NHS: Marrying compassion with competition In a calling where compassion is the core of our work, we are left asking ourselves, how did it come to this? To my mind, any analysis needs to begin with the health reforms of the late eighties, which brought about a fundamental shift in the way the NHS worked. That was when the internal market was created, and funding started to be allocated directly to primary care, making them the "purchaser" of services offered by the "providers" in secondary care. Since then, every government has tweaked the system to varying degrees, but the purchaser-provider split has remained. No doubt there have been genuine improvements in the efficiency of service delivery as a result. The business ethic means that every penny every Trust spends has to be justified and if they start charging too much or delivering too little, their primary care customers will ultimately go elsewhere. There is clearly a need for such rigorous financial accountability, but this does not mean, however, that the system does not also have a serious downside too. Managers" focus has, as a result, shifted towards exactly the corporate culture that Robert Francis QC was referring to when he talked of "an institutional culture which puts corporate self-interest and financial control ahead of patients and their safety" in his report. Because Trust boards are competing with each other, they are forever looking for ways to deliver more for less and, consequently, expand their empire. No one should blame them for this. After all, that is the way business works. Expand or die. Quality of care only comes into focus if it affects the organisation's reputation. In other words, it is only considered in terms of avoiding negatives. The main focus rests on collecting data that verify the Trust's adherence to targets and levels of efficiency in order to satisfy commissioners that they are getting the best bang for their buck. It is in this interface that all the big decisions are being made with regard to patient care, and yet no one at this level is actually talking to a patient, nor are they required to, unless it's to deal with a complaint. Herein lies the heart of the problem. Any market mechanism relies on hard quantitative data to wheel the cogs, yet, where healthcare is concerned, this data will always miss something fundamental; individual human experience. This is why the fact that patients in North Staffordshire were drinking the water from flower vases didn't appear on anyone's radar, because nowhere in the system is this recorded in the data. Healthcare is a very human business - the most human of all - and so it cannot be run on the basis of spread sheets alone. Quality of care is not something that can be wholly measured in a quantitative way. What is needed, then, is an injection of more qualitative data, such as focus groups, into the heart of the process. A series of focus group sessions for random teams across a service, for instance, would give commissioners and managers a feel for the patient experience in a way that they are currently lacking. People at this level should have a visceral sense of what it feels like to be a patient in their hospital in a way that cannot be conveyed by numerical data alone. And this is how we can reintroduce empathy into the system; starting from the top. Empathy is at the root of compassion and that cannot be attained at a distance. Cultivation of empathy and compassion also needs to be incorporated into the regular professional development of managerial as well as clinical staff. In my experience, compassion is not something that anyone can take for granted. We all have it, but we can all have lapses in it too. Most clinical staff are faced with a regular stream of emotional challenges, given the degree of suffering and distress they experience every day. And without developing the proper internal mechanisms to deal with this stress, it can easily get projected back onto the patient in cold, neglectful or even cruel behaviour. The world of psychology and mental health is increasingly waking up to the value of mindfulness and compassion centred therapies and practitioners in them, such as myself, find them equally useful for personal development as we do for clinical management. A regular practice of cultivating compassion should, therefore, be a backbone of all NHS service provision. This way, hopefully, we can balance the emphasis on numbers and contracts with a renewed focus on patients and that which is unquantifiable; their lives and their suffering. This will ultimately help us - clinicians and managers - to regain the energy and compassion that drew us to the NHS in the first place.