Month: September 2013

Care quality in the NHS

.”‘When…only one man is unemployed, that is his personal trouble, and for its relief we look to the character of the man, his skills and his immediate opportunities. When…15 million…are unemployed, that is an issue, and we may not hope to find the solution within the range of opportunities open to any one individual. The very structure of opportunities has collapsed. Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals’. (p9). (C Wright Mills – The Sociological Imagination).

….today we hear about the safeguarding tragedy that was Daniel Pelka. Again, communication issues between agencies and the failure to act have been highlighted. His parents are in jail. If only one social worker failed then we should look to the character of that social worker. When we have a historical record of failures which all highlight communication issues and failures to act, we will not find solutions only in the failings of individuals, the socio-cultural systems itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society.

….we have heard about the care failings that was Mid Staffs. Again, neglect and abuse of frail elderly patients were highlighted. If only one healthcare professional or manager failed, then we should look to the character of that professional. When we have a historical record of failures which all highlight neglect and abuse, we will not find solutions only in the failings of individuals, the socio-cultural system itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society and not just the striking off professionals from registers.

Sir Brian Jarman stated in a recent Lancet article:

“To improve the quality of care in UK hospitals, I would reintroduce the Independent Review Panels and Community Health Councils and develop monthly complaints alerts similar to the mortality alerts. Regulation would be more independent if the CQC reported in public to Parliament, and there would be better communication if it were integrated with Monitor. Additionally, it is important to ensure  there are minimum staff-to-patient levels of doctors and nurses, with 65% trained nurses and  regulation of health-care assistants (my emphasis). I would aim for

total physicians per head of population at the EU average. Ideally I would also like to see training  introduced for the boards of trusts and for them to
have equal representation of patients, clinicians,  finance, and managers. There has been a decade  of concerns about the quality of care in our
hospitals: patients have been ignored, the  regulatory systems have failed, and there has been a culture of denial”.Instead we get the mess that is the Health and Social Act which is supposedly a ‘reform‘, and the NMC engaging in ‘re-validation’.

When will we learn that inspection and revalidation are external post hoc care quality issues, there is of course a place for these processes but there is a need to ensure the quality of care is structurally built into care delivery systems – and that means ensuring that you have enough staff, enough of the right sort of staff, educate and support them and engage in continuing professional development, appraisal and performance management if necessary.

Nursing Revalidation

The Nursing and Midwifery Council > “Following a Council meeting on 12 September 2013, the NMC has committed to introduce a proportionate and effective system of revalidation which enhances public protection by the end of 2015”. On their website they have published background documents and set out their option.

“Revalidation will require registered nurses and midwives to regularly demonstrate that they remain fit to practise. The model agreed will require a third party (such as an employer or manager) to confirm that the nurse or midwife who is revalidating is complying with the revised Code. This confirmation will take account of feedback from patients, service users, carers and colleagues”.

I think this is unnecessary and query the evidence for its effectiveness. In thier draft revalidation strategy they argue ”

“Revalidation is the process by which registered nurses and midwives are required to demonstrate to the NMC on a regular basis that they continue to remain fit to practise. Revalidation not only promotes greater professionalism amongst nurses and midwives but also improves the quality of care that patients receive by encouragingreflection on the revised Code and standards”.

So, it promotes ‘greater professionalism’ and ‘improves the quality of care’. These are two very very strong assertions. When the medics had revalidation introduced, big claims were made for its benefits, based on a study from the Department of Health. However, is medical revalidation the same thing as that being proposed by the NMC? The doctors are having annual assessments and patient feedback. One study involved asking a total of 6433 patients aged 16 years to complete the consultation satisfaction questionnaire (CSQ). While it is useful getting patients’ views, other outcome measures regarding doctors’ actual performance were not tested. Another study similarly found postive benefits from multi source feedback but again did not test outcome measures such as correct diagnosis, treatment or follow up.

So what about the evidence for revalidation for nurses?  What studies show that the quality of care results from such processes?

Ensuring nurses are fit for practice can be done through appraisals, continuing professional development and performance management if need be. I wonder if rv is being introduced based on the recommendation of Frances, because of a failure of hospital management and the NMC’s need to be ‘doing something’?

The resource implications for phase one of implementation will be £4.431 million, with annual running costs thereafter of £1 million. This is peanuts compared to the annula NHS budget. I suspect that this cost will be born by registrants.

A key risk (of 6) indentified is that the process will be ineffective which then damages the reputation of the NMC. That risk is already in danger of being realised.

I would like to see robust studies,  that clearly establish a cause effect link between this layer of bureaucracy and actual improvements in patient care. I suspect however that care standards are rather more affected by other more important contextual and structural issues such as staff education ratios and resources. Dr Zara Aziz recently asked of medical revalidation:  “But is there any evidence that in its current form (which includes a lot of box-ticking and hours of evidence-collection) revalidation ensures medical improvements and patient safety?”. if questions about efficacy of medacl processes are being raised, we should treat this with a good deal of caution.

The NMC want a ‘proportionate’ and ‘effective’ system. Indeed that should be the goal. I suggest that we already have systems that are not working already and are inneffective. Perhaps we should address those first before spending more money.

An impact of male gender on the experience of illness

An impact of male gender on the experience of illness


CECIL R., McCAUGHAN E., and  PARAHOO, K. (2010) ‘It’s hard to take because I am a man’s man’: an ethnographic exploration of cancer and masculinity European Journal of Cancer Care 19, 501–509 

This paper reports on a study into male participation in cancer support groups, which elicited data on the impact of cancer on masculinities. This small qualitative pilot study, which took place in Belfast in Northern Ireland, involved semi-structured interviews with eight men with a history of cancer who were no longer being actively treated (i.e. they were not receiving chemotherapy or radiotherapy), and who were proficient in spoken

and written English. Whereas most studies into men with cancer that have looked at issues of masculinity have been on prostate and/or testicular cancer and have tended to focus upon sexual ability and activity, this study identified more sociological issues of concern that also present challenges to masculinity and to male identity.


Economic concerns were identified as being major issues for men, as were their changing role vis-à-vis their family, friends and colleagues, and changes to their body and to their body image.


The findings from this study indicate that cancer support services need to be gender sensitive in order to ensure that interventions do not undermine masculine values but address men’s concerns and foster their positive coping strategies.




Masculinities (and Femininities).


The above research indicates what being a man is and what values are held by men in Northern Ireland. Three issues seem pertinent for these men surviving cancer:


  • Money worries, perhaps the role of ‘breadwinner’ is undermined.
  • Their other roles in life and how cancer changes that.
  • Body image – virility and strength might be challenged.


These are the subjective experiences of this group of men, so that we can see that cancer not only brings about physical changes but also challenges the very idea of what it is to be a man. Are these men feeling a loss of control and power over their jobs, their lives and their women? In the context of testicular and prostate cancer the idea may be that loss of sexual function or perceived loss diminishes them both in their own eyes and in the eyes of wives and girlfriends.


But, what do we think being masculine actually means for other men? Are these ideas fixed in society?  Raewyn Connell discusses what being masculine means and considers that it is a dynamic concept, i.e. what it means to be a man is not fixed and can change over time and across a society. Masculinity is about where one sits in a power structure, and therefore there is more than one masculinity. So we must be careful to understand that a change in health status may be subjectively different for the metrosexual man, for example living in central London. Connell also refers to a ‘world gender order in which men continue to have power over women’.  A cancer diagnosis for a man will of course impact on his family and partner and if they are feeling challenged in the most fundamental aspect of their identity this may well impact on their on-going relationships. We might ask whether we have a set of norms and patterns for the ‘correct’ social response to these challenging issues.


The research paper suggests that those working with men diagnosed and treated for cancer might want to think about the values men hold , and clarifying with them their coping strategies. It clearly illustrates the psycho-social nature of a condition like cancer. A question remains though around how well equipped nurses feel they are in relation to these issues, is it easier to stick to bio-medical issues around treatment modalities, prognosis and coordinating support services.


Rabin (2009) also reported a US study which suggested:  “Men who strongly endorsed old-school notions of masculinity — believing the ideal man is the strong, silent type who does not complain about pain — were only half as likely as other men to seek preventive health care, like an annual physical”. This then suggest that how men  see and feel about themselves in this manner are putting themselves at risk of for example a too late diagnosis of cancer or other serious conditions such as hypertension.


This anonymous post form the US raises the issue of obesity, ethnicity and class in the relationship between men and their doctors, arguing that condescension, arrogance and rudeness on behalf of some doctors may also be class and racially based:


“The problem is, a LOT of doctors are rude, condescending assholes who may be very good scientists and diagnosticians, but are HORRIBLE at customer service!

For a lot of men – including myself – going to a 12:15 appointment but not being seen until 2 and then being told a whole lot of stuff that I already know AND having to deal with medical arrogance is insufferable!


At this point he is illustrating issues around access to health services – this relates to wider social structures around employment patterns for both men and women who now make up > 50% of the UK workforce, so access issues may not be gender specific but might have socio-economic foundations. In other words people on low incomes with less freedom to leave work during the day might put off going to the doctor unless they really have to. Consider the man with prostate issues or testicular lumps which might not be painful who then does not go to the doctor because of losing a day’s pay. This applies to those who have been labelled the ‘precariat’.

Add to that that I’m fat, African American and working class and multiply the rudeness factor x 20.  I know I’m going to be accused of being a fat pig and a glutton and will be branded as a liar if I comment on what I eat – I know the doctor won’t give a damn if I give him/her an accurate description of how I got fat in the first place – and I know that I will be blamed, guilt tripped, shamed and not listened to – why would I want to subject myself to that bullshit (AND have to pay a $ 20 co pay!)

If I want to be insulted for being fat, I can find some neighborhood elementary school kids who will do it for free!


Here he illustrates obesity as a ‘fatphobia’, or obesity as a personal moral failing which might be the default position of some healthcare professionals. The responsibility deal initiated by Andrew Lansley emphasises taking personal responsibility for health and seeking partners to do so. Being fat could be seen as not taking that responsibility. This view downplays or challenges the idea of an obesogenic environment. It buys into the cultural/behavioural explanation for health, i.e. that illness arises because of the your cultural habits and behaviours (eating junk food and smoking for example) and it also form part of the Moral Underclass discourse which focus on the failings of people themselves and locates the origins of illness in their ignorance and fecklessness.

Like a lot of men, I would NEVER tolerate that kind of rudeness in any other type of social setting, so why would I put up with it from some douchebag wearing a white lab coat?

I suspect women are socialized to tolerate much higher levels of disrespect and verbal abuse than men are – which might explain why they have a higher tolerance level for the verbal and psychological abuse that many doctors inflict on their patients.

They’d have to – because, from what women have told me, female medical exams are not only filled with insults and rudeness but procedures that are actually physically painful (like the mammogram and the speculum).

So, if doctors want male patients to come to get routine checkups, they need to learn how to talk to their patents with courtesy and respect – especially their fat patients, who need more medical monitoring than our skinny counterparts, but are more likely to avoid the doctor’s office because of all the bullshit that many doctors put their patients through.

The same goes with African Americans – we get a double dose of condescension and rudeness, get less pain management and in general get worse medical care than our White counterparts.

I actually had a White doctor at Columbia Presbyterian Hospital accuse me of “fraud” when i came to have a knee injury treated – and he also ordered me to “go to the clinic across the street, where the neighborhood people go” (that is, CPMC’s medicaid clinic, who’s patient load is almost entirely Black and Latino, as opposed to the clinics at CPMC, that treat affluent White patients from other neighborhoods).

In short, it’s not a “masculinity” problem – it’s a medical rudeness problem – and men
are just more likely to avoid doctors to get away from the rudeness and verbal abuse!”






Here we have an illustration of intersectionality, i.e. how class, ethnicity and gender interact to position a person in the social hierarchy and how this then affects health.


So, being a man in a particular subculture can be dangerous: you take risks occupationally which you  might not be able to avoid , for example in the construction industry, and you take risks with lifestyle choices because that upholds your idea of masculinity. Not going to the doctor because a) they are a different class and b) ‘that’s not what mend do’ and c) you cannot afford the time or money further places you into a place of risk of undetected health problems. However, gender is only one aspect of health seeking behaviour, morbidly and mortality patterns. Arguably low socio-economic status is  more important in explaining health inequalities.




See also:


Stets, J., and Burke, P. Femininity/Masculinity in Edgar F. Borgatta and Rhonda J. V. Montgomery (Eds.), (2000) Encyclopedia of Sociology, Revised Edition. New York: Macmillan. pp. 997-1005

The NMC and 3 yearly revalidation.

Here we go again.

Poor service? Always blame the staff and put them through their paces.

I may at times, and on sufferance,  frequent a well known national pub chain that seems to take over town centre premises, note a local theme for its development, and then provide cheap beer and wine in addition to ‘food’. Almost, but not quite, the Ryanair of pubs. I say ‘pub’ but that would be to commit a category error because these establishments are nothing like our treasured timber framed, CAMRA endorsed ‘Plumes of Feathers’ or the ‘Red Lions’ of shire and dale. They serve a particular purpose of course and do so very well. However one thing I often note is the long wait at the bar as the one or two members of staff work hard to serve the hordes of thirsty and often impatient public. As I stand and wait, as they also serve, I could grumble at their lack of attention to my needs, I could complain when they get stressed and do not greet me with bonhomie, I could recommend to friends and family that they give this place a wide berth, I could wonder about staff training and suggest that they undergo frequent testing and certification to ensure that they are up to the job, say every three years at least? But I don’t, because I know that like Rynair, budget pubs provide budget service. Employing more staff would mean perhaps an extra penny or two on the price of a pint and we don’t want to pay more for a pint do we? Well, it seems we will do so if the quality of both service and product increases, that is why the ‘Plume of Feathers’ still exist. When I go to my local, instead of one member of staff per 10 customers, I know the ratio is far far less. Not only that, I will be greeted with a suitable amount of bonhomie.

The Nursing and Midwifery Council however have forgotten this. In the media scrum preceding and following Frances, Keogh and Berwick, we have policy making by the Daily Mail, in perhaps a reaction to be seen to be ‘doing something’ we may have nursing  ‘revalidation‘  every three years? The doctors have it as well so what is the problem?

It blames the staff, focusing on their own failings while ignoring failures in organisational cultures, failures in staffing levels, ongoing training and professional development, clinical supervision. it ignores structural shifts such as dependency levels and throughput. It is blaming the bar staff for your wait, not the management for not employing more staff. It is expecting club class travel on Rynair and then complaining when you have to pay for your own peanuts.

Lets face it, the NMC is powerless to do anything about the structural problems facing the NHS, it can’t do anything about the myriad ineffectual inspection regimes, it is silent in the face of both the Nicholson Challenge and the further cuts asked of NHS provision. What is can do is ‘protect the public’ by imposing more bureaucratic, costly and probably ineffectual revalidation processes on 670,000 registrants. Watch this space for an increase in registration fees to cover admin costs.

What is the evidence base for this policy? The quality of service provision depends on many many things, is revalidation really going to make that much of a difference? The precedent set by doctors does not automatically apply to nurses, and it does just not follow that standards will improve by this measure.

What is does achieve is ‘doing something’, but will that result in better quality care? Will it promote greater professionalism? Having attended the annual NET13 conference, I can tell you there are thousands of professional nurses across the globe who wish to professionally  provide the best care they can. I was heartened to hear stories of success which I think occur despite not because of inspection, regulation and revalidation but despite it.  Professionalism already exists, what is required is not some stunt to, falsely, reassure the public that something is being done. To quote, Roy Lilley: “Fund the front line, make it fun to work there”  and reports such as Frances will be history.

Finally, do I really have to make the point that this is not a defence of abusive, lazy,  socio-pathic or burned out staff? Staff failures should be dealt with by proper management. Staff failures are also management failures. Performance management anyone?





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