Guest Editorial > Intelligent Kindness: reforming the culture of healthcare.



Intelligent Kindness: reforming the culture of healthcare. | Dr Margaret Hannah

Dr Margaret Hannah, in this thoughtful review, describes a book which presents the current crisis in the NHS not as a technical challenge, but a human one.

Intelligent Kindness: reforming the culture of healthcare.


In a profound, timely and nuanced book, Ballatt and Campling delve into the human dynamics which lie at the heart of effective healthcare.  They begin by describing the roots of the word kindness, which is linked to the words “kin” and “kinship”.  The word reflects both a sense of duty towards others and the actions and feelings which derive from a sense of connectedness towards our fellow human beings.


Kindness lies at the heart of the therapeutic alliance – the essential basis of effective healthcare, mobilizing patients’ inner resources in their recovery from illness. But being kind carries risk – maybe getting things wrong or getting hurt in the process.  It also takes courage, to overcome self-interest, anxiety and conflict. Kindness takes a certain intelligence to be useful and wise. It is both natural and necessary for effective healthcare and yet, as the authors go on to explain, there are many reasons why it has been marginalized and corrupted in the 21st century NHS.


Written by two people with extensive clinical and managerial experience in the NHS, the book contains timely reminders of recent tragedies.  They quote from the first Francis report on Mid-Staffordshire NHS Trust, which described abject levels of care and abuse of patients.  The authors apply a psychodynamic lens to the question of why people stopped being kind and started to abuse.  They point out that frontline staff day in and day out face the experience of “ill-being” in their patients.  It is an uncomfortable place for staff to inhabit if they do not have the space or time to process the difficult feelings that can be evoked.  As a result, emotional defences can build-up, which bury feelings of vulnerability and sadness, whilst also diminishing the capacity for kindness.   On top of this, treating people who are ill is inherently uncertain.  We don’t know beforehand, who will get better and who wont, who will live or die.  Facing this on a daily basis can make it difficult to distinguish between a treatment which simply didn’t work and feeling oneself to be a failure.  This can engender a sense of helplessness, leading to self-blame and guilt, which in turn can lead to anger, dislike and even hatred for a person or people that provoked such feelings.


These are difficult areas to explore, when staff are so stretched and with little time for reflection.  The book offers some very useful ways in which this can be addressed, with an emphasis on “good enough” care, based on the ideas of Winnicott; mindfulness training; supervision and support for staff.  One of the systemic ways of achieving this is by re-balancing the effort of quality assurance from outside inspection towards more autonomy for staff but with transparent accountability to the patient.  Too much threat in a system fatally undermines the capacity for kindness.  Rather than think the way to achieve high quality care is through cajoling and chasing poor practice, the emphasis should shift to supporting and enabling staff to do what they would want to do in most cases – provide great care.


This book is not just about understanding individual staff behaviours and how they might be supported to work with attentive kindness, but also explores the human dynamics which can achieve this at every level – in teams, services, organisations and government.  In the last third of the book, the authors make a devastating critique of the incessant change processes, which have be-devilled the English NHS in the last two decades.  They show how these destructive “reforms” reflect a failure of political and NHS leaders to contain their own anxieties, creating fragmentation and alienation in the health service which leave staff feeling disorientated and distracted from their core task of caring.  The insights from Intelligent Kindness point to a new political economy of health. Rather than evading crucial political, moral and ethical judgments through the use of spurious economic calculations, the authors suggest engaging with the messy complexity of reform as a human process.


It is refreshing to read a book, which presents the current crisis in the NHS not as a technical challenge, but a human one.  Whilst sketchy in terms of how to bring it about, it is clear that the quality of services relies less on economics and technology of healthcare and far more on people and how they create a positive therapeutic environment.  Healthcare needs to move on from its technical, industrially-inspired mindset, recognizing it is a psycho-social process, involving human relationships, emotion and the capacity to think about and care for others.  This cannot be achieved through external reform, but by inner change in those of us working in health services, recognizing ourselves as participants in a creative, courageous, human and kindly endeavor.


Dr Margaret Hannah

Deputy Director of Public Health

NHS Fife