Dr Robin Youngson, co-founder of Hearts in Healthcare, shares his insights on the long journey to creating a more humane and compassionate healthcare system. We need a new strategy, he says.
The founders of Hearts in Healthcare have campaigned for a decade to bring more humanity and compassion into the healthcare system. You would think this was a no-brainer: health professionals begin their career with high ideals of compassionate caring. Science proves that patients treated in this way get much better outcomes at substantially lower cost; moreover compassionate care satisfies patients and give meaning and joy to the work of health professionals. It’s truly a win-win-win for patients, providers and funders.
So why doesn’t the practice of compassionate, whole-person care spread like wildfire across the healthcare system? After a decade of efforts, we have to conclude that the existing healthcare system is fundamentally incompatible with compassion, healing and wellbeing.
Dr Don Berwick, the founder and President Emeritus of the Institute of Healthcare Improvement (IHI), when talking about efforts to improve patient safety said, ‘The healthcare system is perfectly designed to achieve the exact outcomes it does every day; the worst plan is to try harder.’ The latest research into patient safety now establishes medical error as the third leading cause of death in the USA, accounting for more than 400,000 deaths a year. A system that maims and kills so many patients can hardly be called compassionate.
Taking a high-level view of the system we have to conclude that, in a capitalist economy, healthcare is perfectly designed to maximise the profits from sickness, not to promote healing, health and wellbeing. Trying harder to make the existing healthcare system humane and compassionate is not only futile but soul-destroying. That does not mean an end to our efforts, nor that we are discouraged, just that we need to change our strategies.
There are four fundamental drivers shaping our healthcare system:
a) Materialistic and reductive science
b) The industrialisation of healthcare
c) Profit motives
d) The heroic model of medical professionalism
a) Materialistic science
Basically, we treat sick patients as if they are broken machines that need to be fixed. ‘Real’ science doesn’t include concepts such as compassion or healing. The placebo effect, despite being a powerful healing response, is dismissed in our analysis of medical treatments. We objectify patients by focusing on the disease process, not the person with the illness. Indeed, we even identify patients by their pathology, referring to ‘the gall bladder on ward 6’ and ‘the breast abscess on ward 4.’
b) The industrialisation of healthcare
Modern systems of healthcare resemble factory production lines more than places of healing. Managers view their organisations as machines, in parallel to doctor’s mechanistic views of patients. Their most important priorities are financial targets, efficiency and throughput. From the managers’ point of view, patient care consists of tasks, procedures and bed days. Care, compassion and healing don’t show up on a spreadsheet.
c) Profit motives
Even in non-profit organisations, the profit motive strongly shapes the nature of medicine because most of our interventions are those which earn money for pharmaceutical and technology companies. In a capitalist economy, the healthcare industry makes money out of sickness and has little interest in promoting health, healing or wellbeing. Even cancer is turned into a chronic disease that earns a fortune for pharmaceutical companies.
d) The heroic model of medical professionalism
The heroic model of medical practice doesn’t allow doctors to have feelings. In our daily work we witness horrible disease, injury, pain, suffering and death; we try to survive this trauma by detaching ourselves from our feelings and pretending we are super-heroes who can fix and save every patient. This heroic role-model of being a doctor means that we, in turn, brutalise our students and trainees. In our relations with patients we too often adopt a clinically detached style of practice that doesn’t acknowledge the feelings of patients either.
No room for compassion
These factors together lead to horrifying rates of burnout among health professionals – international surveys report that about 30% to 40% of all health professionals have symptoms of burnout including emotional exhaustion, depersonalisation and cynicism. There’s a fundamental disconnection between the ideals that motivate health professionals and the reality of the work environment.
The four drivers of healthcare so profoundly affect the culture of healthcare that there is little space, time or incentive for compassionate caring. In this setting, the evidence that compassionate care can improve patient outcomes, reduce costs, and give joy to health professionals simply doesn’t stack up. It makes no sense from a materialistic, business or clinical perspective. Having a great idea, backed up with strong evidence, doesn’t change anything at all if it contradicts the predominant world view.
And so our experience has been that no matter how fired up and enthusiastic health professionals are about bringing their hearts to work, this impulse is too often crushed by the daily realities of the work environment. A few courageous individuals manage to overcome the culture of the system but they are often labelled as mavericks and a threat to authority.
So at Hearts in Healthcare, after many years of effort we have come to the conclusion that it is futile to try to change the existing healthcare system. Healthcare is in deep crisis: rapidly escalating costs, appalling outcome measures, epidemics of obesity and diabetes, and widespread burnout of those dedicated to care. It’s a dying system and the best we can do within the old system is palliative care.
Palliative care asks the question, ‘If we give up all hope of surviving this illness, what’s important in life itself? How can we live our remaining months or years well and achieve the most important life goals?’ It’s a process of finding hope and healing that connects to the deepest human values of love and compassion.
A new strategy
So while Hearts in Healthcare will no longer try to fix the existing healthcare system, we will continue to offer compassionate support and give hope to individual health professionals working in the dying system; we’ll encourage them to rediscover the heart of their practice and find meaning in compassionate caring. When all else is lost, reconnecting to your deepest human values is the path to healing. Contrary to widespread belief, having an emotional connection to your patients protects you from burnout. But empathy alone is not enough, we must step forward into compassion. The health managers deserve our compassion too; they also suffer in a broken system.
Complex systems change through a process of evolution: new species, which are better adapted to survive, emerge and gradually multiply, while the old species decline. So acknowledging that the old healthcare system is dying, we should instead devote our time and attention to creating new healthcare organisations founded on a better set of values and beliefs:
A science of consciousness that sees every patient as a highly responsive, mind-body being, not just a biological machine; the experience of care matters as much as the treatment.
Systems of care that value human connection as much as efficiency.
Alternatives to the profit motive that emphasise generosity, compassion and service, not greed.
A system of training that offers compassionate support to students and young professionals so they keep an open heart through the emotional trauma of early practice, not a hardening into detachment.
Taking a high-level view we know that most patient deeply desire whole-person, compassionate care; many health professionals are aching for the opportunity to care in this way; moreover we know this kind of care will achieve much better outcomes at lower cost, while giving satisfaction to all parties. If we can catalyse a new ‘marketplace’ to bring together health professionals, patients, technology experts, social entrepreneurs and funders we might see the rapid emergence of new provider organisations.
It’s already begun. Buurtzorg is a community nursing service in the Netherlands. Starting with just 12 nurses in 2007, Buurtzorg has grown to 8,000 nurses and has almost completely replaced the old system of care. Buurtzorg nurses work in self-organising teams of twelve and they have no managers. They have complete autonomy to deliver compassionate, whole person care within the communities they serve. So what are the outcomes, compared with the old task-driven system? The consulting company Ernst & Young reported:
Patients are recovering in half the time
Productivity is improved 40%
ER visits are reduced 30%
Average patient satisfaction rating are 9/10, the highest of any healthcare service in the Netherlands
The nurses have voted Buurtzorg the ‘best employer in the country’ three years in a row.
So our new strategy at Hearts in Healthcare is to become a catalyst for the emergence of new organisations like Buurtzorg. If you want to be part of the change, join our Facebook Group ‘Compassionate Healthcare Incubator‘ to share your insights, ideas and solutions. We’re inviting patients who are seeking wellness and health professionals who want to provide compassionate, whole person care. We welcome health managers who want to be part of a new order; social entrepreneurs who see beyond capitalist economic systems; educators who understand holistic science; technology experts; and investors who can see the potential in new organisational forms.
This is not just a place for conversation and ideas – we have the deliberate intention of bringing people together to create new healthcare organisations in an emergent process, starting wherever the ground is most fertile.
We’re aiming to start in primary and community care. Almost all of the determinants of health and wellbeing exist in community – if we get this right we eliminate most of the need for hospital care. I’m sixty years old and in robust good health: I don’t take any regular medications and I’ve never spent a night in hospital as a patient. Why can’t this be the right and expectation of every citizen?
At least one of the new organisations will be in New Zealand, the home of Hearts in Healthcare. And we’ll be excited to see projects emerging in other countries. Come join us.