As Time Goes By

You can`t have opened a newspaper, or watched the news in the last few days without hearing of the Care Quality Comission`s  report, and the subsequent furore over the care (or abuse) of the elderly. As seems commonplace thses days, the report and the media coverage are somewhat different, although it does raise some interesting questions. Its significant, I think, is that a report ordered by Andrew Lansley was released just in time for his Health and Social Care Bill to be voted for in the House of Lords. I also find it somewhat suspicious that, to quote the report, `We had forecast that 10-20 % of hospitals could be non-compliant (20% were), and that a further 30-40% would show evidence of concerns (35% did), based on findings from our first set of inspections. Overall, 55% of hospitals were either non-compliant or gave cause for concern, against a forecast of 40-60%.` So…they found exactly what they were expecting to find.  I make no further comment.

According to the report, only two wards in each hospital were inspected, only during the day, and with just one lunchtime. Yet one of the wards in two hospitals  was considered `of major concern`.  If that is so at mid-day, what was the care like when the day staff went home or at the weekend?  Also, why did two wards in the same unit vary so much?

The biggest question of all though, is, are nurses becoming less caring, more abusive to the patients in their care?

Its important, I think, to distinguish between neglect by omission, and neglect by commission. Nurses aren`t deliberately abusing their patients (commission), but in some cases are neglecting by omission, for one simple reason, something that was mentioned in the report over and over……`‘Sometimes I am the only staff member to feed on the ward.`….“Staff were trying to help patients sit up and serve lunch, whilst a medication round was being carried out at the same time.”….“All the ward staff we spoke to on the stroke unit said they felt the unit was understaffed and the current levels were not appropriate to meet the needs of the patients.”

Indeed, one of the conclusions of the report was….`A lack of time to deliver care (due to short staffing, persistent high demand or excessive bureaucracy) can prevent staff from making sure that people’s needs are assessed and they are given the right support to eat.`

It is noteworthy that figures show the average ‘care of the elderly’ ward has just one nurse for 11 patients.  Often you see comments in the media `My dad waited 3 hours for pain relief while nurses sat around the station gossiping and reading Heat magazine” . What these commenters don`t realise is that these `nurses` aren`t nurses at all…they`re physio, ward clerks or Occupational Therapists etc, and can`t help. Couple this with untrained, `care providers`, (who although willing, are sometimes just cowboys) and you have something that (like my old Austin Healey) looks good, but is going nowhere.

As for nutrition, there`s a couple of things I have noticed myself, both as a staff member, and as an in-patient.  Quite often, the nurses only have a certain time to manage mealtimes. Food gets delivered, and a short time later, the porters have arrived to take the plates, containers and trays back to the kitchen.  This gives the nurses limited time to get all the food out, ensure that its eaten ( and recorded that its been given and eaten) and return all trays back.  Now, I spent a couple of years as a volunteer at both my local hospital, and the local old people`s home…and I know from experience that sometimes, assisting just one patient can take almost an hour…time that an overworked nurse cannot afford to take, no matter how much he/she might want to.

Secondly, many hospital trusts (mine included) has `protected mealtimes`. This evidently, is to `allow patients to eat their meals without disruption`. Truthfully, I can sometimes understand this, since some relatives can be a royal pain. I remember a friend of mine once complaining of supporting an elderly woman to eat as her two daughters sat there watching, while being acutely aware of the woman two beds down not eating at all…, but, on the whole…Why? Why NOT suggest that patients who need support with mealtimes have their relatives allowed in? (Also interesting to note, when Dr. Peter Carters comments saying the same thing in the Mail were printed, most of the comments were…`Its the nurse`s job`. Needless to say, these were the same commenters who moaned that `the nurses were sitting around, blah blah blah`)

On a smaller scale (I`ve only seen 4 consultants ever do it, tbh…but 4 is 4 too many, imo)… Consultants who INSIST on doing their ward rounds at mealtimes. Why? Why did they HAVE to do it then? Limited nurses trying to manage 20 – 30+ patients at lunch time…PLUS a drug round, with the usual suspects interrupting that, hence tabards…and the Consultant sweeps in….

Dame Joan Bakewell was quoted as saying that nurses needed lessons in empathy, which TOTALLY misses the point. Firstly, I am of the firm belief that nurses enter the profession for vocational reasons. But caring and empathy will only get you so far without resources (qualified staff and time both being resources). Secondly…how on earth do you teach `empathy`? You can be taught standards, practices etc…but you can`t be taught to care.

Nevertheless…there ARE occasionally some bad and/or lazy nurses, who deserve to be weeded out. At one hospital, the fact `that people in need of intravenous fluids did not have infusions` is inexcusable.

Having said all that…there ARE real problems in the NHS, which have to be acknowledged, and dealt with.

The problems started, I think, with Roy Griffiths. He was the author of the `Griffiths Report`, which ushered in General Managers. His report contained the famous phrase “If Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge.” At the time, there was great resistance to the report, Doctors and nurses feared their professions would lose influence after the dissolution of the consensus management teams that had run the NHS until then…and they were right, tbh. But after the Government `accepted the proposals`, Regional Health Authorities had four months to appoint their own general managers, then embark on District Health Authority appointments. Districts had until the end of 1985 to find unit general managers. The Department of Health began recruiting a national general manager. Mr Griffiths said this should be someone “almost certainly” from outside the NHS and civil service, with experience of effecting change in a large organisation.

Griffiths had envisaged a major role for doctors in general management, but with the advent of the internal market in the early 1990s, chief executives became legally responsible for balancing the books, which was a major factor in frustrating Griffiths’ vision of doctors in management.“In 1992, Roy Griffiths said: ‘I have a genuine horror that managers in the various professions will go down parallel routes barely touching each other and with very different objectives’. In many instances that is exactly what’s happened. It is ironic and sad that should be the case.”In fact general management’s biggest weakness is widely perceived to be the way it alienated staff from managers. Governments have used thinly veiled threats to make managers conform, usually to unpopular policies. Management have often intruded into clinical issues while overlooking basics – such as cleanliness – that the `old-style` managers rigidly adhered to.

After Griffiths, of course, came other re-organisations, initiatives, and, of course `Competition`, `Choice` and `Change`…and more and more committee`s, boards, directors and the like. It wasn`t THAT long ago that the Health Authority I was with appointed a `Director of Change`…along with staff. The decoration, carpetting and furnishing of her office came to over £20,000, yet soon after we had to close 4 SCBU beds…we couldn`t afford the staff. There ARE problems in the NHS, and those problems need fixing, now and not later. BUT,  I don`t think this bill..or the direction the NHS is taking, will solve anything.  Privatising parts of thr NHS will make a select few quite a lot of money, but one thing it won`t do is improve standards.Having (albeit well-intentioned) untrained staff with fancy titles won`t help the situation…and, since it will then require clipboard carrying `inspectors` to ensure quality will just increase cost.I fear that the NHS is on its last legs, to be honest. In a few years, it will be part of `Global-MediCare Inc`…and it will all be too late. Maybe I`m just getting more cynical…but I expect a slew of stories in the media of how bad the NHS is in the next few days, though.

Which leads me to a question…and one I have no answer to….Just WHY do we always look at the US model of healthcare for direction..and nowhere else?

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