Month: October 2013

Too posh to wash? Failures of the governing, managerial and political classes

Too posh to wash? Reflections on the future of Nursing.


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…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”. (C Wright Mills – The Sociological Imagination p9).



In the many contributions to the debate about poor quality care, there is often a distinct lack of a sociological imagination. While individuals can be rightly criticised for giving poor care, the antecedents are to be found beyond the personal trouble of individual nurses and their patients, and can be classed as a public issue: that of the political, social and economic failures of the governing, managerial and administering classes over the past few decades.


‘Too posh to wash’ is the title of a recent publication on the condition of nursing in 2013 and reflects newspaper headlines and the Health Minister, Jeremy Hunt’s, call to student nurses in March 2013. In it there is a range of contributions from various practitioners and experts on the delivery of care in the UK. They were asked to address various questions:


1. Why do we have lapses in nursing care and what needs to be done to prevent poor care back into caring?


2. In striving for professionalism have we over qualified yet undertrained today’s nurse? Are they too posh to wash? What mechanisms and support systems need to be in place to ‘bring excellence’ back into the profession?


3. Has the role of the nurse leader been devalued? Has respect for their knowledge and expertise and a desire to emulate them decreased?


4. Why have boards within both NHS and non-NHS organisations appeared to have failed to deliver the expected improvements in quality of care? Are board members unaware of the standards on their wards or in their care settings?


Various issues and solutions were raised but the answer to the title appears to be: “no”, students are not too posh to wash.  The myth of a golden age was shown to be just that – a myth. Menzies Lyth’s 1960 paper was quoted and is still worth a read today. I would also refer to Kath Melia’s work around the challenges students faced nearly three decades ago.


Among the normative statements made, i.e. what nurses ‘ought’ and ‘should’ do, there was some attempt at analysis of underlying reasons for poor care. This included societal attitudes to ageing and caring, and technology and is affects on communication. There was no call however to return to apprenticeship training outside the University. This accords with the findings of the Willis Commission (2012).


What was striking was the almost passing references to systemic failures within the NHS around the structures for providing care. These failures are the responsibility of the governing political and managerial classes who are charged with running the NHS. While we are acknowledging ageing populations, increasing frailties and complex care needs, there is a a requirement to examine the context of care. To examine what structures have been put in place to deliver care to increasing numbers of frail elderly people in acute hospitals and care homes. Student nurses in particular are placed in clinical practices which are not conducive to compassionate care, and are often the least equipped to understand, analyse and bring about change.


Universities can support the development of critical thinking and underpinning knowledge but are almost powerless to affect this care context in which students find themselves. No amount of curricular changes emphasising compassion and caring will work if students continue to experience Melia’s 1984 and Lyth’s 1960 descriptions of the care environment.


Menzies Lyth (1960) argued that nurses experienced high levels of anxiety due to their work and that there was an absence in the hospital of any mechanism through which to ‘positively help the individual confront the anxiety provoking experiences’. The result was a set of defensiveness techniques including the splitting up of the nurse-patient relationship. A more recent research report (Hillman et al 2013) also report ‘defensive practice’ resulting in an ‘us and them’ subject position regarding their patients as nurses felt the pressures of litigation, complaints and the pressing need to meet the managerial requirements of the organisation.


Melia (1984) outlined two competing ‘segments’ – the ‘educational’, focusing on learning, and the ‘service’ which focused on ‘getting the work done’. In learning to ‘fit in’ students experienced a transient approach to nursing implicitly supporting a lack of commitment to nursing as an occupation. This is mirrored in a 2010 study of Norwegian students in which it is argued:


“While clinical practice often has focus on practical problem-solving and procedures, the college tends to focus on abstract theory. Both of these promote the privatisation and neglect of the students’ experience of care. The paper concludes with a call for teaching and learning strategies targeting the use of nursing students’ personal experience of care”. (p73 Solvoli and Heggen 2010).


So, no ‘golden age’ then or now.


In the 2013 ‘Too posh’ document, three commentators pointed out the critical place that clinical practice experiences have which implicitly build upon Menzies Lyth and Kath Melia.  Professor David Sines argued that there needs to be:



1. dynamic placement opportunities for students that expose and challenge them to confront the complexity of health and social care, within, between and across clinical care pathways, supported by a curriculum that is ‘wrapped around the patient’s/user’s real experience and journey’;


2. robust, enhanced and effective mentorship and preceptorship partnerships with our Trusts;


These 2 ambitions will not be achieved in care environments where there is poor skill mix; care given by care assistants who may be poorly supervised and trained; poor staff-patient ratios and minimal professional support and development. Sines goes on to argue:

“Above all our next generation workforce requires access to expert mentorship and role models to nurture and inculcate excellence in practice and resilience in attitude to deliver optimal standards of care at all times, turning each patient encounter into a learning opportunity that leads to sustainable excellence” (p15).


Again this is a key issue: ‘Access to expert mentors’. Far too many students report the lack of both access and the quality of support in this area. Therefore this may sadly, in the current context, be too idealistic. This might be born out by Bradbury Jones et al (2011) who reported that not all students have a positive experience:


“Unfortunately there were many examples of disregard and disrespect of students as learners. Lack of encouragement and responsibility were significant issues and this had a negative impact on students’ knowledge and confidence. These findings are consistent with nursing literature in terms of lack of support and encouragement and specifically, lack of interest in learners (Lindop, 1999). The findings also mirror those of Levett-Jones and Lathlean (2008), who reported that while a number of students in their study had positive placements, too many had experiences where their learning was not optimised and their competence and confidence were negatively affected. Like the students in this study, Levett-Jones et al. (2009) found that some mentors seemed to disregard students’ feelings and made little attempt to hide their impatience and frustration” (p371).



Maura Buchanan also focuses attention on the clinical environment:

“ I would argue that the main responsibility for failing standards lies not with nurse education, rather, with the clinical practice environment for which employers must take blame” (p17).


Jenny Aston also points to deficiencies in the clinical environment:


“With university based training (sic), considerable responsibility is left with the placement mentor to ensure that students have the necessary hands-on nursing skills. Many students have minimal one-to-one learning from their clinical mentors,who are busy with their own responsibilities, and have little or no protected time to teach the essential skills…University lecturers rarely have the time to visit, let alone work, in the clinical areas”. (p21)


The responsibility for safe compassionate care rests with Trust boards. NHS management has taken its collective eye off the ball and is often ill equipped to know if poor care is being given. Universities cannot do the work for Trust boards. Any call for a return to apprenticeship training within NHS trusts must address this fundamental issue. In far too many cases there are insufficient governance practices in place to ensure care standards are upheld. Aston argued:


“There is a need for governance measures to be in place to ensure that care is of a high standard as there will always be a conflict between cost and quality. Board level

decisions need to be based on a good understanding of how care can best be delivered and measured so on the ground clinicians need to be informing high level decision makers. Great care needs to be taken to measure the right things and not just numbers; otherwise real improvements will not be demonstrated. An experienced pair of nursing eyes and ears can identify good and bad care in a way that complex audits or form filling may fail to achieve”.


Roy Lilley has often stated: ‘Fund the front line. Make it fun to work there, that way you will make Francis history”. Nurses and nursing students have been criticised as lacking in compassion. No doubt this is true for some nurses. However, it is the lack of governance and poor clinical environments that both grows uncaring attitudes and fails to weed them out. Trust Boards through excellent management must implement strategies that ensure the front line is properly supported and developed.


When only 1 nurse provides poor care, that is their personal trouble….when we have had a catalogue of reports into poor care,  that is a public issue and we should not find the solution in the situation of any one nurse. We must look into the economic and political nature of NHS Trusts and of society to move beyond criticisms of individual nurses and their personal failings.

















Beer, G. ed. (2013) Too posh to Wash.  Too Posh to Wash?


Bradbury Jones, C., Sambrook, S., and Irvine, F. (2011) Empowerment and being valued: A phenomenological study of nursing student’s experiences of clinical practice. Nurse Education Today. 31 p368-372


Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. doi: 10.1111/1467-9566.12017  pp1-17


Levett-Jones, T., Lathlean, J. (2008) Belongingness: a prerequisite for nursing students’ clinical learning Nurse Education in Practice, 8 pp. 103–111


Levett-Jones, t., Lathlean, J., Higgins, I., and McMillan, M. (2009)

Staff-student relationships and their impact on nursing students’ belongingness and learning Journal of Advanced Nursing, 65 (2) pp. 316–324


Lindop, E, (1999) A comparative study of stress between pre- and post-Project 2000 students Journal of Advanced Nursing, 29 (4), pp. 967–973


Menzies Lyth, I. (1960) The functioning of social systems as a defence against anxiety. Human Relations. 13 (2) 95-121


Melia, K. (1987) Working and Learning: The Occupational Socialisation of student nurses. Tavistock press. London.


Solvoli, B., and Heggen, K. (2010) Teaching and Learning Care – exploring nursing students’ clinical practice. Nurse education Today. 30 (1) p73-77


Willis Commission (2012) Quality with compassion: the future of nursing education.


Wright Mills, C. (1959) The Sociological Imagination. Oxford University Press. Oxford.


Indur Goklany and Daniel Ben-Ami on health, climate change and progress: A necessary corrective to Costello et al’s climate change health ‘propaganda’, or co-opted apologists for the neoliberal hegemony?



The health impacts of climate change have been much discussed internationally, however there is some disagreement about the magnitude of those effects, when they will occur and what the right course of action is. Underpinning those disagreements is a joint uncritical acceptance of the fundamental structure of the political economy of late modern capitalism (neoliberalism), with the differences being around whether climate change requires more immediate public policy intervention or whether capitalism will address the health issues though economic development. In other words, both use the frame of reference of capitalism to argue for more market freedom v statist intervention. This paper seeks to outline the arguments over the health effects of climate change while rooting that discourse within wider often background taken for granted political economy. Two writers, Indur Goklany and Daniel Ben Ami will be used to represent the critical camp in riposte to Costello et al’s 2009 Lancet paper on climate change and health.


Climate change ‘debate’


The Intergovernmental Panel on Climate Change 5th Assessment Report (IPCC 2013) argues that scientists are 95% certain that humans are the ‘dominant cause’ of global warming since the 1950’s (McGrath 2013). Thomas Stocker, IPCC co-chair stated:  “…in order to limit climate change, it will require substantial and sustained reduction of greenhouse gas emission…” (BBC 2013). Despite this, there is continuing doubt, denial and a focus on uncertainty in many countries, especially in news media, that Climate Change is human induced and that it requires radical shifts in public policy. See for example Delingpole (2013) in the United Kingdom and particularly in the United States and Australia (Painter 2013). The UK’s Owen Paterson, secretary of state for environment, food and rural affairs, told the 2013 Conservative party conference not to worry about global warming. “I think we should just accept that the climate has been changing for centuries.” (Syal 2013). Previously on BBC television’s ‘Any Questions’, he repeated ten discredited claims about climate change (Mason 2013).


This sits in opposition to many in the medical and public health domain. The World Health Organisation accepts IPCC assessments and considers climate change to be a ‘significant and emerging threat’ to public health (WHO 2013 a,b), while previously ranking it very low down in a table of health threats (WHO 2009). In the United Kingdom, Costello et al (2009) argue that climate change is a major potential public health threat that does require major changes such as action on carbon emissions. In addition, Barton and Grant’s health map (2006) has in its outer ring ‘Climate Change, Biodiversity and Global Ecosystems’ as key determinants of health and supports the WHO view that alongside the social determinants of health, health threats arise from large scale environmental hazards such as climate change, stratospheric ozone depletion, biodiversity losses, changes in water systems, land degradation, urbanisation and pressures on food production. WHO (2013c) argues:


“Appreciation of this scale and type of influence on human health requires a new perspective which focuses on ecosystems and on the recognition that the foundations of long-term good health in populations rely in great part on the continued stability and functioning of the biosphere’s life-supporting systems”.


It is this call for a ‘new perspective on ecosystems’ that indicates why there is a backlash that underpin long standing critiques of the link between climate change, environmental issues and human health. Many of those critical are libertarian, anti state conservatives defending the neoliberal hegemony of free market dogma which ‘new perspectives’ may threaten.  For example, Stakaityte (2013) argues:


“Free market proponents are quick to point out that the whole climate change issue has been used to stifle freedom and to expand the nanny state – and they are right. If the climate is changing, and if humans really are responsible, the market will adapt”.


The WHO call for a ‘new perspective’ however is not a radical critique of neoliberal capitalism or a call for its replacement by other political economies. It sits within an overarching acceptance that capitalism is the only economic model, and that only its particular current form requires changing, for example by investments in green technologies.


Critical discourse over such an important issue is crucial. Argument should proceed over matters of empirical facts, within discourses of risk and an understanding of scientific uncertainty (see Painter 2013). Attention also should turn to philosophical positions on political economy in which the dominant neoliberal hegemony (Crouch 2011, Plehwe et al 2006) attempts to build and maintain a sceptical view in the media on climate change and on alternative, including no growth, economic models (Jackson 2009) because it is antithetical to ‘nanny state’ intervention implicit in public health ‘upstream’ analysis.


Health Impacts of climate change and the policy response


Indur Goklany and Daniel Ben Ami respectively are noted writers on the topic and both are in the sceptical camp regarding what to do about climate change. Both however appear to accept the fact of climate change, they just don’t agree with the focus on carbon reduction targets. They are both far more nuanced in their arguments than other commentators such as the UK’s James Delingpole; Andrew Bolt of Australia’s Herald Sun and Steve Molloy of the United States’ Fox News. However, Goklany is associated with the Heartland Institute, but care should be taken not to debunk his thesis merely because he publishes at that anti climate change organisation.


For the health community that makes decisions on what the main threats to health are, there is a need to carefully weigh up the evidence for threats to population health in the short, medium and long term, or what Goklany calls the ‘foreseeable future’. This means addressing Goklany’s argument, especially, on the ranking of health threats and Ben Amis’ argument on progress. For Goklany the health threats are not from climate change, nor will they be for the foreseeable future. For Ben Ami, the answer lies in any case of more progress based on economic growth and development.


Both Goklany and Ben-Ami’s faith in human progress is based on inductive reasoning, ignores the key statistical problem of exponential growth, and may be over confident that limits have been correctly identified or can be overcome. Goklany might turn out to be empirically correct that in the ‘foreseeable future’, defined as 2085-2100, climate change will not be the major threat to public health, however this line of reasoning gives support to the denial of climate change in particular and obscures the requirement of addressing the sustainability of current economic structures. It also sidesteps addressing the language and discourse of risk (Haggett 2010, Painter 2013) which includes considering that human action should not be based on total certainty but on the assessment of the probabilities of high and low impact events. However, the position taken by both writers is that humanity needs more capitalist economic and technological development even if that results in a warmer world.


Goklany (2012) argues that humanity, in developing and using fossil fuels, both freed itself from the vagaries of nature’s provision and also has saved nature from humanity’s need to turn more of it into cropland. The inference from this argument is that we ought to continue to use fossil fuels to further human progress and to save nature from ourselves. Increasing global GDP, i.e. a wealthier world, would also be better equipped to deal with future global warming issues (Goklany 2007). This is inductive in that it assumes that this past pattern of innovation will be repeated in the future.


Daniel Ben-Ami (2010) also forwards this argument in ‘Ferrari’s for all –a defence of economic progress’. He points out that we are living longer and healthier lives than ever before thanks to economic development and growth. Therefore, inductively, we need more growth. The book is also based on the idea that humanity is apart from nature – human exceptualism – and is capable of enormous technical, cultural and progressive ingenuity. Humanity should strive to achieve more in terms of economic development so that everyone should have access to a Ferrari if they want it.


It is a counter to what he terms ‘growth scepticism’, i.e. the “tendency to undermine economic progress by indirect means” (p3). If populations are to be in better health and free from poverty then the only answer is more of the same. Those who suggest climate change is a health threat do not address this economic and development argument head on, there may be implicit acceptance of the current economic models of development. Instead there is a focus on the magnitude of climate change per se as a health threat rather than the economic structures which may drive climate change and other unsustainable practices such as deforestation.


Costello v Goklany


So, Costello et al (2009a) argued that climate change is the biggest global health threat of the 21st century’ (p1693). Goklany in the same year replied and argued that climate change is not the number one threat to humanity and questioned whether it is “the defining challenge of our age” (Goklany 2009a). Costello replied to Goklany’s riposte again in 2009, but Goklany in 2012 further rebutted that claim.


Goklany argued Costello et al made their claim about climate change in 2009 without a comparative analysis of the magnitude, severity and manageability of a range of health threats at that time and therefore ranking it as the No 1 threat is untenable. Goklany (2009c) argued that climate change was ranked 21st out of 24th global health threats. Goklany’s rebuttal data comes from a World Health Organisation World Health Report 2002 and Comparative Quantification of Health Risks 2004 and he uses results from “Fast Track Assessments” (FTAs) of the global impacts of global warming (Arnell et al 2002, Parry 2004). In his 2012 article he also cites Parry (1999) and the World Health Organisation’s 2009 Global Health Risks.


Costello et al (2009b) in reply to Goklany argued that “The ranking of climate change at 21st out of 26 risk factors was made at a time when global temperature rise was only 0·74°C, and when the effects of climate change on the other risk factors was unclear” and they claimed that there has since been substantial changes in our understanding of climate change risks. They cite two papers showing that about 1 trillion tonnes is probably the cumulative limit for all carbon emissions if we wish to stay within the 2°C “safety” limit, and that, without action, we shall exceed this limit before 2050.  They also cite a paper by Schneider (2009) who raised the prospect of worst case scenarios: warming at 3°C gives a 90% probability that Greenland will melt, raising sea levels by many metres, and that on present evidence and trends there is a 5—17% chance that temperatures will go up by 6·4°C by 2100, “a risk way above the threshold at which people would usually buy insurance”.  Goklany’s position (2012) is that the 2 degree target is irrelevant in any case and he seems happy to accept a 4 degree rise.


The 2013 IPCC report AR5, while accepting a pause in warming over recent years, argues that climate change is a continuing very serious issue and now post dates this difference in Goklany and Costello’s arguments which are based on data from 1999 to 2009. This will need constant revision as more scientific data is published. The IPCC WGII contribution on ‘impacts adaptation and vulnerability’ is due to be reported in March 2014. The report makes it clear that even if greenhouse gas emissions are stopped right now climate change will persists for many centuries, much of it will be irreversible characterised by impacts such as sea level rises. The last time the world was 2 degrees warmer , sea levels were 5 -10 metres higher.


On what to do, Goklany (2009c) argues that ’Societal resources devoted to curb carbon dioxide and other greenhouse gas emissions will be unavailable for other…more urgent tasks including vector control, developing safer water supplies or installing sanitation facilities in developing countries….’ (p69). However this sets up a false dichotomy. The decision to spend on carbon reduction is not an either/or one. There are myriad spending decisions being made, and those choices are made from a raft of competing priorities. One could equally argue that resources devoted to nuclear armaments and other military spending is unavailable also for these other urgent tasks. So to focus on emissions reduction as the spending that diverts funds away from addressing other pressing health issues is a biased view. Goklany could argue for an end to subsidies for the fossil fuel and nuclear industries, reductions in military spending, changing the international tax regimes to access wealth deposited in offshore accounts, or the introduction of a Tobin tax on financial transactions. These are admittedly biased positions and may be seen to be too left wing, and ideologically incompatible with current the neoliberal hegemony (Crouch 2011).


Whether funding spent on carbon reduction actually works in terms of human welfare and is less expensive than alternatives, is a valid question but has to be seen in a wider political discourse about spending decisions. His points regarding the need for poverty reduction via sustainable economic development and advancing our adaptive capacity would possibly bring broad agreement. In any case some consider that it is too late (Peters et al 2013) for mitigation and that adaptation to a warmer world is now needed. Goklany (2009b) uses the term ‘focused adaptation’ meaning taking advantage of the positive benefits of warming. If sea levels are to rise by 5-10 metres this is beyond the foreseeable future and so we should focus on economic growth and development to adapt to those future scenarios rather than wasting time resources and energy on emission curbs. However, this seems somewhat an anthropocentric view taking in little regard for biodiversity loss and ocean acidification. Both of which are also threats to human health


Ben Ami and Goklany put faith instead in ‘secular technological change’. This believes that


1) Existing technologies will become cheaper or more cost effective.

2) New technologies that are even more cost effective will become available.


They may well be correct. They argue the potential health threats may be addressed through human ingenuity based on economic progress and economic progress is best served by accepting the IPCC worse case scenario which would result in greater per capita GDP and thus release capital for adaptation (figure 1).





Figure 1: net GDP per capita, 1990-2200, after accounting for upper bound estimates of losses due to global warming for 4 IPCC scenarios. The warmest is A1FI (4 degrees C) and the coolest is B1 (2.1 degrees C) (source Goklany 2012)



Figure 1, therefore, indicates that if humanity has a choice, it ought to strive for the developmental path corresponding to the richest IPCC scenario (A1FI  – 4 degrees C above 1990 by 2085) notwithstanding any associated global warming. Because this increases adaptive capacity and poverty would be eliminated. Other health risks that rank higher than global warming are also associated with poverty and would thus also be eliminated. Poverty related diseases contribute to mortality and morbidity 70-80% more than warming. Mitigative capacity would be increased, therefore health improves with economic and technological development, and development encourages the ‘environmental transition’.


This is a very risky strategy which future generations will have to judge the merits of. There is gathering evidence beyond climate change suggesting that humanity is already transgressing other environmental limits, transgressions which will not support a ‘safe operating space’ as we enter a new era, the ‘anthropocene’. (Rockstrom et al 2009).


Risk Discourse


Goklany (2012) further argued “This paper does not address hypothesized low-probability but potentially high consequence outcomes such as a shutdown of the thermohaline circulation or the melting of the Greenland and Antarctica Ice Sheets, which have been deemed unlikely to occur in the foreseeable future by both the IPCC and the US Global Change Research Program, among others”, although the IPCC has since (2013) stated that it is “very unlikely that the Atlantic Meridional Overturning Circulation (part of the global thermohaline) will undergo abrupt transition or collapse…however, a collapse beyond the 21st century…cannot be excluded” (IPCC 2013 SPM-17).

Goklany, in not addressing these risks, appears to dismiss the need for ‘risk discourse’ to frame public debate relying on ‘kicking into the long grass’ serious consequences of climate change.


‘Risk’ is already an essential part of everyone’s experience, including in the world of insurance, health and investment. It is not uncommon for people to insure against low probability but high impact events such as house fire, or critical illness. People also invest for the long term, for example in a pension that might take over 40 years to pay off. It is thus arguable that the thermohaline shutdown and ice sheets melts may well be just the sort of low probability but high impact events that humanity ought to be insuring against and taking measures to prevent through carbon emissions reductions. Painter (2013) suggests therefore that elements of risk discourse would provide a better frame for debate than disaster and uncertainty frames, which are both more prevalent in news media.


Space precludes an examination of the concept of exponential growth and the requirement to produce resources to meet the needs of potentially 9-10 billion people by 2050. Costello et al’s position seems to be that climate change will stress ecosystems before we have time to adapt and that both direct and indirect affects will adversely impact on global health. They are not so sanguine about our ability to live within our limits.





Goklany is correct to point out that currently that health threats arise from poverty and underdevelopment. In this assessment he is in accord with the WHO social determinants of health approach. Costello et al have not dismissed this and as public health experts would probably accept a similar position. A focus on the social determinants of health to address poverty needs to run alongside carbon reductions or else the good work could be undone by a low probability but high impact event such as the melting of the Arctic Ice. They differ on when climate change will be a health threat and importantly on how to address it. Goklany and Ben Ami appear to be on the market driven economic development model as the answer whereas Costello et al argue for more immediate state and public intervention in addressing climate change. All however do not critique the fundamental neoliberal economic model or call for alternative economic ‘no growth’ models (Jackson 2009).  There is little doubt that we are running an experiment with the climate, there is agreement that this will impact on global health but the answer seems to be either more or less tweaking with capitalist growth models rather than a sustained examination of alternatives.


















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Care Quality in the NHS. We can do better than this.

Care Quality in the NHS. We can do better than this.


Just published: a research study into culture and behaviour in the NHS. Dixon-Woods et al (2013) undertook a mixed method study from multiple sources using surveys, ethnographic data, board minutes, publicly available data sets and interviews. The reasons for doing this of course are well known post Francis and Keogh. So what did they find?


“an almost universal desire to provide the best quality of care…bright spots of excellence…but considerable inconsistency”.


The reasons put forward will resonate to many interested in quality and management issues in the NHS. Nonetheless it is useful to have some empirical data to support what we think we already know. Working against the desire to provide high quality care are the usual suspects:


1. Unclear goals

2. Overlapping priorities that distracted attention.

3. Too many external regulators

4. Poor information systems

5. Variable management and staff support


They concluded “…put the patient at the centre…get smart intelligence, focus on improving organisational systems, nurture care cultures by ensuring staff feel valued, respected, engaged and supported”. This last sounds like Roy Lilley’s oft quoted ‘fund the front line, make it fun to work there…’


Where does one start with this little list? First…get those pockets of excellence out in the light, let everyone see exactly how some are getting it right. Network, share, talk!


There are many intelligent people in the NHS, some of the staff are the cream of the educational system and others, what they lack in super cognitive functions, they more than make up for in commitment and care. What is lacking is the organisational foundations to harness this.


Nurses tell me that they have little or no time for professional development, clinical supervision or networking because they fill their time with giving care. They are already ‘putting the patient first’ but they lack ‘smart intelligence’, i.e. data that tells them that care is good or poor. Instead they are bombarded by other data that provides managerial information but little in the way of the patient’s actual experience. My blind uncle’s cup of tea being placed on the other side of his bed out of reach and with no verbal communication to tell him it was there, is a bit of data that does not get fed back to anyone. The RN’s need to be able to know if poorly trained staff require performance management. They need an ‘organisational system’ that allows the supervision and training of support staff that they oversee so that cold cups of tea are not left bedside.



Managers need to give more than lip service to making staff feel valued, respected, engaged and supported. And that is the crux, because Trusts chasing other organisational goals are liable to take their eye of this particular ball, measure success in terms that do not relate to the care experience and are liable oversee a culture in which staff become disengaged, disillusioned, distracted and demoralised.


The issue is of course wider than Trust and NHS management. It is about the value society is willing to place upon care, and thus how society structures itself to provide that care. Are we then asking too much of Trust managers?


It is of course the case that the vast majority of care is done outside the NHS most often by family, most often by women. This of course applies to both health and social care. This is the socio-political context in which the NHS has to work, picking up the pieces when care cannot be given by this informal unpaid army. The NHS can intervene magnificently when that care need is medical or surgical, but it just was not designed for the sheer number of frail elderly people requiring some form of care. Neither is society now structured to cope.


Social and geographical mobility that fragment communities and families; different societal and individual expectations; the changing demographic of an ageing population; longevity and medical advances that keep us alive but also result in many more experiencing chronic illness that requires supervision and care; the unglamorous nature of care; the still gendered nature of care; the structure of financial penalties for leaving the job market or career ladder to look after ‘mum’; the structure of rewards that channels money into socially useless bullshit jobs; the structure of rewards that sees prizes, fame, medals, celebrity heaped upon narrowly talented non entities too often still just out of nappies; the ability of the feral elite to ferret the lion’s share of the nations’ wealth into offshore tax havens; a government that sees public service and the public sector as dirty words; a government that is leaving it to the market to sort out, an education system working for the minority while the majority compete against each other in a rigged system; a job market increasingly characterised by an increase in low skilled, part time, low waged employment; a private sector that will not rightly touch getting involved in care, a risk averse managerialist, bureaucratic and financial accounting approach to care…


In short, care costs, but the costs are externalised onto those who too often are unable to pay. We have increasingly individualised the risks and costs arguing that health and social care cannot be afforded by the state, especially now in times of ‘austerity’. The State is not the same thing as society but society needs some organising structure to put its values into action. We have left the values of individualism and market freedom blind us to the changing nature of society and the care pressures that come with it. We are now ill equipped in many areas to provide the context for high quality care.


A question then can be raised about whether the bright spots of excellence exist despite the overall socio-political context? Could the NHS better foster those bright spots if its supporting context was different?


NHS is not just about Trust management, it is also about society having a different vision.







The democratic deficit: who runs the country?

The end of democracy now!

No, this is not a call to end democratic politics but to acknowledge it’s demise. We must acknowledge our inability to control our affairs, our politics and our social policy. We have sleep walked into a situation whereby we have ceded power to unelected and barely accountable corporations and markets. The neoliberal state has become the bedfellow for undemocratic power. This is now happening across the globe. The triumph of corporate power exists despite the financial crash of 2008. Rather than pulling the edifice down, corporate power has succeeded in harnessing the resources of the state for it’s own purposes. Civil society has been silenced or ignored in the process.

The paradox is that while espousing ‘Free’ Market ideology (neoliberalism) which calls for the withering away of the state, corporate power has entailed state intervention on a scale that might make a Marxist blush. Resources and power have been transferred from individuals and civil society to a global elite whose only interest is profit and monopoly capital.

They peddle a false dichotomy of private sector = good, public sector = bad. This is ideology. There is no homogenous private sector, an examination of non government private sector organisations reveals a huge diversity: some highly efficient global corporations, SME’s close to their customers, financial institutions that nearly brought the economic house down, firms using sweatshops, exploiting child labour, firms making shoddy goods, down market cafes and restaurants serving unhealthy and unhygienic foods, building firms that never complete on time, media and satellite companies fighting to monopolise, polluting mineral extracting companies which have had little regard to environmental concerns…there is no such things as ‘the’ private sector about which generalisations about efficiency, quality and customer relations can be made.

In addition the line between the private and public sector is blurred as Corporations are now involved in the running of public services to such an extent that they are now involved in social policy with little involvement of the publics they serve.

So, the state, the Market and corporations form a triumvirate of power usurping the democratic power. The fourth voice of civil society is now urgently needed. We need to call to account, to harass and to investigate the misdeeds and greed of the other three voices. This is to thus acknowledge that in becoming consumers we have abrogated our responsibilities as citizens, and thus we will get the social and political policy we deserve unless we exercise our voices loudly. We must speak truth to power and do so before we are further impoverished and diminished as subject rather than sovereign citizens.

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