Category: NHS

The Transition to Professional Practice. The reality for the Newly Qualified Nurse (NQN).

Photo by Daan Stevens on Unsplash

 

The current context of nursing is complex. The Health and Social Care Act (2012), Deficit Reduction targets (‘Austerity’), Brexit, the NHS funding gap and Trust deficits, lack of integration of health and social care, ‘safe’ staffing levels, skill mix, post Francis fall out, and for the NQN: preceptorship and managerial support, competence worries and occupational socialization. The NQN also has to consider ‘patient opinion’, the 6Cs, revalidation and the new nursing framework. These latter three may be passing fads, but it is too early to say.

 

Philip Darbyshire (2017) writes on the perennial issues faced in health care delivery that is also the context for the NQN:   http://onlinelibrary.wiley.com/doi/10.1002/nop2.80/epdf

 

 

  1. Staff working under constant pressure (notwithstanding substantial increases in the number of clinical staff in recent years) in the face of growing demand from an ageing population with complex needs
  2. Difficulties for hospital staff in communicating with GPs about patients who are admitted to hospital, including knowing who patients’ GPs are
  3. Problems in communication within the hospital between acute medical staff and A&E staff, as well as between different specialist teams
  4. Difficulties in communicating with staff in other hospitals when patients are transferred
  5. Delays in ordering and receiving the results of diagnostic tests, which in turn lead to delays in treatment and increase in the time patients spend in hospital
  6. Challenges in teamworking, for example, on ward rounds when consultants are sometimes not accompanied by trainees and nurses
  7. Information systems that do not link data about patients held in primary and secondary care, and that are often slow in use
  8. Patients having to repeat their histories (where they are able to) at different stages in their treatment
  9. Care being delivered inefficiently and often ineffectively because of the amount of re-work required by the above
  10. Old buildings and cramped layouts that do not allow privacy and sometimes dignity for patients, or space for staff to work without interruption
  11. Poorly organized paperwork and documents
  12. Inefficient organization of supplies and workflows on hospital wards

 

Linking these together is the NQNs ability to exercise personal agency within these structures.

A small part of the literature on the experiences of NQNs:

Horsburgh and Ross (2013) stated that we know that inadequate staffing levels, eclectic support and concerns over competence provide the challenging context for NQNs.

In their study the NQNs stated:

 

“…flung in at the deep end”

 

“…sink or swim”

 

Colleagues were perceived as “ingrained in the woodwork” and resistant to change, even of a minor nature. That there was:

 

“Institutional negativity”

 

They suggest undergraduate nursing programmes should prepare students for the reality of delivering care despite competing commitments.

 

Whitehead et al (2013) undertook a systematic review of support for newly qualified nurses in the UK. This was done in 2011. Three themes were identified:

 

  • Managerial Support Framework.
  • Recruitment and Retention.
  • Reflection and critical thinking in action.

 

They conclude that there is strong evidence that NQNs benefit from supported and structured preceptorship which then improves retention. This could have been hypothesized beforehand. The three themes indicate contextual issues.

 

 

 

Kelly (2014) commenting on Horsburgh and Ross argues:

 

“However, the need for individual nurses instinctively to take personal responsibility for quality healthcare delivery, to break through cynicism and malaise and to effect change requires individual leadership attributes described by Friedman et al. (2003) as resilience which includes self-mastery, bounce-back-ability or ability to handle stress together with resourcefulness, self-belief and motivation. These are all traits which can and should be nurtured through supportive clinical environments but to a large degree should be innate in the next generation of nurses and cannot always be reliant on others to direct and instruct on these matters”.

(my emphasis)

 

 

 

 

 

Is the emphasis on ‘personal responsibility/resilience’ placing undue burdens on new nursing staff who have to exercise responsibility without full control?

 

 

Horsburgh D and Ross J (2013) Care and Compassion. The experience of newly qualified staff nurses. Journal of Clinical Nursing. 22(7-8):1124-1132

 

Whitehead B, Owen P, Holmes D, Beddingham E, Simmons M, Henshaw L, Barton M and Walker C. (2013) Supporting newly qualified nurses in the K: A systematic literature review. Nurse Education Today. 33(4):370-377

Health and Social Care – the Tory Legacy

Health and Social Care – the Tory Legacy:

 

David Cameron appeared in jovial mood both in the commons and on the steps of number 10 when he recently left office. Cameron joked at his last prime minister’s questions in the House:

other than one meeting this afternoon with Her Majesty the Queen, my diary for the rest of the day is remarkably light“.

He listed his achievements in office and seemed not to be too bothered to be leaving.

It is not clear whether people, especially frail older people, will be so sanguine about his record.

When it comes to health and social care, ‘the nasty party’s’ record is appalling. Following largely on the heels of the Health and Social Care Act 2012 and Osborne’s deficit reduction targets for the public sector, and in the face of increasing demand, we have what Roy Lilley (2013) predicted, and called, ‘The big blue bit of doom’:

His diagram was prescient, as two reports below indicate. This is having an effect on staffing levels and thus on the quality of care people get.

 Jim Mackay, CEO of NHS Improvement, recently was reported in the Health Service Journal (July 2016):

“…Trusts exceeding the 1:8 nurse to patient ratio could be told “we can’t afford that”.  

Trusts, he suggested, should not automatically spend money on new staff or better facilities on the basis of a CQC report or in an attempt to meet Royal College standards.

Janet Davies CE of the RCN stated in reply

This gives completely the wrong message to trusts, whose boards are responsible for the care, treatment and safety of their patients, by suggesting that finances are more important than patient care”.

 I’m afraid in the current context that major decision makers do think finances are more important than the quality of patient care.

 

The King’s Fund (2016) reports:

 

  1. NHS providers and commissioners ended 2015/16 with a deficit of £1.85 billion – the largest aggregate deficit in NHS history
  2. The scale of the deficit signifies a system buckling under the strain of huge financial and operational pressures.
  3. The principal cause of the deficit is that funding has not kept pace with the increasing demand for services

 

The 2016 ADASS (Directors of Adult Social Services) budget survey report states:

 

  1. Funding doesn’t match increased needs for, and costs of, care for older and disabled people.
  2. More people’s lives are affected by reductions in social care funding. The quality of care is compromised: 82% of Directors report that more providers already face quality challenges as a result of the savings being made.
  3. Directors are increasingly unclear where the funding needed will come from.
  4. The continuity of the care market is under threat. Providers are increasingly selling up, closing homes or handing back the contract for the care they deliver to older or disabled people.
  5. Investment in prevention is being further squeezed.
  6. Reduction in funding for social care has wider impact. Directors feel that negative consequences due to budget cuts have already been felt right across health and social care and agreed particularly strongly with statements regarding issue faced by the wider sector:
  • 85% thought that the NHS is under increased pressure
  • 84% thought providers are facing financial difficulty
  • 85% thought providers face quality challenges

 

NICE produced the original safe staffing guidance, centred on the idea that 1:8 was acceptable, provided somebody could wave a ‘red-flag’ and additional staff summoned. The guidance was based on the work of Anne Marie Rafferty et-al, who never said 1:8 was safe, it will not be.

Roger Watson (editor of Journal of Advanced Nursing), wrote for The Conversation UK on a recent study:  https://theconversation.com/youre-more-likely-to-survive-hospital-if-your-nurse-has-a-degree-61838 and thus provides more evidence of the strong correlation between education and outcomes. My worry is that in the UK we have drifted into ‘policy’ based evidence rather than EBP. Safe staffing levels may well be decided by finance directors (what can we afford) rather than sound evidence. This reminds me of the climate change ‘debate’ of which Roger Pielke applies the ‘iron law of economics’:

When policies on emissions reductions collide with policies focused on economic growth, economic growth will win out every time. Climate policies should flow with the current of public opinion rather than against it, and efforts to sell the public on policies that will create short-term economic discomfort cannot succeed if that discomfort is perceived to be too great. Calls for asceticism and sacrifice are a nonstarter.”

So ‘when policies on nurse staffing collide with policies focused on deficit reduction, deficit reduction will win out every time. Staffing policies will flow with the current of finance directors/CEOs opinion, and efforts to sell them policies that may cost them cannot succeed if that cost is perceived to be too great’.

A question is that while there is a perception that degree nurses and lower nurse patient ratios will increase the wage bill, while not providing savings ‘on the bottom line’ then we have a political battle not an evidence battle. The externalities of FDs and CEOs decisions fall onto individuals, families and nurses rather than the organisations balance sheet. Do we have metrics that force the financial externalities back into the equation, or is there evidence that hospitals see this evidence and are changing staffing practice?

The Tory Legacy is that we are still chasing a target of deficit reduction within a wider ideology that is suspicious of public sector provision at best. The drift is towards more private provision with perhaps a base line that the tax payer pays and a system of tops ups and private insurance schemes. This will be sold as “we cannot afford the NHS as it is” to cover for much further privatisation, marketization and a return to individualising, rather than socialising, risk. Health and Social Care as we knew it is over. If you or your parents need caring for in older age, or if you need non urgent surgery, you will need to save more money to pay for it, take out private insurances, top up your pensions or pay more tax.

Hunt’s agenda

The ideology of health care provision.

 

 

Amid the junior doctors strike of 2016, the health secretary Jeremy Hunt was embroiled in a conflict with the BMA over doctors’ contracts designed to address a 7day NHS. This is the surface issue but sits upon a deeper ideological conflict, one that many of the doctors will be unaware of but will suspect, especially if they have read Alysson Pollock’s works on the privatisation and corporatisation of the NHS. Hunt argued he has a ‘mandate’ to introduce a 7 day NHS and perhaps realises that if this policy cannot be introduced, the balance of power over the future of the NHS will swing back towards the BMA and other health professional groups. The irony is that the BMA opposed the introduction of the NHS back in 1948 but now is one of the strongest supporters. Since 2012 however, the NHS has been dismantled and been replaced with privatised and corporatized service provision, with ‘patient choice’ and ‘patient safety’ being used as the ideological veil which masks the corporate face. People have not noticed this detail because so far ‘free at the point of delivery’ is still in place, but this principle, along with universal and comprehensive cover, is under threat. The government remain the almost monopoly purchaser of health services on our behalf but for how long? The care home crisis points in the direction of travel. This will be withdrawal of state funding and reliance on private provision which will not be ‘free at the point of delivery’.

 

 

 

In 2005 ‘Direct Democracy – an agenda for a new model party’ was published, the authors include the current health secretary Jeremy Hunt. It is not government policy and does not represent the full range of conservative views. The Tory party itself is home to those of a ‘one nation’ persuasion who mix ideas of ‘noblesse oblige’ with a modicum of a social welfare, safety net, public service ethos. It is also home to ‘neoliberalism’ rooted in anti State sentiment based on freedom of the individual and free market economics. This ideology can be clearly seen in the 2012 book ‘Britannia Unchained – Global lessons for growth and prosperity’ which argues for further free market economics based on a bonfire of employment laws. The book suggests:

 

“The British are among the worst idlers in the world. We work among the lowest hours, we retire early and our productivity is poor. Whereas Indian children aspire to be doctors or businessmen, the British are more interested in football and pop music.”

 

This one quote conveys the disdain neoliberals have in general for those less well paid, less “successful” and less powerful than themselves. Boris Johnson’s speech in 2013 on the impossibility of equality being based on differences in IQ, implied some people are too stupid to get ahead. This individualises issues, while ignoring structures of class, gender, ethnicity and privilege. He said:

 

And for one reason or another – boardroom greed or, as I am assured, the natural and god-given talent of boardroom inhabitants – the income gap between the top cornflakes and the bottom cornflakes is getting wider than ever. I stress: I don’t believe that economic equality is possible; indeed, some measure of inequality is essential for the spirit of envy and keeping up with the Joneses that is, like greed, a valuable spur to economic activity.”

 

Two ideas are core here: that the working class and the poor are so because they are more lazy and stupid than the ruling class, and that the answer to this is to increase competition and to use inequality as incentives for personal improvement. Of course said like that to the electorate, it would seriously threaten voter support. Instead the discourse of market efficiency, effectiveness and choice is used to justify privatization and corporatization of public services. The message to the public is clear: take responsibility for education, health, social care and housing. It is down to individuals and families to provide by working hard and being prudent.

 

The arguments over the NHS have to be seen within this wider context. At heart, many in the current Tory party viewed the state run NHS as anathema. As such they have succeeded in dismantling the post war structure of the NHS following the Health and Social Care Act 2012. This allowed for private providers to bid for the provision of health services but keeps in place, for now, principles such as ‘free at the point of delivery’.

 

According to Alysson Pollock, the Health and Social Care Act 2012:

 

  1. Removed the duty of the Secretary of State for health to secure and provide health care for all.
  2. Introduced US style insurance schemes.
  3. Gives the secretary of state legal powers to create a market, allows providers to pick and choose which patients will get care, services to be provided and what will be charged for.

 

A market has been introduced into health service delivery, and markets operate through risk selection and appraisal resulting in fragmentation of provision. That is to say a market provider needs to pick and choose which patients are profitable in competition with other providers. We now have clinical commissioning groups modelled on insurance based lines. Those with high risk or multiple needs will be expensive to provide care for.

 

The ‘NHS’ is now fragmented in which:

 

  1. Services are broken up and put out to tender to commercial companies.
  2. Commercial shareholders have new legal powers to decide who gets care, what the get and what they pay for.

 

This current state of affairs is not enough for neoliberal thought. So what is the vision of this group of neoliberal Tories? How did this happen?

 

Direct Democracy argues:

 

“Several other countries operate political systems based on localism and direct democracy. Two outstanding examples – one much smaller than the United Kingdom and one many times larger – are Switzerland and the United States. In their different ways, both states respect the principles of the dispersal of power, the direct election of public officials and the use of the referendum as a legislative tool. Our proposals for the devolution of power directly to the citizen – notably in the fields of education and health care – have also been successfully trialled abroad, often in unlikely places. No less corporatist a state than Sweden has introduced a form of school voucher, while almost every state in Europe, at least since the fall of the Berlin Wall, now provides for an element of health insurance”.

 

This goes to the heart of the matter, note how the US and the Swiss are held up as models. The principles of localism and direct democracy are invoked as justifications hiding their argument and belief about market mechanisms. The United States is a beacon for the dispersal of power? One cannot expect anything other than this nonsense from neoliberals, wilfully ignorant as they surely must be of the work of C Wright Mills, Herbert Marcuse, Jurgen Habermas, David Harvey, Thomas Picketty, Graham Scambler, and Yanis Varoufakis? This also ignores the literature on social inequalities and inequalities in health and the social and political determinants of health. At this point we must also point to the wealth of feminist and post-colonial literature on ‘power’. In short it is an invocation of bourgeois patriarchal perspective on the exercise of power which blinds them to actuality.

 

As for Switzerland, the OECD reports that compared to the UK’s 9.3 % of GDP, the Swiss pay 11.4%. The UK used to pay under 6% but has seen a rise, not totally due to actual health spending but to cater for administration and profit for private companies. The US spends 16.9% (OECD 2014) and has introduced ‘Obama care’ to address the plight of uninsured americans. Obama care is an outcome of class struggle which has been hotly contested in the ‘land of the free’.

 

 

 

‘Direct Democracy’ claims to hold to three principles:

 

  1. Decisions should be taken as closely to the people they affect.
  2. Law makers should be directly accountable.
  3. The citizen should enjoy maximum freedom from state control.

 

 

On the face of it who would argue with that? Certainly not anarchists, socialists or libertarians. The problem is that these principles exist within a social and historical context, one characterised by imbalances of power along class, gender and ethnic lines and this cannot deal with the reality on the ground. Hunt et al are blind to the context in which ‘men of wealth buy men of power’, a world in which the capitalist class executive and the political power elite exercise a new class/command dynamic which neoliberal ‘reforms’ ushered in since about the 1980’s especially in the US and UK.

 

Yanis Varoufakis (2016) clearly discusses the effects of such things as the “Nixon Shock’ on the post war global financial settlement, the outcome being that the ‘strong do what they can and the weak suffer what they must’. Global health corporations need new markets and looked to the UK’s NHS as a source of rich pickings. This is the context in which Hunt’s bourgeois democracy operates.

 

  • Decisions about who provides health care, what health care looks like and where it is provided are taken by unelected clinical commissioning groups operating within a profit driven market context.
  • Patients do not have an electable secretary of state who has a statutory obligation to provide health care services.
  • Freedom from state control for health service provision has morphed into control via corporate decision making.

 

 

Direct Democracy (2005) argues:

 

‘The problem with the NHS is not one of resources. Rather it is the system remains centrally run, state monopoly designed over half a century ago’ (p74).

 

Clearly this is a statement that ‘the system’ needs to go. The resource issue in the context of increasing demands and costs is brushed aside. This remark now looks questionable at best in 2016.

 

“We should fund patients either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice. Those without means would have their contributions supplemented or paid for by the State.” (p74).

 

Holding on to a notion of ‘free at the point of delivery’ implied here, it is clear that private provision is to be introduced. The language is anodyne, context free, taking no notice of what private provision might look like, who would provide it and what the consequences of the inevitability of a market might be. The State at least has a role in providing for the poor. The writers of this document are part of the political power elite, or may wish to be, and the coherence of interests with the corporate/capitalist class executive are hidden. Those who sell insurance have not been lobbying for this change then? A bit of research into who benefits from this change might prove insightful. Are there links between corporate interest and the politicians who are driving the changes?

 

Hunt et al feared the NHS would only be second to the US in terms of % of GDP spent. This has not occurred. They report a study ranking the UK 18 of 19 countries. This is selective in the extreme, and is now way out of date.

 

Many of the critiques they evoke of the NHS are a result of the rise of new public management, or ‘managerialism, introduced into the system by previous governments both New Labour and Tory. For about three decades managerial control, targets and distrust of professionals have eroded the ability of the NHS to be the best in the world.  The judgment about the efficiency and effectiveness of health services partly depends on what criteria are being used to judge them. The % spend of GDP is a crude figure as it hides a plethora of costs and profits.

 

Other measures of success could include universality of access, comprehensiveness of cover, mortality and morbidity outcomes, and the publics’ safety and satisfaction.

 

Mark Britnall has written ‘In search of the Perfect Health System’ (2015) of the complexity of comparing health systems. Britnall is no Tory ideologue and describes his approach as more brown mud than blue sky thinking:

 

He also wrote in 2011 before the 2012 Act:

 

“[o]f course, the vast majority of care – quite rightly in the UK context – will always be provided by public sector organisations (currently, about 95% of it) and will be paid out of taxation” and “[t]he issue of competition, which now seems to be conflated with privatisation, is unhelpful and misleading and, at best, only a small part of reform. Competition can exist without privatisation and the NHS can maintain its historic role in funding care while dealing with a richer variety of providers – public sector, social enterprise and private organisations”.

 

This 2011 comment predated the 2012 Act and can be seen as a statement of intent than actuality on his part. In 2010 there was some controversy over his statements in the US about private provision.

 

One area in which private provision is facing severe challenges is the care home sector.

 

Roy Lilley, writes a daily blog, and has considerable experience in the health service and with private sector organisations. He is no left wing radical. He writes in ‘They don’t matter’ (3rd May 2016) that success in private provision in the community has been ‘patchy’, citing Circle’s loss of £5 million and the paying of another £2 million to get out of the Hinchinbrooke contract, while SERCO and Bupa ‘bailed out’ of provision leaving Virgin clinging on. He argues that the private sector can be nimble and quick to adapt, but of course needs to make a profit.

 

However, the largest care home provider, Four Seasons, is in talks to ‘restructure its debt’ as they face a 39% drop in profits. Most of their ‘customers’ have their fees paid by social services. This amounts to some local authorities paying £385 per week which is just not enough. The living wage is also an issue for them, they have over 30,000 staff but with no way of adjusting prices to pay for the increase and with no operating surplus. It has a debt of £510 million. If Four Seasons go broke they have 450 care homes at risk.

 

The bottom line is that health and social care costs money. There is not enough money in the system to pay for the care required. Some private families are paying £1,250 per week. Company Watch data which covers 20,000 homes, indicates that there is a funding black hole of half a billion pounds. This is market failure due to inadequate funding by design. It is almost as if the government is deliberately forcing people to find the money themselves either through savings, insurance or property while state funding through local authorities is slowly wound down.

 

Mark Britnall’s approach is scholarly, based in experience managing health care organisations and a deep knowledge and overview of many health systems. However, is Britnall sufficiently aware of the political economy of neoliberalism and its agenda for health?  Roy Lilley’s highlighting of the care home crisis clearly shows the political, austerity driven nature of the issue.

 

‘Direct Democracy’ and ‘Britannia Unchained’ are ideological approaches to health and social care. Whether Hunt has the temper for addressing Britnall’s insights or whether he still stands by the document he co-wrote is anyone’s guess. However, I know where the smart money would go. His face down of the doctors is more to do with power and who exercises it rather than the future of the health service as we knew it. If the neoliberals can get away with it, then free at the point of delivery will be severely challenged perhaps using spurious arguments stigmatising drug users, alcoholics, smokers, the obese, self harmers, self inflicted sports injuries, prostitutes, the promiscuous and Johnson’s ‘stupid’ as a wedge driven between the deserving and the undeserving ill. The care home crisis indicates that older people are ignored and the costs increasingly privatised as the state withdraws, or should we say abdicates, support. The NHS was to socialise risk, to spread its cost across the whole population. Instead we are rapidly moving towards individualising risk and private insurance based provision as the state withers away.

 

How responsible am I for my health 2

How responsible am I for my health?

 

The answer to that question from the dominant discourse is an overwhelming “very”.

This response sits alongside more scholarly understandings of the social determinants of health.  This ‘upstream’ understanding is open to ‘Lifestyle Drift’ , ‘downstream’, responses to health. Lifestyle Drift is:

“the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors” (Popay et al 2010)

McKenzie et al (2016) argue:

“Although policy documents may state that the causes of poor health or inequalities in health are to do with poverty and deprivation, the interventions which actually operate on the ground focus much less (if at all) on changing people’s material circumstances and rather more on trying to change behaviours (which are in fact heavily shaped by material circumstances)”.

Nurses might understand the concept of the social gradient in health inequalities but drift into advocating lifestyle changes for the individual, centring around smoking, diet, and exercise messages.

So why is this happening? Why resort to lifestyle approaches to health when we know health is largely socially and politically determined?

 

One answer is that lifestyle answers fit within the neoliberal social imaginary which individualises health and social problems and seeks market solutions to those problems. Neoliberalism is a doctrine well known to many scholars and academics but is hardly mentioned in popular discourse.  To understand responses to health inequalities and poverty , we need to understand the tenets of neoliberalism underpinning much of current thinking:

 

  • Neoliberalism sees competition as the defining characteristic of human relations. Therefore competition between service providers should be introduced into the NHS.
  • It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. So patients can and should choose between hospitals and GP practices as consumers of health care using their purchasing power (not yet realised in the NHS). This way, poor service providers should go out of business.
  • It maintains that “the market” delivers benefits that could never be achieved by planning. Therefore NHS = bad, US private health insurance = good; BBC = bad,  SKY/Fox = good;  British Rail = bad, Great Western/Virgin = good; Royal Mail (state owned) = bad, Royal Mail (privately owned) = good.
  • Attempts to limit competition are treated as inimical to liberty. Thus socialised NHS service provision must be broken up to allow freedom in the market. The BBC must be sold off because it is unfair competition for Sky.
  • Tax and regulation should be minimised, thus the use of offshore tax havens, reduction in top rate of tax, mistrust of EU environmental standards and hatred of health and safety regulations.
  • Public services should be privatised. The Health and Social Care Act 2012 facilitates this, there may well be more to come for the NHS.
  • The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Unison, RCN, BMA etc, must have their power curtailed. The Junior doctors cannot be allowed to win or else it will be a victory for organised labour.
  • Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Those at the bottom require incentives to better themselves, therefore benefits need cutting, those in the middle will benefit from wealth creation.
  • Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve. The arguments from books such as ‘The Spirit Level’ are therefore irrelevant. If there is a social gradient in health then this is the natural outcome of people’s decisions and choices and any attempt to change this invokes  ‘moral hazard’ arguments; that is if people know they have a safety net (someone else takes the risk) they will not try to avoid poor choices.

(Monbiot 2016 The Zombie Doctrine)

 

 

 

Tory Rituals on poverty:

 

 

·         Blame the individual for their illness and poverty.

·         Benefits cause dependency , repeat this ad nauseam.

·         Deny any political responsibility for ill health, emphasise culture as causative.

·         Divide population into:  skivers v strivers, deserving v undeserving poor, low achievers v high achievers.

·         Deny the ‘social’ exists, there are only individuals

·         Privilege wealth through tax breaks and preferential treatment.

·         Deny one’s own privilege as a white affluent male.

 

 

These attitudes underpin the ideology of neoliberalism.

 

For a statement about what the Conservative Party should be about see:Direct Democracy – an agenda for a new model party’ (2005) especially the chapter on health:

 

 

“The problem with the NHS is not one of resources. Rather, it is that the system remains a centrally run, state monopoly, designed over half a century ago”.

 

 

 

All of this results in the politics of blame and shifting responsibility for health fully onto individuals.

If material health assets are paramount, poverty and our response to it is a foundation for understanding health in society. Poverty can be defined as 60% of the median income or using the ‘consensual method’  it is “enforced lack of necessities determined by public opinion”.

However, the UK government’s position is that poverty is not caused by lack of income. Based on Charles Murray’s idea of the ‘Culture of Poverty’, poverty is a result of individual deficits, as Kitty Jones writes:

“the poor have earned their position in society, the poor deserve to be poor because this is a reflection of their lack of qualities, poor character and level of abilities”.

Kitty Jones has written clearly on this issue in 3 blogs, which can be found here.

The alternative view, expressed in for example the ‘Greedy Bastards Hypothesis’ is that poverty, and health inequalities, is caused by the rich, often through unintended consequences of their actions but also through design. It results from structural socio economic conditions that neoliberal governments encourage: for example, low wages, withdrawal of benefit provision and the use of offshore tax regimes. Osborne’s ‘living wage’ is a cynical political manoeuvre designed to woo middling swing voters rather than to address structural economic issues such as under and unemployment , lack of investment in a green economy, deficits in the housing stock and affordability and a zero hours, self employed precarious job structure.

 

Nurses offering health advice, are not immune to this dominant discourse. It suffuses health advice on such sites as NHS choices and is supported by health campaigns which focus on changing individual habits. Action on social inequalities as root causes for ill health sits within specialised public health literature, for example ‘Fair Society,  Healthy Lives’, and unless nurses are exposed to an alternative perspective they will naturally draw upon dominant explanations for health inequalities. These are often either biologically/hereditarian explanations* or a ‘moral underclass discourse’ (Ruth Levitas) or a mix of the two. The politics of neoliberalism encourages the latter perspective.

 

 

Benny Goodman 2016

 

*See Chapter 4 in Psychology and Sociology in Nursing  Goodman 2015 for explanations.

Watch Richard Wilkinson discuss inequalities at a TED talk.

https://www.facebook.com/groups/Sociologyhealthnursing/

 

 

 

 

 

 

NHS Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

How satisfied with the NHS are we? The British Social Attitudes Survey has been tracking satisfaction levels since 1983. In 2011 it reached the highest it had been (64%), much higher than the 39% recorded in 2001. In 2000 there was a large rise in funding and according to John Appleby (Kings’ Fund) the change upwards might reflect that extra funding. In 2010 the rate had hit 70%, while in 2015, 65% stated they were quite or very satisfied, with dissatisfaction at a low of 15%. Now, in 2016, dissatisfaction rates have hit a 23% ‘actively dissatisfied’.

 

For trends see the graph at:  http://www.bbc.co.uk/news/health-35527318)

 

 

So, should we read anything into these figures? The “NHS’ is a complex set of organisations and services, and is affected by such external factors such as social care. It is probably foolish to peg changes in attitudes to any one factor (such as funding or waiting times). The survey does provide some information as to why those who are dissatisfied say so:

 

The stand out reason is taking too long to see a GP (60%). Interestingly only less than 5% state ‘stories on TV or radio’. However, 6 reasons above that are also gained by reading the press, watching TV as well as being supplemented by actual experience of friends and family.

See reasons at http://www.bbc.co.uk/news/health-35527318)

 

The figures cannot be directly tracked to funding or political party. The background of the Health and Social Care Act 2012 has not on the face of it made a difference to people’s attitudes. The high rate of satisfaction in 2010 of 70% has dropped to around 60% since, while dissatisfaction has only just started to rise again from the 2011 level.

 

If you want to change the way the NHS is funded, this survey is still an issue. Too many people like it the way it is, “free at the point of delivery” is a possible reason. Social Care (means tested) ranks the lowest on these satisfaction scores and might indicate that funding is a real issue for people.

 

 

The context for this includes 4 assumptions held by governments over the past 25 years: Neena Modi in the Guardian writes:

 

  • Personal responsibility for health supersedes government responsibility.
  • Markets drive efficiency.
  • Universal healthcare is unaffordable.
  • Healthcare is a business.

 

For example, Christopher Smallwood wrote ‘Free at the point of use’ has had its day and argues for private health insurance.

 

Each one of these assumptions are questionable and draw upon a certain view of the role of the state vis a vis the private individual (neoliberalism). Alongside that there are profit making health care organisations looking for new business opportunities that the relatively closed NHS used to block. Graham Scambler’s ‘Greedy Bastards Hypothesis’ suggests that health inequalities are the unintended consequences of the actions of a core cabal of the ‘capitalist executive’ who, aided by the ‘political power elite’ engage in business activities aimed at capital accumulation which includes commercialisation of health services for profit. The Health and Social Care Act 2012 provided an opportunity for just such private sector involvement. A problem for the private sector is that much demand for services comes from an increasingly ageing population whose needs are difficult to make a profit from.

 

 

There are very real discussions to be had about the sort of health service we want and the principles that should underpin it. There is now increasing argument for a rolling back on its founding principles of universal access, comprehensive coverage, equity of service and free at the point of delivery all in the name of ‘affordability’ underpinned by an ideology that deplores public sector provision. Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

 

 

 

For discussion on health services globally see:

 

  1. Which country has the best healthcare system?
  2. Britnall, M (2015) In Search of the Perfect Health System. Palgrave macmillan .

 

 

 

 

 

‘Moral Failing’ in Nursing?

The NHS is often in the news, and not always for the right reasons. Health care staff are working hard to keep the ship afloat but do so often at great personal cost due to stress and burnout. Unison (2014), in their report ‘Running on Empty. NHS staff stretched to the limit‘ outline the reported conditions in which NHS staff are giving care. It is not good reading. Two quotes illustrate the situation:

“Every day we struggle with beds . Constant harassment from managers to free beds and discharge patients, sit patients out of bed, etc . There is no time for anything meaningful. Managers are obsessed with targets . Targets don’t measure quality of care .”

and

“On occasions, staffing levels are bordering on dangerous.  We are in a Mid Staffs situation and I don’t believe we are the only ones.”

In 2013 the RCN published a similar report ‘Beyond Breaking Point‘ in which it is suggested that patient care is under pressure from nurses’ stress.

However, Dan Poulter of the coalition government have argued that although the NHS faces challenges, the “health service is bearing up and treating people very well“. This may well be true. The quality of care may well be good to excellent. The King’s Fund suggests:

“…in broad terms the NHS has continued to provide services to a growing population and to maintain the quality of those services. However, there is deepening pessimism about the ability of the NHS to make ends meet financially, particularly in 2015/16”.

Talk about crisis may be premature, but it may well be the case that patients are getting good care despite, and not because of, the structures and finances to support staff giving that care. patients may be getting care at the expense of the wellbeing of some staff.

This may well have always been the case. One long standing description of nursing may not have been helpful in the past, but due to changed circumstances, may now have become an out dated and indeed injurious conception of what nursing now is. This description of nursing as individual moral work, or perhaps otherwise called a ‘vocation’,  is under now under continued scrutiny.

Much has been written about Mid Staffs and perhaps this is fading into history. However, for nurses the underpinning pressures on them remain. Michael Traynor (2014)  in a recent article highlights one of those pressures: the identification of nursing as ‘character based moral work’. This is reflected also in the United States in that some states require assesment of ‘good moral character’ for licensure to practice. In the UK the purpose of ‘values based recruitment‘ is:

“…to ensure that we recruit the right workforce not only with the right skills and in the right numbers, but with the right values (my emphasis) to support effective team working in delivering excellent patient care and experience”.

There is nothing intrinsically wrong with this approach. In fact I would hope that all health care staff, and indeed all of us, come to work with ‘good moral character’ while holding the appropriate values. This applies to a taxi driver as well as to politicians.

For nurses, however this emphasis on their work as ‘character based moral work’, supported by University recruitment that focuses on those with a ‘caring orientation’,  may operate to deflect analysis of the systems of work that result in ‘cognitive, professional, bureaucratic and work’ pressures (Traynor 2014) which may, for too many, result in stress and burnout. Failings in care are also seen in these terms – i.e. that of the individual failure of the moral character of the nurse.

Traynor’s argument is that:

1.  Nursing failures are possibly an inevitable consequence of work in health systems  under pressure.

2, Nursing is often viewed as primarily ‘character based moral work’, to an extent not applied to other occupations.

3. The profession focuses on recruiting those with a caring orientation but does not equip these new recruits with an adequate understanding of the causes of inadequate practice.

4. This leads to acquiescence to poor standards and hinders the development of ‘critical resilience’.

Student nurses learn about the legal and ethical basis for care, they study leadership and management theory, they address quality enhancement as well as developing clinical skills. They do so often without a critical theory of the context of the care system they enter and often face moral distress when the care they want to give is bounded by the myriad pressures they and their mentors face in reality. Instead personal accountability is stressed and their individual moral character is scrutinised. Before they can register a declaration of good character has to be signed. All of this is blind to the reality of practice.

Perhaps it is time to reexamine the chimera of ‘character based moral work’, divest ourseleves of this misleading description of the basis of nursing practice and instead use our sociological imaginations to develop political and critical resilience in student nurses.

I may warm to this theme.

The NHS in ruins: Small state private medical care is the future?

You would have to have been living on a desert island, celebrity obsessed or just plain ‘not interested’ to know there is an issue with NHS funding. The issue at stake is not that there is a funding gap between demand and provision, although that is certainly the case. The issue is the dismantling of the NHS as a publically funded service based on core principles. These principles are based on progressive, socialist/collectivist values rooted in social democracy. In short, the larger political project currently underway is the shrinking of the state by transferring its core functions of empowerment and protection of the public, to private, often global, corporations. The ‘moral mission’ of government is being eroded in favour of profit and individualising risk and responsibility.

 

Before we briefly examine this claim, it might be a good idea to remind ourselves of the current basis for the NHS:

 

The NHS was a political project founded in 1948 on the following guiding principles to address inequalities in access to medical services. The 3 core principles were:

1. that it meets everyone’s needs.

2. free at the point of delivery.

3. based on clinical need, not the ability to pay.

Since then these 3 have been developed into 7 principles underpinning the NHS constitution.

1. The NHS provides a comprehensive service available to all.

2. Access to NHS services is based on clinical need, not an individual’s ability to pay.

3. The NHS aspires to the highest standards of excellence and professionalism.

4. The NHS aspires to put patients at the heart of everything it does.

5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population.

6. The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.

7. The NHS is accountable to the public, communities and patients that it serves.

NHS Core principles

 

These principles derive from a social democratic root, instigated initially by the post war labour government under the guidance of Aneurin Bevan , Minister for Health in the Attlee government of 1945 to 1951 at a time when the UK owed far more as a % of GDP than it does now. Despite this national debt, the Attlee government still found the money to set up the NHS. So from the outset, this was a political project based on collectivist principles and for this reason is now seen by free market conservatives, neoliberals and small state conservatives, as undesirable. However, as the NHS has huge public support, these critics of collectivism use the language of ‘affordability in austere times’ to frame the debate rather than outright argue for the wholesale privateering of the NHS and a move to individual responsibility for health based on health insurance. As part of this process, there appears an almost deliberate softening up of the public for this privateering and abdication of government responsibility for the protection of the public’s health and medical services. As a result of government policy we are being exposed to stories about NHS funding such as:

The Royal College of General Practitioners asks patients to petition the government on the issue of funding cuts”. This was reported by Neil Roberts in May 2014, who writes that a poster showing queues outside a GP surgery, and a claim that up to 100 practices face closure, is being sent to GP practices. Roberts states:

“The poster and petition, which the college is asking patients to sign, are part of the Put Patients First: Back General Practice campaign, run with the National Association for Patient Participation. The campaign calls for an increase in general practice’s share of NHS funding to 11% by 2017”.

Is this a case of special pleading? I don’t think so, the health service is facing a funding issue, including the £20 billion Nicholson challenge. In the context of rising demand, and an increasing gap in the budget to meet that demand, the NHS requires some radical changes or faces a ‘productivity challenge too far’ (Appleby, J. (2013) A productivity challenge too far? BMJ 344 e2416). One report from the parliamentary Public Accounts Committee, suggested that 1 in 5  NHS Trusts were in financial trouble and bankruptcy was a real option, this despite the NHS having an overall surplus of £2.1 billion in 2012-13. This surplus may not last, and the seemingly disorganised, costly management and inspection schemes alongside the disintegration of the providers into an ‘any willing provider’ mix of public and private do not bode well for the financial future of the service. The Private Finance Initiative (PFI) schemes have also locked some NHS organisations into costly long term contractual agreements.

So, yes the NHS is facing many challenging issues that some argue require a solution not yet fully implemented, although started, by the Health and Social Care Act 2012. This solution is to reduce public provision and encourage private sector organizations to tender and compete for services, they would be known as ‘any willing provider’. In theory this means Tesco as well as small social enterprises.

To get to this position, the NHS has to be seen to be not working and the current pressure on reducing public spending assists this process. Lack of funding, allied to poor services, paves the way for further privateering. The argument is that the state cannot provide the funds and also should not provide the funds, but it is the former argument – ‘austerity’ that is being used as a shield for the latter.

David Cameron, in a speech at the Lord Mayor’s (of London) Banquet on November 11th 2013, outlined the strategic objective: ‘austerity is here to stay’, he said:

“The biggest threat to the cost of living in this country is if our budget deficit and debts get out of control again…we have a plan…it means building a leaner, more efficient state. We have to do more with less”.

Debt reduction as an imperative, masks the ideological position for a smaller state.

Let us not forget, for this government will have you do so, that the debt rose as a result of the bank bail out rather than out of control state spending. The successful narrative is that the debt is all Labour’s fault and that big state spending cannot go on. The global financial crash of 2007-8 is a very useful smokescreen hiding conservative wishes to reduce the state’s functions.

Health and medical services in this worldview is not a public good, it is a commodity to be bought and sold in the market. If the NHS can be seen to be failing, to be expensive, then you have a narrative which states that the answer is selling off the services to private companies and introducing competition. So, why not privatise the NHS?

We already have a model for this; it is childcare, the costs for which is seen primarily as the responsibility of the individual and the family, with just a little state support. The private sector is paying so little for so many families with children, and private sector landlords have private rents so high, that the state is subsidizing low pay with benefits. The idea that the whole of society benefits from well educated, healthy children, and thus has an interest in supporting their development, is sidelined when it comes to paying for that care. Childcare costs are largely picked up by individuals and families. The state supports families with tax credits, child allowance and is introducing some measure of support for childcare for parents who are working. This support derives from a collectivist, not an individualist, political philosophy, and as yet has not been fully withdrawn. This is partly meeting the government’s moral mission to empower and protect its citizens. Conservatives argue however that benefits should be cut, and wonder why those who choose to have children are not fully paying for them, after all it was their choice!

We do not know how far Cameron wants to push competition and more private provision for medical services, we don’t yet know how much of the more expensive US health insurance system he wants to copy. We do know that corporate lobbying for state contracts from companies such as Serco, Capita and GE occur for the more profitable services. See this short film on NHS lobbying .

The Free University argues:

The UK government is proposing to privatise yet more public services including Ministry of Defence procurement and the Fire Services. Other institutions such as the Met Office are also being considered for sale. Privatisation of NHS services has been underway for some time and will accelerate under the secret US/EU Free Trade Agreement currently in negotiation. These are all a manifestation of “Liberalisation“.

Linda Kaucher in 2013 stated:

“Liberalisation means offering investment opportunities transnationally and since the 1980’s, successive UK governments have prioritised liberalisation in both private and public sectors. Private sector liberalisation has resulted in overseas ownership of most UK enterprise. Privatisations in the public sector have been simultaneously liberalised, so overseas investors are involved in the public sector sell-offs (e.g. water, rail), private contracting (e.g. waste collection, hospital cleaning) and PFI schemes. Right now, it is the NHS that is at stake, as it is divided up, privatised and liberalised – potentially forever: once overseas companies are involved, it is very difficult to reverse liberalisations, and, inherently, also the privatisations underpinning them. This is even more the case as liberalisations are committed to international trade agreements –  which is precisely the purpose of trade agreements.”.

The drift is towards more privateering of medical services. Will we get a better health service with improved outcomes? Lets not confuse health with medical services; health is largely socially and politically determined, so even if the NHS is fully publically owned, health outcomes are determined elsewhere (socio-economic status, ethnicity, gender….). The NHS is providing medical services to treat illness and disease and to manage chronic long term conditions. So, will private provision improve medical outcomes, will it improve services for dementia, mental health, elderly care?

Nurses for Reform.

A free market nurse think tank:

“NFR has long argued that the NHS is an essentially Stalinist, nationalised abhorrence and that Britain can do much better without its so called ‘principles’ ”. (2008).

 

Health care is part of the ‘moral mission’ of government (Lakoff 2008 ‘The Political Mind p141) to empower and protect citizens. Lakoff argues that other forms of protection, such as the Police and the Fire services, don’t require insurance and health security likewise should be a function of government. Conservatives do not believe this, they feel that you should have health care only if you are willing and able to pay for it. If you are not making enough money then you probably do not deserve it. For conservatives, health is a commodity that should come with a price in the market. The post war consensus between conservatives and socialists in the UK held back this belief. This is now breaking down and conservatives are emboldened and empowered not only to make this argument, but to enact it.

 

Lakoff poses a simple question…will the privateering of the NHS serve the overall moral mission of protection and empowerment, will protection and empowerment be best served or undermined?

 

Those who argue it will not undermine this moral mission are also set to make a very large profit out of it.

 

 

 

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

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? 

Government, managerialism, leadership and poor care in the NHS

Today the government responds to the Francis Reports into the care failings between 2005-2009 at Mid Staffordshire NHS Trust. What can we expect?

 

I suspect that there will be a good deal of initiatives and new regulatory effort but little in the way of actual practical relevance.

 

In March 2013 the government published its initial response Patients First and Foremost in which David Cameron apologised to the families involved through parliament acknowledging systemic failures. It is to these systemic failures we must look to find some answers, but I suspect that my definition of a systemic failure may not be the same as Cameron’s. First lets consider where we are so far.

 

Jeremy Hunt’s foreword in March focused on creating a culture of safety, compassion and learning that is based on cooperation and openness. He identified four key groups who are essential in providing this culture:

 

  • Patients, service users, families and friends.
  • Frontline staff.
  • Leadership teams – Trust boards.
  • External structures: commissioners, regulators, professional bodies, local scrutiny bodies and Government.

 

The government’s response was, through the CQC, to appoint a new chief Inspector of Hospitals. Secondly, making hospital performance more transparent through a system of ratings. Then, something called a ‘single failure regime’. There would also be a Chief Inspector of Social Care. In addition the government would ‘foster a climate of openness’. How it would do that when it has no control at all over NHS organisations seems moot.

 

That was 8 months ago and so we cannot expect too much to change in a group of organisations that make up the NHS brand, a brand that is now a complex system of public and private provision distinct in organisational form from each other and from social care provision. What remains of the complex system is the underpinning Health and Social Care Act 2012.

 

Many of the 12 points in this March response are hard to critique, for example who does not want ‘Respect and Dignity?’ However there is a little nugget, point 8:

 

“We will work together to minimise bureaucracy, enabling time to care and time to lead, freeing up the expertise of NHS staff and the values and professionalism that called them to serve”.

 

This goes to the heart of the process of care, but there are no short cuts to doing this. Minimising bureaucracy requires leadership to address certain managerialist cultures. Prior to Mid Staffs, Leadership was seen as a key aspect of NHS culture changes. However, Leadership operates in certain organisational cultures and that rests mainly with management and can be strangled by a managerialist culture putting organisations into a catch 22: we need leadership to change cultures but we need culture change to allow leadership. However, it is bureaucratic management chasing non care oriented targets in order to maintain or gain Foundation Trust status which have distorted the care process and hampered frontline staff’s ability to deliver. This operates in wider socio-political context of the devaluing of care in that we accept the need for care but will not provide financial and social structures to allow it to flourish. Instead we have individualised care, leaving it mainly to families and women who are often provide it for free or for low pay.

 

Of the four groups identified above by Hunt, it is the leadership teams, especially hospital management and their Boards, which carry the most responsibility for care in NHS Trusts. Patients can exercise their voices, frontline staff can advocate or try to exercise clinical leadership, external groups can respond to failures often only after the event and were largely ineffectual as they may continue to be. Roy Lilley suggested that weighing a pig does not make it fatter – you have to build in quality from the outset, inspection is a post hoc activity. Trust Boards however set the tone and provide the resources and thus have the primary responsibility for the provision of good quality hospital care.  The Secretary of State for health has now abdicated that responsibility in an increasingly market driven health care system.

 

John Robinson, age 20, died in 2006 as a result of a ruptured spleen after a mountain bike accident. He was discharged from Mid Staffs Accident and Emergency department and died less than 24 hour later. A second inquest is being conducted. Caution must therefore be exercised in making any conclusions about the quality of care John received and whether it was in fact deficient. Claims regarding negligent care require certain conditions to be met and this has not been established in this case.

 

John’s parents claim that he was examined by a junior doctor, and that a consultant was not available. They suggested that if a more senior doctor had examined John then the chance of a ruptured spleen might have been considered. The junior doctor may have been incompetent, or she/he may have been acting within the limits of his competence, we do not know. The point however is that staffing of accident and emergency, and the training and development of staff who could spot this condition, are ultimately the responsibility of the Trust Board. Professional staff have a duty to make known their concerns regarding staffing and the competence of the team they work with, but they need the confidence to act on their concerns and the recognition by management that the exercise of clinical leadership involves challenging structures of support for clinical practice.

 

Therefore, professional staff have to be able to exercise clinical leadership safe in the knowledge that issues will be listened to and acted upon. However, managerial leadership may militate against this because their aims and objectives may blind them to real clinical needs. This was a criticism of Mid Staffs management.  In John’s case, if it was the poor decision making of an inexperienced junior doctor that was a major contributor to his death, we do not know if clinical leadership was exercised to address any issues of the training and support for junior doctors.

 

John Edmonstone (2008) suggested that clinical leadership is distinct from managerial leadership and is often ignored or not addressed by those considering leadership in the NHS. In addition he describes a disconnected hierarchy operating in health care organisations: a clinical hierarchy and a managerial hierarchy. This disconnect results in differing objectives, visions and ways of working. This is reflected by Robert Francis (2013 p3) who argued that the failings at Mid Staffs was primarily caused by:

 

“a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care”.

 

Prior to this Hewison and Griffith, in 2004 argued, “too much emphasis on leadership without an equal concern for transforming the organisations (nurses) work in may result in leadership being added to the list of transient management fads”. Hewison in 2011 went on to argue that the focus on leadership as a solution to organisational ills remains in the NHS. This is rooted in assumptions that leadership, changing cultures and producing effective leaders will result in improvements in management and organisations. Hutchinson and Jackson suggested in 2012 that discussions around leadership often fail to address the issues of power, politics, dominance and resistance in organisational cultures. Both pre date Francis comments about the nature of Trust management at Mid Staffs.

 

Faugier and Woolnough (2003) provided some evidence of what organisations feel like to work in. and thus illustrate how management cultures can distort care practices. They describes three types of organisation:

 

  1. The Machine
  2. The Choir
  3. The Living organisation.

 

In their research 45% of respondents stated that their organisation felt like a machine in which leadership is generally driven by senior management to establish order and control. Strategic decisions are made through a formal planning process and change is planned and programmatic. Employees feel like a ‘cog in a wheel’. Faugier and Woolnough concluded that there was serious work to do to ensure clinical staff feel engaged and empowered. They argued that too many staff felt like cogs with high levels of disengagement and disillusionment and that that the implications for patient care were obvious. This was written in 2003, before Mid Staffs made the headlines. One can’t help but think that the antecedents for poor quality care were already established and were being written about for some time.

 

Questions remain: Will the government be able to do anything about how individual Trusts are run and financed? Will the frontline be properly staffed and supported; will they feel free to express concern about poor quality care?

 

Is clinical leadership any better supported, and will staff feel empowered and engaged? Will today’s government response address any of the fundamental issues?

 

 

Issues to address to address in this regard:

 

  • In a public sector organisation, clinical leaders cannot easily affect, or redefine public policy or legislation set by politicians and so they operate within the conditions set by others. Since the Health and Social Care Act Government has released the reins of control and conditions to NHS organisations and can no longer provide or dictate such issues as minimum staffing levels without enacting new legislation.

 

  • Nursing culture may inhibit clinical leadership development; issues of gender and medical power may continue to inhibit strong nursing leadership within Trusts and in clinical commissioning groups.  Has nursing got the respect of the public, politicians, policy makers and other professional groups to allow the to exercise strong leadership?

 

  • The focus on developing the person, their competencies and their traits, which are often based on male assumptions about what leadership looks like, may be in conflict with the exercise of leadership that focuses on relationships (shared leadership) within complex organisations.

 

  • The ratio of professional nursing staff to non-professional staff requiring training, supervision and regulation by clinical leaders is wrong. Not enough nurses, too many support staff.

 

  • Health care organisations may be risk averse and heavily regulated which counters leadership development that encourages risk and creativity and the challenging of the status quo.

 

  • Inspection and regulation are post hoc activities: are the CQC, Monitor and the Professional Bodies fit for purpose in terms of preventing poor quality care?
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