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At 6Cs and Sevens: Are the 6Cs just a smokescreen?

March 24, 2013

Right, let’s concentrate – oh, ha ha! – no, that’s not one! I mean – let’s think. OK. Care. Compassion. Confidence…no...Competence…um…Courage, Communication and…I know there’s another one…don’t tell me, don’t tell me…Courtesy? Is that one? No? Collaboration? That’s got to be one…No? OK. OK. I give up. I can’t remember all the 6C’s, all together, all at one time. But let’s face it – can anyone?

Somebody somewhere must have done some research into how long a list words beginning with the same letter a single human brain can memorize with sufficient accuracy to allow its owner to reel them off in one go when needed. My personal feeling is that six is pushing it a bit, but maybe I’m just getting old. The Department of Health (DoH) however, appears to care not a jot about my rapidly deteriorating cerebral function. So confident is it of caring professionals’ powers of instant recall that it has put the 6Cs of (and I’m using a crib now) Care, Compassion, Competence, Communication, Courage and Commitment at the heart of its ‘vision and strategy’ for nursing, midwifery and care staff. This ‘vision and strategy’ is set out in detail in a document called Compassion in Practice, published at the end of last year.

If the DoH was hoping that Compassion in Practice would represent a more positive contribution to the seemingly relentless tide of negative media stories about nursing, they were in for a rude awakening. The reaction of many grass-roots nurses was one of hurt and anger at the implication that they needed to be told that their professional philosophy should be guided by the values of the 6Cs. ‘We are being belittled and ridiculed by our own profession. The national scheme of so-called 6Cs suggests that the majority, if not all, of nurses do not possess these qualities – what an insult’ fumed one contributor to a Nursing Times online discussion. Others felt that the daily reality of understaffed wards and increased workloads means that nurses have far more pressing concerns than paying homage to the latest trendy management-think. ‘Most of us already have the 6Cs, we just need enough staff to put them into action in a timely fashion when patients need us. With low staff/patient ratios this is impossible’ said one.

This second poster then went on to urge national leaders to ‘stop using such crass gimmicks which make us as a profession look like Mickey Mouse. Would the police, military, legal profession, estate agents, etc etc submit to this childish nonsense?’ It’s a good question. Explaining the rationale behind the adoption of the 6Cs, Compassion in Practice states (p.11) that ‘[they] resonate strongly with both staff and people who use our services, across the whole range of health and care settings’. Sorry, but it’s not much of an insight, is it? Why wouldn’t they ‘resonate strongly’? They’re exactly the kind of warm, feelgood values we all love to sign up to. Any organisation with pretensions to providing a public service should regard them as just standard. And yet for some reason, nursing feels obliged to articulate them as nothing less than its national ‘vision and strategy’. Why is this?

The answer is very simple: it’s the age-old problem of nursing not really knowing what it is or what it does. And it is this uncertainty that Compassion in Practice exploits in order to pursue a carefully-concealed, politically-motivated agenda which culminates in a startling new definition of what nursing is. This definition is not to be found in the facile sloganeering of the 6Cs – if you were feeling exceptionally cynical, you could even say that they are just there to be the headline-grabbing smokescreen. To discover it, you have to get to the real guts of the document: the ‘Delivering the Vision’ section. Here, you will find that every other sentence is liberally peppered with talk of ‘measuring’, ‘metrics’ and ‘indicators’. That these words are given such prominence is a clue to the ‘real’ vision of Compassion in Practice: nursing as commodity.

To support this hypothesis, we need to ask two questions that most nursing commentators seem so far to have skirted discreetly around. Firstly, who has produced Compassion in Practice? And secondly, why now? Compassion in Practice was written by the NHS Commissioning Board (NHS CB -soon to be re-named NHS England) and published under its aegis. NHS CB is a new body, set up by the government specifically to regulate and oversee the operation of the Health and Social Care Act (HSCA). As the whole point of the HSCA is the opening up of competition in UK health care, the realisation that Compassion in Practice has NHS CB’s fingerprints all over it should definitely set alarm bells ringing. Because Compassion in Practice, published just four months before the Act is due to take effect, is actually a statement of how the DoH expects nursing to respond to the new dispensation. And what it expects can be summed up in a single word: measureability. Nursing is about to embark on an orgy of button-counting.

Believe it or not, this could be a not-altogether negative development. It has long been a commonplace in nursing that one of the things that holds us back is the difficulty of measuring care. Without solid ‘scientific’ evidence that good care makes a tangible difference to patient experience and outcomes, we have often been reduced to relying on anecdote and ‘gut instinct’ to make the case for more staff, or to describe our conceptual framework. Compassion in Practice promises to address this by the identification of ‘metrics and indicators, which reflect compassion and effective care’ (p.20).

Similarly, the report recommends that ‘Directors of Nursing in Trusts should agree staffing levels through the application of evidence based tools’. It goes even further by advising that ‘these are published at least every 6 months’ (p.22). Readers with an inclination to look on the bright side could view this as welcome recognition of something nurses have been calling for for years: a genuine attempt by management to understand the reality of nursing and the impossibility of delivering high-quality care without sufficient staff. Could the stage be set for a massive boost to nursing numbers? In your dreams! The key to understanding Compassion in Practice is to look at the context in which has made its appearance. And it is a context of competition and cost-cutting.

As with the Friends and Family Test, the whole point of Compassion in Practice is the provision of a framework through which Clinical Commissioning Groups (CCGs) can compare services and identify those which provide the best value for money. Nursing is just another factor in the cost-benefit analysis, exactly the same as back slabs and bandages and tins of baked beans. CCGs’ interest will be in identifying the highest standards of care with the best rates of patient satisfaction at the lowest cost. Because that’s what business is. The ‘6C’s’ and all that waffle about care, compassion and cuddly bunnies is nothing more than NHS CB’s way of firing a warning shot across nursing’s bows: in the face of all this squeezing, you are not to let your moral fibre weaken.

Jeremy Hunt, Secretary of State for Health, has made much of his commitment to cut paperwork in the NHS; he was at it again this very week (1). But on the evidence of Compassion in Practice, this looks like La-La Land-thinking. Wards will inevitably be forced to collect more information about their acuity levels in order to provide data for the ‘evidence-based tools’ geeks to work with. Meanwhile, Trusts may well try to get around the document’s injunctions on staffing levels by making greater use of nursing ‘pools’ so that they can move nurses around hospitals day-by-day or even hour-by-hour in response to specific crises, leaving ‘less pressurized’ areas with fewer staff.

Heralding a new party game of seeing who can be the fastest to name the 6Cs after a couple of white wine spritzers on the ward night out is not what Compassion in Practice is about. Most hospital nurses have no idea how much the implementation of the Health and Social Care Act is going to impact on them and are sleep walking into the massive changes it will bring. Time to wake up.

1. Hospital Staff to get more time with patients after bureaucracy crackdown; The Guardian Online; 22-03-2013.

Department of Health (2012): Compassion in Practice. Nursing Midwifery and Care Staff: Our Vision and Strategy; Published in electronic format only at

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