would share their stories more widely), you wouldn't need to strain your ears that much. 
 
 
 
 
________________________________ 
 
 
        From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Ali Shukor 
        Sent: 26 May 2011 20:31 
        To: [log in to unmask] 
        Subject: Re: Voice, etc. 
 
 
 
        Thanks, Adam. Despite the billions spent, delivery can - bewilderingly and stubbornly - suck. We seem to be great at finding innovative ways of caring for, but not about, people. The vast majority of our academic intelligentsia seem to fail to understand the sophisticated philosophical underpinnings of the scientific theoretical models and frameworks presented to us in Donabedian's 'Quality of Care', and Starfield's 'Health services research: A working model'. 
 
 
 
        The key quality underpinning their philosophy is love - not that Western modern romanticized selfish love of a aesthete - but love derived from self-knowledge; the self-knowledge derived from humility and honesty. Yes, that same true love finally discovered by an ailing Oscar Wilde. The key philosophical quality underpinning today's so-called 'scientific' theories is egoism, manifested by hubris, in the form of infinite scientific 'frameworks' being published, ad nauseum. Quoting Donabedian: 
 
 
 
        "Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system's success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system."  ~ Donabedian 
 
 
 
        And it is hard to really love anyone or anything in a world where we annually spend more on dog food, than on the amounts needed for global basic health, nutrition, sanitation, and basic education, as estimated by the UNDP my father served in for 40 years. It is shameful when my cousin in Baghdad calls and says he wishes he were a dog in the West... And so, in this world - where humanity is, as Sartre put it, estranged from itself - that nurse will keep feeding that elderly patient NHS grade dog-food. 
 
 
 
        150 years ago, a fellow Englishman by the name of John Ruskin published a beautiful series of essays entitled 'Unto This Last', highlighting a possible way out of our philosophical morass by rediscovering our humanity through reaffirming our 'social affections'. Mohandas Ghandi translated it into his famous 'Welfare for All'. For anyone interested, here it is: http://www.efm.bris.ac.uk/het/ruskin/ruskin 
 
 
 
        And until we really understand what Ghandi taught, delivery will continue to 'suck'. Unfortunately, humanity seems to be moving further and further away from even closely attaining that true knowledge... But God is good, and where there are those who lovingly seek Truth, there is always hope. 
 
 
        Kind regards to all from a pleasant Toronto, 
        Ali 
 
 
 
 
        On Thu, May 26, 2011 at 8:52 AM, Adam Oliver <[log in to unmask]> wrote: 
 
                Hi, 
 
 
 
                Since recently observing a number of cases of very poor quality care in the NHS (which I might write about), my mind has turned (again) towards what can be done about it (I've seen some examples of excellent NHS care too). I'm doubting that high level 'macro' debates around choice, control etc have that much effect on the ground. Voice could work to some extent I guess. James Munro has set up quite an interesting initiative on this, which can be seen at: www.patientopinion.org.uk <http://www.patientopinion.org.uk/> 
 
 
 
                I'm wondering whether there are some voices, though, that never get heard no matter what, partly because the people directly affected can't express them. The very elderly, for instance, or those with dementia? I recently heard of a nurse telling an elderly patient that the NHS food that the latter was served wasn't fit for a dog. The nurse wasn't exaggerating that much, but she (or someone) should be trying to do something about it. 
 
 
 
                The above is relevant to a BBC news story today, that David McDaid forwarded to me, which cites examples of poor quality care for the elderly in the NHS: http://www.bbc.co.uk/news/health-13545780 <http://www.bbc.co.uk/news/health-13545780> 
 
 
 
                To me, the NHS has the basic financing structure right (tax funded, free care at the point of use). Delivery, though, often sucks. Some people say the NHS is cheap, but almost 10% of the nation's wealth is a lot of money. 
 
 
 
                Best, 
 
                Adam 
 
 
 
 
 
 
                Please access the attached hyperlink for an important electronic communications disclaimer: http://lse.ac.uk/emailDisclaimer 
 
 
 
 
        Please access the attached hyperlink for an important electronic communications disclaimer: http://lse.ac.uk/emailDisclaimer 
 
 
 
 
        Please access the attached hyperlink for an important electronic communications disclaimer: http://lse.ac.uk/emailDisclaimer 
 
 
 
 
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