Tag: Francis Report

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?

“Missed care” in Hospital, we may need more nurses*

Yesterday this research based report argued “There is strong evidence to show that lower nurse staffing levels in hospitals are associated with worse patient outcomes. One hypothesised mechanism is the omission of necessary nursing care caused by time pressure—‘missed care’ “. To investigate this a survey was undertakenof 2917 registered nurses in 401 general medical/surgical wards in 46 general acute National Health Service hospitals in England. This is a decent enough sample frame to begin to make inferences, so what did the researchers conclude? That, according to this cohort care is frequently left undone and that this, unsurprisingly, is related to lack of time. The activities include: comforting or talking with patients, educating patients and developing/updating nursing care plans. Two factors also highlighted was that 1) the number of patients per nurse  and 2) ward patient safety ratings are significantly associated with missed care. This report follows a warning by nurse leaders over nursing numbers and a call for minimum staffing levels.

The wider context is of course the concern around the quality of nursing and medical care given in some Trusts, some of which have focused on ‘compassion in care’. However, following the publication of the Francis Report, the health secretary,  Jeremey Hunt, failed to argue for minumum staffing levels. That being said NICE is working on a tool to be used to establish just such levels. It has been reported that Hunt confirmed that it is not the job of the health secretary to do so.


It is very hard to see that when the NHS is experiencing the Nicholson challenge and may well have to deliver further costs savings  that Trusts, will spend any more on staff.  Considering ward budgets,  pay for staff can be the single biggest expenditure.  The context is that, as I heard clearly stated in a Trust recently, that “this is not a hospital, this is a business” and that budgetry control involves making financial savings year on year. Bruce Keogh, in his recent 2013, report argued that three dimensions of quality were: clinical effectiveness, patient safetey and the patient experience. These three in reality have to be delivered withing a context of cost savings.

This is market discipline in the health service. Private sector organisations (whether they for example, like Farmers, receive state subsidies or not) know this discipline very well. Control your costs or you competitiors will undercut you and force you out of business. However, even in the private sector cost is not the only concern – quality is and customers make decisions not only on cost but the quality of the service or product.

People know however that the NHS is not a private sector organisation and that switching brands is not an easy way to signal dissatisfaction. People also know that poor staffing levels seriously diminishes the quality of the service they recieve. there is no geting away from the fact that care costs money.

This is therefore political and a social battle. The NHS is currently compared to other healthcare systems very good value for money. However, chroinc staff shortages will challenge public support and may make some consider private provision. This is the wrong solution to the wrong problem.



The Francis Report and poor quality care

Roy Lilley has argued:

Francis talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will.  Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have have stood still.


“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”

A nurse was quoted on… wait for it….the ‘One Show’ saying that she came in on her day off to feed a patient, another story was that two male nurses laughed at a half naked elderly man with a catheter. Two ends of the same care story that is the NHS. There is a problem with attitude/culture but there is a problem with structure (e.g. poor staffing) which gives rise to poor culture. Cultures arise out of structures, they do not just appear out of nothing. The way people relate to each is influenced by so many variables but in an organisation set up with a purpose in mind, those variables start to filter down into the structures that are in place to fulfill the stated purpose. If the purpose is to diagnose and treat a minor illness in an otherwise healthy person, the structures you need are relatively straight forward. The structure of staffing: A doctor or suitable qualified nurse with enough time to take a history, carry out an examination, come up with a diagnosis and then initiate treatment. The structure of place: A clean, well lit, warm private space. The structure of resources: for example assessment tools, stethoscopes, sphygmomanometer, examination table….  These are the foundations to encourage a culture of respect and co-operation. Of course having the structure in place does not guarantee a patient centered culture. The reverse is true, take away the GPs structures and you will more than likely get a little less respect and quality care.

The emphasis on culture and NHS leadership has let society off the hook because we then don’t talk about structures. No doubt the culture and leadership in some Hospitals must change…in addition society has to accept that care work costs money. We just don’t seem willing to put in the extra resources to ensure that the vulnerable are not abused. Feminists have long argued that because patriarchal societies view ‘care work = women’s work’ and women’s work has been seen as ‘domestic’ and unskilled (i.e. required very little training because it is ‘natural’ to women) , care work receives little recogniton and value and sinks into invisibility. The structures to support care work in the UK and in many ‘advanced societies’ are creaking to breaking point, relying on armies of unpaid and unsupported family members.

The analogy is with motherhood and the structures that support it: unpaid, hard work, no training, no sick pay, little support…many mothers go the extra mile every single day, some crack under the strain and abuse or neglect. A minority of mothers abuse because they know no better, they are ill or have given up caring. Any care work that is not properly valued recognised and supported runs the risk of increasing the ratio of abuser to saints. Just as mothers need all the support they can get from society, so do nurses. If you isolate, divide, and undervalue their work do not be surprised when there is an increase in neglect. Society ascribes value to work through pay, status and perks….and so you can get an idea of what society values by examining who gets the pay, status and perks. Capitalism has long divided ‘proper’ work (men’s work) in the public sphere which it has paid for on the one hand, and ‘non’ work (female work) in the private sphere, i.e. the home, which it is unwilling to pay for, on the other. Socialists and feminists arguments have tried to get this private sphere work as being properly recognised in the patriarchal hiearchy and so we have child benefit etc. Historically, if men were nurses, and care work the preserve of men, this would have elevated its status and hence support, education and pay. Roy Lilley is calling for funding the front line, to support the structures of care. Watch however how we turn ourselves inside out trying to correct cultures.





Francis Report into NHS care


This is a wide ranging report into the failings at Mid Staffordshire NHS Trust. The above link takes you to the home page. I cannot do justice at this stage but this affects everyone working in the NHS.

This is not a new issue. I ‘trained’ in the 1980’s and saw nurses struggle to give care to the standard they wanted to. I knew students who gave up because of the gap between the ideal and reality. In 2001 the department of health published ‘essence of care for patient focused benchmarking, which are the sort of standards discussed in the report. This did not prevent Mid Staffs. A ‘patient centred NHS’ is not a new conceopt either. Nightingale once said “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm”. [1859]. Francis kept mentioning culture today and I agree. In our book ‘Psychology and Sociology for Nurses’ the power of culture and socialisation was discussed as mechanisms which allow poor care to flourish. in the leadership literature, there are warnings that leadership development could be just another fad if the organisation of the NHS does not change. Quality and Leadership have been core aspects of nurse education for well over a decade as exemplified in the Dept of Health document ‘Making a Difference’. There is a plethora of models, education, literature, quality improvement provisions, leadership development programmes, for nurses but all to no avail it seems in some NHS hospitals. Kath Melia described the difficulties students faced when in practice back in the 80’s, not being able to put into action what they might have been taught. The concept of the Theory-Practice gap has been known for decades. This refers to theoretical knowledge (such as ‘holistic care’) not being applied in clinical practice, or clinical practice rendering theory irrelevant. The NHS has been badly managed and resourced. Care work is invisible and not measured and so does not show up in Trust accounting and priorities. Being able to drink a cup of tea is a priority for patients in many wards but this may not help the Trust acheive its targets, save money on its budget or acheive its Foundation status. Nurses and patients know ‘its the little thngs that count’ – count that is for patients and nurses but not it seems to organisations. Society must also shoulder some responsibility for our structures for care of older people – dehumanised, isolated, institutionalised and underfunded.

Care, Compassion and the Social Structures of Oppression

Care, Compassion and the Social Structures of Oppression


Nurses are asked to consider dignity and compassion as nursing issues. However if media reports such as ‘my husband died like a battery hen in hospital’ are correct , and  there are far too many to be dismissed, certain practices can squeeze compassion out of nursing care.  We therefore need to be critically self-reflective and critically thinking (Morrall and Goodman 2012) of the ‘social structures of oppression’ (Harden 1996).  Jeremy Hunt has recently described ‘the normalisation of cruelty’ in NHS organisations. If this is correct we need to analyse why this might be so. However, and accepting that there is poor care,  this phrase is part of a campaign of criticising public sector organisations in order to soften up the public mood for privatisations. It is part of this wider public relations exercise. That being said, we cannot overlook the real pain and suffering of patients as being only down to ‘them’ (whoever ‘they’ may be).


Thus, it is necessary for nurses to reflect upon the reasons we see such poor quality care. This is not just or only a case of failing, uncaring individuals which require calling them to account, although there is truth to this. There will always be individuals who ‘do not give a stuff’ and see care work as only a means to an end, i.e. the pay.

Up to the point when the struggle for material conditions no longer becomes an issue, money is an extrinsic reward and motivator. The fundamental basis of most work in a capitalist system is the ‘cash nexus’ i.e. the starting point for work is the pay. This is an extrinsic motivator. Take away this extrinsic motivation, and then take way all other intrinsic motivations (to care, be compassionate, to make a difference, because it is fun….) work then becomes meaningless. Many nurses and care assistants are relatively low paid and this is their sole extrinsic motivator. Nurses don’t get much in the way of other extrinsic motivators such as status or privileged/free access to important goods and people (perks). Thus to keep working they rely on their intrinsic motivators just mentioned.

To demonstrate the importance of pay, just consider how many nurses would stay at their posts if they a) won the lottery b) came into a decent inheritance c) were independently wealthy. There would no longer be the extrinsic reward and motivator to work.  Would any intrinsic motivator that one still has (the sheer love of caring) still make one go to work? So let’s be honest with ourselves first. Without pay many of us would not nurse. That being said nurses do then bring into their daily lives their intrinsic motivators. Then they are paid just enough to care, just enough so that any innate compassion can be exercised. However that is a fine line.

Nursing work is often dirty ‘body work’ that few would willingly take on just for the love of it. The ’emotional labour’ involved also takes its toll. However, there is still a caring ethic underpinning nursing and most nurses wish to be compassionate and nurse because of the pay yes, but also because they want their work to ‘mean something’. This compassion can be trampled upon by the context in which it has to operate – job losses, poor staffing levels, poor skill mix, lack of clinical supervision, poor access to professional development, lack of social status and esteem, patient complexity and consumerism,  hierarchical, patriarchal and bureaucratic managerialism to name just a few oppressive social structures.  So, in essence, poor care is a political and social issue not just an individual one. Too often we pick on the failing individual nurse(s) when we should be stripping away the layers of context which promotes uncaring attitudes or does nothing to weed it out. The Francis Report into Mid Staffordshire NHS Trust, for example, shows certain management cultures that hardly supported good care, and the Margaret Haywood case shows what happens to whistleblowers.

However, we also need to consider the fact that within similar organisations experiencing the same funding and staffing issues, why there are differences in compassion and care? What are some ward managers and individual nurses doing that demonstrates that care is not being compromised? I suspect there is a complex interplay of various social and local factors which play out in hospital and care homes that results in horrific experiences for one and superb care in another. I also suspect that articulate, confident, intelligent nurses give high quality care despite and not because of the social and organisational contexts they find themselves. As nurses and care assistants in the NHS come under increasing pressures, the bad apples will have more space to operate and compassion fatigue could set in even further.

So students of nursing and nurses are being exposed to savage criticism of nursing care, we have to be honest and say that in some cases this is justified. However this is complex and the analysis of the antecedents of poor care must take us beyond simply blaming failing individuals. Indeed a recent, February 2013, Nursing Times survey indicates that nearly 50% of staff consider ward staffing levels to be dangerous. This is part of the context ‘failing’ individuals find themselves.

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