The BBC and The IPCC working group 2 report on Climate Change

The BBC and The IPCC working group 2 report on Climate Change.  30th March 2014.

 

As part of its periodical Assessment Reports, the Intergovernmental Panel on Climate Change (IPCC) has just published working group 2’s (WGII): Climate Change 2014: Impacts, Adaptation and Vulnerability’. Before I get onto the content, the spin, has inevitably begun but sadly on the BBC radio 4 today programme. The chair of WGII was interviewed by Justin Webb who is gaining a reputation as a climate change sceptic. As part of the interview Webb focused on the economist Dr. Richard Tol’s withdrawal of his name from the report on the grounds that the report was not positive enough on the benefits of extra carbon dioxide. The report, Tol said, was too alarmist. His disagreement is how science actually works, but Webb’s focus on this point supports those who think the science is not settled enough.  The report itself was a result of a team of 70 scientists working on revisions so it is not surprising that at least one will disagree with the final report and will wish to remove their own name.

Tol’s argument appears to centre on farmer’s ability to adapt to new circumstances and that carbon dioxide is actually good for plants, a point accepted by WGII. The IPCC, in their video,  state that yields would not have improved without climate change which is neither alarmist or underplayed. It is a fact.  Adaptation is now clearly on the stage as well as mitigation, they are complimentary according to WGII. Adaption will bring benefits to some sectors and populations, but clearly mitigation (reducing emissions) has to run alongside adaptive responses. If we don’t try to mitigate, we run the risk of the climate overpowering adaptive systems. Low probability but high impacts events like the melting of the Greenland Ice sheets should lead us to consider insuring against that risk and trying to prevent it.

We might ask if the media is responsible for supporting scepticism on climate science; Does the media, in the interests of ‘balance’ give too much time to climate change sceptics?

Alistair Burnett , editor of the World tonight argued in 2009 “From the BBC’s perspective, the answer to this question is that our journalistic role is not to campaign for anything. Impartiality means not taking sides in a debate, while accurately representing the balance of argument. So, in the case of climate change we need proportionately to reflect the sceptical view but also, for example, reflect the debate among climate scientists about the most effective way of dealing with global warming”.

The word here is ‘proportionate’.  So 1 scientist in 70 wants his name removed from the final report. Perhaps Webb could have mentioned this and moved on the explore the more substantial discussion regarding adaption and mitigation.

More recently, February 2014, the BBC responded to complaints regarding the inclusion of Lord Lawson on the Today programme: “We believe there has to be space in the BBC’s coverage where scientific consensus meets reasonable argument about the policy implications of that consensus view. That said we do accept that we could have offered a clearer description of the sceptical position taken by Lord Lawson and the Global Warming Policy Foundation in the introduction. That would have clarified in the audience’s minds the ideological background to the arguments”.

 

There are very real debates to be had on this issue and the adaptation and mitigation angle is very pertinent. The good news is that, at last apart from a very few,  most accept the fact of climate change. It is what we do about it that is causing the heat. The BBC can help by reflecting the science, and ensuring we know what the ideological positions of prominent, and financially supported, sceptics are.

Nurse -patient ratios – what is the evidence?

Peter Griffiths of Southampton University wrote on the researchgate site:

“…..this is an area with a massive literature. The positive association (between more nurses and better patient outcomes) has been demonstrated against a range of quality and safety measures – primarily safety. Linda Aiken is not the only researcher in the area but possibly the best known. 

Try : Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., Wilt, T.J., 2007. The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care 45 (12), 1195-1204 1110.1097/MLR.1190b1013e3181468ca3181463.

…for a comprehensive if slightly dated overview of the safety literature.

Recent reports from the RN4CAST study show associations with other outcomes e.g.:

Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E., Griffiths, P., 2013. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety.

Aiken, L.H., Sermeus, W., Van den Heede, K., Sloane, D.M., Busse, R., McKee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L., Kutney-Lee, A., 2012. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. British Medical Journal 344.

Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Sermeus, W., 2013. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50 (2), 143-153.

…although limited as they are all self report.

The translation of this to specific ratios is difficult – largely for the reasons highlighted above and the evidence on that policy is less clear cut. Try

McHugh, M.D., Brooks Carthon, M., Sloane, D.M., Wu, E., Kelly, L., Aiken, L.H., 2012. Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California. Milbank Quarterly 90 (1), 160-186.

For a favourable gloss.

Some of the limitations are covered in:

Griffiths, P., 2009. RN+RN=better care? What do we know about the association between the number of nurses and patient outcomes? International Journal of Nursing Studies 46 (10), 1289-1290.

…one issue that is very germane for many health sectors is the absence of medical staffing from this literature. See

Griffiths, P., Jones, S., Bottle, A., 2013. Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? Observational study. International Journal of Nursing Studies 50 (2), 292.

 

I would add:

This question is rooted within a wider context – that of managerialist control of care environments (Traynor 1999, Lees 2013) in which efficiency, effectiveness and economy are to the fore. This approach can militate against the consideration of qualitative, non measurable, outcomes which make a real difference to patients’ experience (Tadd et al 2011, Dixon-Woods et al 2013, Hillman et al 2013). The reality is that many health and social care sectors, in the UK, are under such financial pressure and managerialist control,  that the quality of the care experience is squeezed. Given current narratives of austerity, female undervalued labour and ‘private = good public = bad’, UK society has accepted that for example long term care of older people, and mental health, have to fight their corner for government and personal funding. I suspect that funders (e.g. DoH and FTs) ignore evidence, in any case, of staff-patient ratios, viewing it as idealistic and costly. However, they will not frame it in this way – the response will be that ratios are a blunt tool and should not be set down in terms of basic minimums. While I think it is imperative that evidence comes forth on this topic, we might need to consider that the translational model of evidence to policy is flawed. In the context of climate science,  Pielke (2010) describes the actual relationship between public policy and scientific research as problematic; it is not a linear ‘evidence to policy’ model.  The translational model, or ‘knowledge translation’ (Kerr and Wood 2008), in which scientists come up with answers which are then put into practice by policy makers (Wynne 2010) is contextualised within political and ideological frameworks such as that of neoliberalism and its adjutant, managerialism.  Naively we may think that the job of scientists, and their allies, is to improve the process of knowledge translation so that policy makers, guided by clear evidence, can make the right decisions. Drugs policy research is another example of the failure of this model. In nursing, even if we had irrefutable evidence, there is no necessary link to this and health policy on nurse staffing. The UK’s NHS is a ‘highly politicized setting’ (Traynor 2013), staffing of wards is as much a political as an empirical question.

Dixon-Woods, M., Baker, R., Charles, K., et al (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety (published online) http://www.ncbi.nlm.nih.gov/pubmed/240195079th September 2013 accessed February 25th 2014
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. 35 (6) pp 939-955
Kerr, T., and Wood, E. (2008) Closing the gap between evidence and action: the need for knowledge translation in the field of drug policy. International Journal of Drug Policy 19 (3) pp 223-234
Lees, A., Meyer, E., and Rafferty, J. (2013) From Menzies Lyth to Munro: The problem of Manageralism. British Journal of Social Work. 43 (3) 542-558
Pielke, R. (2010) The Climate Fix. Basic Books. New York.
Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton
Traynor, M. (1999) Managerialism and Nursing: beyond profession and oppression. Routledge. London
Traynor, M. (2013) Nursing in Context. Policy, Politics, Profession. Palgrave Macmillan.
Wynne, B. (2010) Strange Weather, Again. Climate Science as political art. Theory Culture and Society 27 (2-3): 289-305

Funding cuts to nurse education – austerity hits students

“Universities say nursing education has reached a “tipping point”, with proposed funding cuts putting the quality of courses and ultimately the quality of nursing care at risk”

The funding cuts and increase in student numbers may well have a detrimental affect on the learning experience. To address it we have to adopt new methods – some of which we need to do anyway – such as increasing use of web 2.0 technology for example ‘webinar’ presentations and discussions. Simulations are expensive and time consuming and allied to pressures on mentors, we have an overall picture of stress on the system. This will increase the call to take education back into the NHS, to see students as part of the workforce and not supernumerary, and the adoption of training rather than education. The wider context is the increasing control of nursing for managerial reasons within the contested economic policy of austerity. The country largely believes there is no money for education, health or welfare. In addition the policy is one of creating a market for those public goods based on the idea of a ‘consumer’ exercising rational choices. That is why the student pays fees so that through a market mechanism they will drive up quality by only buying education from quality providers. That is the theory. There is money – its just that it is in the hands of the few that gov’t dare not touch.

In a report, a Tale of Two Britains, Oxfam said the poorest 20% in the UK had wealth totalling £28.1bn – an average of £2,230 each. The latest rich list from Forbes magazine showed that the five top UK entries – the family of the Duke of Westminster, David and Simon Reuben, the Hinduja brothers, the Cadogan family, and Sports Direct retail boss Mike Ashley – between them had property, savings and other assets worth £28.2bn.

The UK study follows an Oxfam report earlier this year which found that the wealth of 85 global billionaires is equivalent to that of half the world’s population – or 3.5 billion people. The pope and Barack Obama have made tackling inequality a top priority for 2014, while the International Monetary Fund has warned that the growing divide between the haves and have-nots is leading to slower global growth.

This is the real issue – inequality politics resulting in an impoverished public sector. JK Galbraith way back in 1958 argued that a feature of advanced capitalism was that public (sector) squalor went alongside private affluence. Quite.

RIP Tony Benn

Ask this of the powerful in society:

1. What power have you got?
2. Where did you get it from?
3. In whose interests do you use it?
4. To whom are you accountable?
5. How do we get rid of you?

Only democracy gives us that right. that is why no-one with power likes democracy and that is why every generation must struggle to win it and keep it: including you and me here and now.

Tony Benn 2005

On the day that Tony Benn dies, we are reminded that he said that the NHS was our greatest socialist achievement. And there you have it. The current political elite know it is a socialist project and that is why they wish to dismantle it. First came marketisation,  now comes privatisation by stealth. The outgoing boss David Nicholson outlined the scale of the challenge facing the NHS in terms of required funding.

We will be told that the country cannot afford it and so the best way forward will be more private healthcare provision, and individual insurance schemes. This flies in the face of evidence and the facts regrading the actual costs. The constant media drip of stories outlining deficiencies in social care and mental health provision allied to gaps on health care provision are softening up the public for the inevitable push towards full privatization. Cuts to nursing staff will result in more mid staff scandals which will enrage the public who will demand the gov’t ‘do something’ – that something will be a sell off and a break up of the NHS. RIP Tony Benn, RIP the NHS. Don’t be poor, don’t be old, don’t be sick unless you are rich.

 

Nursing and the NHS – wtf is going on?

I cannot take credit for this, it is Roy Lilley, and although I was about to write about it,  I thought, nah, Roy has done it better: 

 

Talk to the DH and they will tell you there are more nurses than there are daffodils smiling in the spring sunshine.

 

An extra 2,400 hospital nurses have been hired since Francis and over 3,300 more nurses working on wards since May 2010.  The bit that is missing is; ‘more’ doesn’t mean ‘enough’ and enough doesn’t mean enough of the ‘right sort’.

 

The RCN says; The NHS has lost nearly 4,000 senior nursing posts since 2010.  The ‘missing’ nurses include ward sisters, community matrons and specialist nurses.  They’ve gone because they cost more; drop them and you save loadsamoney… quicker.

 

According to the latest data, November 2013; the NHS was short of 1,199 full time equivalent registered nurses compared with April 2010.  The RCN says; ‘… hidden within wider nursing workforce cuts is a significant loss and devaluation of skills and experience’… just under 4,000 FTE nursing staff working in senior positions.  Band 7 and 8 have been disproportionately targeted for workforce cuts.  It looks like nursing is being de-skilled. (Must look graph).

 

If the evidence of my in-box is to be believed nursing is not just being de-skilled, it is being denuded.  Time and time again I hear stories of nurse patient ratios of 9,10,11,12,even 18 and often quickly beefed up for the benefit of the CQC.

 

“Let each person tell the truth from their own experience.”  Florence Nightingale.

 

Funnily enough, I am writing this on a plane where the cabin-crew to passenger ratio is a matter of law.  I see no reason why the nurse to patient ratio shouldn’t be a matter of law.

 

The Chief Nurse doesn’t agree.  She’s faffing-about with her half-dozen C’s and ignores the risk that one nurse looking after a dozen or more vulnerable patients is a risk to the Six C’s.  She speaks, unthinking, with her master’s voice…  I hope she’s ready to explain the inevitable.. the next Mid-Staffs.

 

“The very first requirement in a hospital is that it should do the sick no harm.”  Flo Nightingale again.

 

There’s a wilful blindness to what’s going on; on the wards and at the ‘high-end’ of nursing; nurse specialists.  If the RCN is right (and this H&SCIC FoI confirms) it is a madness that their numbers are reducing.

 

Nurse Clinical Specialists are highly skilled and there is overwhelming evidence that better skilled nurses are better for patients, and reduce admissions, re-admissions and waiting times, free-up consultant’s, improve access to care, educate and share knowledge with other health and social care professionals and support patients in the community.

 

“Were there none who were discontented with what they have, the world would never reach anything better.”   

Fabulous Flo again.

 

Yup, I’m discontent Flo!  There are only 2 types of post-reg’ training programmes; Specialist Community Public Health Nurses and a Specialist Practice Qualification and for all practical purposes, degree entry-level.  We know they work (chronic heart failure for example and in Stoma nursing) so the default position should be; all patients, with long term conditions, should have access to a specialist nurse… but here we go again… there are not enough of them.

 

A new, free web-resource for Specialist Nurses caught my eye; help with job plans, annual reports and service summaries and I particularly liked the ‘Speaking up for my Service’ section.  I hope they and their managers do. 

 

“How little can be done under the spirit of fear.” More Flo truth-to-power-talk.

 

Nursing is the Swiss Army knife of the NHS; versatile, multi-purpose, portable, one-stop.  Nurses build, work and fix services, flex them and extend their reach and cover.  But, we patronise them and squabble over their numbers. 

 

“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” Yes, Flo again… in full flow!

 

It looks to me very like nursing is in a muddle, confused, a jumble.  No one seems to have a clue what is ‘the right thing’, the right numbers or the right training.  Nursing, the biggest group in the NHS workforce, lacks direction… leadership.  Buried in directorates, managed by administrators shoved around by everyone’s agenda.   A Chief Nursing Officer (Carbuncle) and a Director of Nursing (DH), all chiefs but what about the Indians.

 

Events, technology, finance, balance sheets, bed-sheets, need and resources pull nursing in different directions.  The profession needs to stop, catch its breath and think about its voice, role and purpose.

I wonder what Flo would say? 

Planetary and Public Health – its in our hands ?

From public to planetary health: a manifesto.

The Lancet (Horton et al, 2014) has just published  a manifesto for transforming public health.

You can read the full one page easy to read manifesto here.

This is a call for a social movement at all levels, from individual to the global, to support collective action for public health. Public Health has been widely defined in this manifesto and draws upon the ideas of Barton and Grant’s health map which has climate change, biodiversity and global ecosystems as the outer ring of the determinants of health.

The current definitions of public health, for example from the Faculty of Public Health,  draw upon Acheson’s 1998 definition “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”.  However this definition may now be outdated as there is no mention of environmental or ecological determinants of health and no express action on planetary health at all.

Therefore this manifesto is an implicit call to redefine what public health means. Currently you can read the FPH’s approach to public health and fail to consider issues around climate change, biodiversity loss or the crossing of planetary boundaries which delineate a ‘safe operating space for humanity‘. This needs changing.

The main points within this manifesto  include a definition of ‘planetary’ , rather than ‘public’ health which they argue is an “attitude towards life and a philosophy for living… emphasising people not diseases, and equity not the creation of unjust societies”.  There is a strong focus in the manifesto on the unsustainability of current consumption patterns of living, based on the harms this has on planetary systems. They argue “overconsumption…will cause the collapse of civilisation”. Jared Diamond is worth a read on the collapse of civilisations,  and this argument is in line with his analysis.

Interestingly, an overt political statement is introduced: “We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”. They attack the idea of progress, and of neoliberalism  including ‘transnational forces”, for deepening this ecological crisis and for being socially unjust. There is also a hint of the ‘democratic deficit‘ in which trust between the public and political leaders is breaking down.

The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness, a new vision of democratic action and cooperation.  A principle of ‘planetism’ is invoked which requires us to conserve and sustain ecosystems upon which we rely.

Finally they suggest that public health and medicine can be independent voices of conscience who along with ’empowered communities’ can confront entrenched interests.

So far so good, and in a one page document the detail is necessarily missing.  The principles outlined in this manifesto and the analysis focusing on neoliberalism and ‘entrenched interests’ point us in a direction. However, there is now a need for a map.

I am not convinced that public health, medicine and certainly not nursing, is sufficiently politically aware of the scale of the issue and the sheer force and dynamic of capitalism to even begin constructing the map. That may be an unfair criticism because the education of health care professionals is ‘ahistoric’ and ‘apolitical’ by nature,  they simply lack a sociological or political imagination underpinned by a critical theory of capitalism. And for good reasons.

However, if doctors and nurses are to engage with this manifesto and to debate and argue for an alternative world view, then there is an urgent need to understand the forces railed against them. This manifesto rightly points out the political nature of the issue and the authors no doubt have a clear idea what they mean, however I doubt very much if the majority of healthcare professionals really understand, or even perhaps care about,  the concept of neoliberalism.

In the UK we will be having an election in 2015, in which we will be offered similar versions of the system that is causing the mess. There will be little in the way of mainstream reporting or argument on radical alternatives to consumption or finance capitalism. Indeed parties will be arguing over who can best manage the system.  The only exception will be the Green party who are a fringe party, in terms of votes.

As an example of the scale of the problem, consider Bill McKibbens’  ‘three numbers‘ argument: 2 for two degrees, the threshold beyond which we should fear to tread; 565 gigatons of CO2 we might be able to put into the atmosphere and have some hope of staying below or around 2 degrees; 2795 gigatons which is the amount of carbon in current reserves, but is the the amount of carbon we are planning to burn!  Further, the wealth of investors is tied up in this number and would evaporate like petrol in a hot day should we globally decide that this reserve should stay in the ground. This is an example of an entrenched interest backed by neoliberal politics which is antithetical to global and governmental regulations. The current TTIP negotiations which is trying to establish a free trade area between the US and the EU,  possibly exemplifies the powerlessness of states in the face of lawsuits by corporations if George Monbiot is correct. TTIP is a public health issue and forms part of the backdrop to this manifesto.

I welcome this manifesto, and would urge public health bodies to become overtly political in their statements about public health, perhaps revisiting Acheson and redefining public health to include planetary health.

Following that observation, a new publication published in February 2014, appears to address the politics in an overt way. The Lancet – University of Oslo Commission on Global Governance for Health argues in a document called ‘The political origins of health inequity: prospects for change’ : “Although the health sector has a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors in pursuit of other interests such as protection of national security, safeguarding of sovereignty, or economic goals.”

This then sets up political determinants of health which sit alongside the social determinants of health. Whether it goes as far as critiquing the underlying dynamic of various forms of capitalism remains to be seen.

Poor nursing care and record keeping: Is caring behavior of nurses always documented?

“Is caring behavior of nurses always documented?”

This question was posted in the Researchgate site, by Leadoro Labrague and it generated a few responses Which I think amounted to a ‘no’.

I tentatively add….  “and don’t bother”.
Managing risk in organisations, characterised by increasing managerialism, and the effects this has on practice and documentation was  mentioned in the responses, as was the difficulty of defining care, despite the list of these caring behaviours outlined :

 

attentive listening, comforting, honesty, patience, responsibility, providing information so the patient can make an informed decision, touch, sensitivity, respect, calling the patient by name” .

 

These behaviours, however can be and should be applied by many occupations and professions: teaching, social work, policing, medicine…hotel and customer services…you get the picture. Therefore caring behaviors are not the preserve of the nurse. However, we must be careful not to suggest that care is a defining essence of nursing. This would be erroneous both in theory and in practice as the long historical list of uncaring practices reveal: Stockwell 1972, Jeffrey 1979, Beech House Inquiry 1999, Francis 2013 and for our Australian friends: O’Niell 2013. I’m not suggesting that nursing is in essence uncaring, just that there are enough breaches to warrant further investigation into what nursing work entails and the context that binds it. Other occupations engage in caring behaviours, why should we expect nurses to be the only occupation to document them? Rather, lets critically examine the context of nursing practice and notions of idealized and unrealistic practice.

While I appreciate the differing regulatory and legal positions of say nursing, teaching and hotel customer services, are these contexts so different that nurses could be required to document care when in fact these should be the bedrock of practice for the host of occupations that routinely do not document them? Not only do they not document them, they would throw their hands up in horror at the bureaucratic load if asked to do so. Why should nurses document care and teachers not do so? I’m not convinced by the argument that if caring behaviors are not documented then they will either die out or be non existent (except of course in the legal sense of ‘if its not written it was not done). I would rather focus on developing and clarifying with students what a good/therapeutic relationship between nurse and client looks like and not worry too much about adding any other layer of documentation. Apart from the legal requirement to document certain interventions, do we have to describe how we carried them out as well?

Lets face the reality rather than rhetoric: Much, but not all, of nursing practice is technical, based on rational task orientated non autonomous direction by medics and managers.  Nurses themselves will undertake these tasks robotically and/or humanistically, regardless of documentary requirements. I suggests that adding documentation would increase the likelihood of non humanistic care (see for example the descriptions of care in Dixon Wood et al 2013, Hillman et al 2013, Tadd et al 2011). The context in which that practice is carried out will affect how nurses go about their daily practices with the humanistic nurse’s values being supported, or crushed, depending on managerial practice, interprofessional working, health care assistant ratios, patient dependency, illness and challenging behaviors, their education and continuing professional development……

As a would be patient who could be seriously ill, let me make a provocative statement: I would rather have a technically proficient nurse who makes the right clinical decision but perhaps is not quite as sensitive or touchy than a nurse who makes me feel great by engaging in the above list of caring behaviours, but fails to intervene quickly enough when I deteriorate through, for example, septic shock. I know this is a false dichotomy, in that I would like both technical and humanistic practice. But in many settings I want technically sound scientific care, and if that is the only thing on offer I’ll take that over ‘caring’ any day. I have heard so many times the lament about an academically failing student ‘but she is so good in practice, the patients love her”, while I think yes, but will she spot, and intervene on, sepsis quickly enough? That is the difference between the caring customer service in a hotel and nursing, the receptionist has little in the way of scientific techniques to apply and then the only thing they should be doing is facing a customer as a person not a ‘thing’.

Nurture and support the humanity students have, and in those who lack it, then engage in those activities to develop it, but documenting care practices may only satisfy out inner idealised notions of what nursing is when in fact the contextual issues are what actually define nursing.

 

Beech House Inquiry. Report of the internal inquiry relating to the mistreatment of patients residing at Beech House, St Pancras Hospital during the period  March 1993-April 1996.  Camden and Islingon Community Health Services Trust.

Dixon-Woods, M., Baker, R., Charles, K., et al (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety (published online) http://www.ncbi.nlm.nih.gov/pubmed/240195079th September 2013 accessed February 25th 2014

Francis, R. (2013) http://www.midstaffspublicinquiry.com/report.

Jeffrey, R, (1979) ‘Normal Rubbish’ Sociology of health and Illness (1) 1 http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.ep11006793/pdf

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. 35 (6) pp 939-955

O Neill, L . (2013) Aged care workers cite abuse and neglect of nursing home patients http://www.abc.net.au/news/2013-08-13/aged-care-understaffed-as-nursing-home-patient-numbers-rise/4884056

Stockell, F. (1972) The unpopular patient http://www.rcn.org.uk/__data/assets/pdf_file/0005/235508/series_1_number_2.pdf

Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton