The evidence for improved patient and service-user outcomes

SUZIE: Hi Michael, this afternoon we’re talking about improved outcomes for patients and communities. What do we understand the evidence base to be with regard to compassionate leadership and how it contributes to improved outcomes? What do we understand the evidence base to be with regard to compassionate leadership

MICHAEL: Well, there’s such a lot of evidence and for me it’s at a number of different levels. There’s a very deep level about how compassion is so important in terms of basic human behaviour. So we know there’s a difference between merely being sympathetic and empathic and being compassionate which has that extra helping element to it. Neuroscience studies show that when we ask people to be sympathetic or empathic to another person in pain, that it’s associated with the activation of pain centres in the brain and that makes sense because what we’re doing is mirroring the other’s pain or distress in their own feelings.

But when we ask people to be compassionate, with that additional element of helping, it’s associated with the activation of reward centres in the brain and that makes sense too because we’re hard-wired, virtually all of us are hard-wired, to be altruistic and helpful and compassionate because that’s what enables us to create communities and groups to feel a sense of belonging, to feel safe, to feel trust and so on. So at that very deep level, the evidence tells us something really fundamentally important about compassion in human behaviour, you know it’s the glue that binds us together in a way.

SUZIE: Absolutely. In terms of what we’ve learned over the last year, do you think that has given people extra emphasis on the importance of compassion in regard to each other? Do you think the pandemic has taught us anything?

MICHAEL: It is interesting because this morning I was on a Zoom call like this with about 400 people from an integrated care system and I asked the question, ‘What’s enabled you to cope during this last year?’ And so many people said ‘It was my colleagues being supportive and kind’, ‘it was family, it was friends, it was neighbours’, ‘it was everybody being warm, compassionate and kind and holding each other’ and I think that is what’s enabled us to cope.

The compassion that health and care staff have shown for patients and the compassion that staff have shown for each other, the hugs, the cups of tea, the checking in on each other and the compassion that people in the community have shown, for example, for elderly people living alone. It’s certainly, for me, it’s been family, it’s been working with close colleagues like you, keeping in touch and checking in on each other that’s made it really possible to cope I think.

SUZIE: Certainly, what we’re hearing from leaders, clinicians, managers right across the health and care system, that actually despite the horrors of the pandemic and the pressure that people felt under, that actually it has really emphasised teamwork, compassionate ways of working with each other and that they are deeply connected to their intrinsic motivation for working in health and care in the first place.

MICHAEL: I think that’s right because what compassion does is blur the boundaries between self and other, increases that sense of belonging which is fundamental to us. On the opposite side of the scale, if we don’t feel a sense of belonging, it’s really damaging. You know, we’re as likely to die from the effects of loneliness as we are from the effects of smoking or obesity, so belonging is important to our health, to feel included, to feel cared for, to feel connected in that way. So it’s a health issue fundamentally as well.

SUZIE: What about the argument that actually, health care is really about technical expertise? That actually, what we need is highly-skilled professional clinicians and actually there just isn’t the time for this compassion stuff.

MICHAEL: We get very technical and intellectual about things. Sometimes, we miss out what’s fundamental about humanity. For me, what’s been a revelation over the course of the last few years is reading a review conducted by two American medics, Trzeciak and Mazzarelli into the role of compassion in health care. It’s just such an amazing review, hundreds of studies they reviewed, and basically what the review concludes is that compassion (this is me interpreting) is the most important intervention that there is across the board in health care.

So, we see, for example, if anesthetists visit patients prior to surgery and are compassionate rather than give sedatives, then patients have a much lower requirement for painkillers post-surgery and they have a much shorter length of stay. There’s another brilliant study, it’s a study of tragically patients with an early diagnosis of non-small cell lung cancer and it was actually a study of quality of life. What they did was assign patients either to normal early cancer care or to early palliative care, lots of extra compassion. Quality of life was indeed much better for the patients who were in that palliative care condition.

But what was a real surprise to the researchers was that the patients in the palliative care condition lived significantly longer. The evidence is really clear, if you look at the treatment, for example, of long-term conditions where clinicians - doctors, nurses, AHPs - are compassionate in their interaction with patients, for example with diabetes or HIV, outcomes are just so much better, adherence to treatment protocols is so much better. The same in the treatment of mental health problems, where you have compassionate clinicians, outcomes for people with mental health difficulties are just significantly better. It presents this amazing picture of just how fundamental compassion is in health and social care.

SUZIE: I’m really struck by that evidence, their book is amazing as you say and they talk about it with such passion. They came to it with skepticism about what was the role of compassion in health and care and in study after study after study - I think there’s over a thousand studies and research papers that they looked at - and consistently they have seen that outcomes are improved for patients.

The other things that they explore are around time for compassion, the pressure for people to say ‘Well, I haven’t got time to be compassionate’ and they’re basically saying ‘You haven’t got time NOT to be’, that actually the evidence base is that to be compassionate towards someone takes less than a minute. Imagine that, less than a minute to change the outcomes for people that you’re caring for.

MICHAEL: For me, all this work that they did and others have done around compassion and compassionate leadership, to me it’s somehow brought together many streams of knowledge from psychology, from philosophy, from our understanding of human behaviour, that compassion is fundamental and that if we want to create compassionate cultures, we need our leaders to embody compassion in their leadership. When you ask clinicians, the majority of them say that they haven’t got time to be compassionate and as you say, you haven’t got time NOT to be.

And some of those interventions that they described just involved scripts that were 20 seconds long, saying things like ‘I know this is going to be really hard for you to hear today and I want you to know that I’m with you on this journey and I’ll be with you all the way’. Scripts that took no longer than 20 seconds, 30 seconds but make such a difference to outcomes and the effects are remarkable. Effects that are greater than the effects of asprin in the treatment of heart attacks or statins in the five-year risk of a cardiovascular event, and the huge cost-savings associated with compassion as well.

One of the things that really struck me, it mirrors what we were saying about the neuroscience studies and the role of compassion in human behaviour. For example, in one study, general practitioners were asked to be extra compassionate in all of their consultations over a 14-day period. Actually, what you see is a significant improvement in their own mental health, significant declines in anxiety, stress and depression because we’re compassionate, somehow that nourishes us in our ability to be happy and to be more at peace in the world. I think that’s really profound and inspiring, particularly given what you and I have been studying over the last years, around levels of stress amongst staff.

SUZIE: Returning to the specific questions around improving outcomes for patients but also the opposite of that, around harming patients, I’m struck as I’m listening to you to think back to the very dark days of the Mid-Staffordshire review in England and the absence of compassion and what was happening in the culture there and as a result, the damage that was being done, both to patients, obviously their families but also to the staff. The absence of compassion, what that can do in terms of impacting on the quality of care and outcome for patients.

MICHAEL: I think it goes back to what we were saying earlier, we can become very technocratic, very mechanistic in our thinking about organisations and the delivery of health care but actually it’s a very basic, human kind of interaction. Mid Staffs shows what happens when you become more concerned with financial performance and targets, accreditation visits than you are with the core purpose of delivering high-quality, compassionate care. We have 18 years of data from the national staff survey now with over half a million people a year responding.

SUZIE: That’s in the NHS staff survey?

MICHAEL: The NHS staff survey, yes. We’ve been able to, over the years, many researchers, to do the most sophisticated longitudinal analysis and what it tells us is those leadership behaviours that constitute compassionate leadership, where they’re in place, patient satisfaction with care is much higher. Where staff report that their leaders listen, understand, empathise and help, then you see much higher levels of patient satisfaction. Where staff feel that they’re not listened to, they’re under pressure, there are high levels of stress, in those organisations subsequently, what you see is significantly worse care quality.

As you say, what the Care Quality Commission’s audit shows is that significantly worse financial performance, lower levels of patient satisfaction and higher levels of staff quitting and in the acute sector, significantly higher levels of patient mortality. The evidence at every level about the fundamental importance of compassion as a core value and compassionate leadership and compassionate cultures for the outcomes that we seek - care quality, patient satisfaction, people able to live their lives longer and the wellbeing and flourishing of our staff - the case is so clear. The challenge is how we convert that knowledge into practice by transforming cultures at every level and it’s a journey that you and I have been on together for a number of years now.

It feels really encouraging that so many places are focused on developing compassionate leadership now.

SUZIE: I think it’s really encouraging, it’s not just the moral value of doing compassionate leadership and having compassion in our work but actually that it makes economic sense as well for all of those reasons. It’s also good to see it coming into public policy. I’m reminded of Julia Unwin’s work for the Carnegie Trust about the importance of bringing greater kindness and compassion into public policy. The idea that public services are totally rational and are not relational, she talks about the importance of getting both the relational and the rational together and having those in balance.