Is the NHS really failing the elderly, as the ombudsman says?


4:01 pm - February 18th 2011

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contribution by Dr AlienfromZog

“The NHS is failing to treat elderly patients in England with care, dignity and respect,” said the health service ombudsman this week.

The report also claims that these are not isolated incidents and are in fact illustrative of the poor quality of basic care in the NHS. But there are simple reasons why these claims are unrepresentative.

1. The kind of events described in this report are not acceptable. These things should never happen. This is not healthcare, it is plainly wrong that anyone should be treated like this.

2. The way this report was constructed makes it very unlikely that these cases are representative – in fact statistically, the opposite is true.

I joined medicine to care for people. I have in my career worked with a large number of nurses, some good some bad, some excellent. For the most part they do a very difficult job really well and despite the ‘hard-working-nurses’ rhetoric are not appreciated for what they do.

But let’s look at the wider picture.

The health service ombudsman exists to investigate complaints where local complaint-handling services have not reached a satisfactory conclusion. These ten cases come from a 1 year period in which the ombudsman received around 9000 cases.

Of these, 1620 were concerning the elderly and only 226 of those met the criteria for full investigation. Richard Blogger explains very well, the reasons for not investigating. Of these 226 cases, fully investigating, the ombudsman pulls out 10 specific stories.

According to the official figures there were over 14 million ‘completed hospital episodes’ in that time period. This figure gives some idea of how much activity there is in the NHS – especially as most healthcare activity takes place in the community not in hospitals.

These cases are selected out of complaints that reached the ombudsman, were fully investigated and then pulled together because of the seriousness of the issues.

However, to imply as the Ombudsman, the Prime Minister and most of the press have, that these cases are ‘the tip of the iceberg’ and the NHS must be overhauled is nonsensical in the extreme. Not least because the methodology of producing this report is very good evidence that such happenings are in fact not typical.

I would even go so far as to say that it is really sick to use the suffering of these victims to further a political agenda.

Dr Alienfromzog BSc(Hons) MBChB MRCS(Ed) DCH
[With special thanks to Richard Blogger]

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Reader comments


First, a general point about the medical professions unwillingness to present themselves publicly. DrAlienfromzog provides a pseudonym. Papers regularly carry letters from spouses or parents of medics voicing their complaints (there was a spate of pathetic letters during the furore over the online junior doctors new application system a few years back with parents complaining that their darling offspring would have to move town to get a job they wanted, which obviously doesn’t happen in any other profession)
And this goes to the nub of the problem. I don’t blame the Dr here for using a pseudonym – don’t knowingly take on the NHS bureaucracy. They are incredibly good at closing ranks and defending their own. The figures cited here, I would suggest, say more about the ability of the NHS bureaucracy to fend off complaints on behalf of vulnerable people than they do about the true picture of mistreatment of the elderly. Just as there is almost certainly more child abuse than as a society we would like acknowledge, this is hardly the first report of abuse of the elderly in the NHS. Not only did NHS staff do this, others must have known it was happening and turned a blind eye. I’m all for defending the NHS against coalition cuts, but attempts to pretend everything is rosy won’t wash. Sorry, but this defence here isn’t persuasive.

Nothing to see here.

All is well.

I’ve recently been treated in an NHS hospital and then went on to private convalescence afterwards. I’ve also friends of a similar age who have been in various NHS hospitals.

Speaking with other patients, their experience of NHS hospitals based on their pesrsonal observations is that patients who are rated by nursing staff to be senile are often neglected. They recount instances where they have personally observed this.

I salute the health service ombudsman for picking up on treatment of the elderly and do hope we are not going to be treated to the usual spate of denials whenever any criticism is made of the NHS.

A reminder from an earlier post of mine – when the surgeon presented me with a consent form to sign at that recent stay in hospital, it specified the wrong operation and required a manuscript correction before I would sign. That provided an insight into how deadful mistakes are made – suppose I had been more poorly than I was or dozing just before an operation? Fortunately, the surgery went well after that.

“More than 3,000 hospital patients have died because of errors by NHS staff in England over the past year, figures show. Hospitals reported 3,645 deaths in 2007-8 from patient safety incidents, data from the Lib Dems showed.”
http://news.bbc.co.uk/1/hi/7813634.stm

“More than 5,700 patients in England died or suffered serious harm due to errors latest figures for a six-month period show. The National Patient Safety Agency said there were 459,500 safety incidents from October 2008 to March 2009 – the highest rate since records began. Patient accidents were the most common problem, followed by mistakes made during treatment and with medication.”
http://news.bbc.co.uk/1/hi/8295417.stm

Recognising that there is a real problem is an essential first step for resolving it IMO.

4. James Alexander

Respect the argument, respect the tone, just need to see the sheer volume of anecdotal evidence encountered (to me trustworthy and detailed) lining up with and predating the report over a long period, (including personal experience of treatment of deceased parents), worries me. I’d so like the word from Zog to be right.

5. James Alexander

Sorry, that 4 is a mess. Make it this.

Respect the argument, respect the tone, its just the sheer volume of anecdotal evidence (for me trustworthy and detailed) that lines up with and predates the report over a long period, (including personal experience of treatment of deceased parents), that worries me. I’d so like the word from Zog to be right.

6. the a&e charge nurse

Elderly care can be patchy in the NHS, sometimes even shocking, but given the widespread cultural denial that exist when it comes to the final years of life I very much doubt if the elderly can suddenly expect to be nursed in the type of environment one comes across in a glossy Bupa brochure?
http://www.luxmoore.co.uk/health/images/health_d.jpg

First of all we have seen the burgeoning tendency for families to ‘outsource’ elderly relatives to care homes (whenever costs are not too prohibitive) – the latest figures show around 500,000 being warehoused in such places (compared to around 160,000 NHS beds).
Most care homes have a low threshold for phoning an ambulance whenever residents become unwell, not least because they have few medical skills or even the nursing skills to set up IV lines and give the necessary drugs.
http://www.independent.co.uk/life-style/health-and-families/health-news/dire-state-of-care-homes-for-the-elderly-is-only-going-to-get-worse-says-top-inspector-2195530.html

Once on an NHS ward it is soon apparent that there is no meaningful recognition of how labour intensive, or ruinously expensive round the clock care is, instead a few exhausted nurses simply become punch bags for the understandable frustration of relatives (and managers) who become rather upset about the fact many elderly patients are in a very poorly state as they wind down through the last few months of life.

Anybody who has worked on an elderly care ward will recognise such patterns as more or less par of the course but instead of resourcing the sort of (expensive) standards we would all like for our own families we get lots of harrumphing from ‘experts’ who are generally rather thin on the ground when 2 or 3 demented patients become incontinent at 3 o’clock in the morning.

In short I would rather such people either put on the uniform, roll up their sleeves and get stuck in or keep their rather useless platitudes to themselves.

7. Chaise Guevara

I agree. Using ten anecdotal examples of appalling service to declare that the NHS suffers from systemic failure is clearly nonsense. You could equally as well find ten accounts of NHS staff going above and beyond the call of duty and use that to declare that the service is perfect and an example to us all. Makes no sense.

Is the NHS really failing the elderly, as the ombudsman says?

This is the wrong question I think. Better to ask what IF the NHS was failing? Would the Left and NHS lobby groups actually want to know? Especially if it was failing at a time when they were resisiting all refroms to the state monopoly.

It is certainly strange that the Government and media only want to talk about the elderly when they can kick the NHS by doing so. Most of the time they are as negligent and uncaring as the rest of society. But that is why I think there really is an iceberg concerned. The cases we heard of had angry and articulate relatives fighting for them. When I was caring for my mother, who had alzheimers, I was repeatedly told by nursing staff that I would have to fight for her to have adequate care. The care went to those who had advocates. But there are, by the nature of things, thousands of elderly patients who are alone, isolated and without people ready to champion their cause. It is the fate of these people, the meek and voiceless, which should most concern us. They are far too easy to push to the back of the queue and ignore.

‘Using ten anecdotal examples of appalling service to declare that the NHS suffers from systemic failure is clearly nonsense.’

We have our answer. The health service ombudsman knows less than Chaise Guevara and real peoples complaints are ‘nonsense’.

The voice of the state monopoly – the NHS is great and its users should be grateful and shut the hell up.

11. Chaise Guevara

“We have our answer. The health service ombudsman knows less than Chaise Guevara and real peoples complaints are ‘nonsense’. ”

I don’t know more about the NHS than the health ombudsman. However, I probably know more about pretty much any topic than someone who makes straw man attacks and doesn’t understand basic logic.

But no, I’m interested: please explain how ten anecdotal examples can give us a fair picture of the system overall. I’m agog.

@7: “Using ten anecdotal examples of appalling service to declare that the NHS suffers from systemic failure is clearly nonsense.”

We’ve had statistics about NHS treatment errors galore – such as those I quoted @3 above here. Perhaps the ombudsman was trying to get a message across by going beyond the mere data and looking at examples of how real people in NHS care were actually treated.

Whenever any criticism of the NHS comes out, it’s absolutely predictable that the usual band of NHS propagandists come out with general denials – which is very likely one reason the NHS problems stay unresolved and become entrenched year after year.

In independent, international assessments, the NHS has not been highly rated compared with the health services in other west European countries.

I admit I’ve a continuing personal interest, my local hospital was named in 2001 by the government’s health improvement commission as the worst hospital in the country – I can post the link to the press report in The Guardian in case anyone wants to challenge this. In August 2007 I received a letter from the Pathology Dept asking me to return so they could take another blood sample as insufficient was taken at my recent blood test. That recent blood test was in April. It took from April until August for them to realise they they hadn’t taken enough blood to conduct all the tests requested by my GP. Fortunately, the tests weren’t critical.

13. Chaise Guevara

@ 12 Bob B

“We’ve had statistics about NHS treatment errors galore – such as those I quoted @3 above here. Perhaps the ombudsman was trying to get a message across by going beyond the mere data and looking at examples of how real people in NHS care were actually treated.”

Sure, and I’m absolutely cool with that. If the ombudsman wants to generate public interest in improving the NHS, illustrative examples are an effective tool.

What I object to is people extrapolating wildly from these ten examples and acting as if they are representative of the entire health service.

14. the a&e charge nurse

[8] ahh, so it’s the fault of a ‘state monopoly’ – but many care homes are privately run, aren’t they – surely we can see a gold standard of care once free from the shackles of big brother?

Dream on, Tory

15. Chaise Guevara

@ 14

To be fair to Tory, given that he thinks I said “the NHS is great and its users should be grateful and shut the hell up”, or words even slightly to the effect, he’s obviously just bashing at his keyboard at random in the hope that the result will make sense.

As you can see, this technique isn’t working.

I could not agree more if I jumped up and down 1000 times shouting “I DISAGREE!”

What’s more a doctor is NOT the best placed to judge how good patient care is. Yes nurses work incredibly hard under difficult conditions, but frankly there is systemic failure within the NHS to care for patients – even to a basic level.

It’s taboo, sure. But I must have been an inpatient 15 times in the last 20 years, for weeks at a time. I’ve been bullied, ignored, I’ve had a stroke mistaken for a panic attack, I’ve been screamed at by nurses, I’ve been left for hours on end in agonising pain, I’ve been given drugs I’m severely allergic to over and over.

I’ve been misdiagnosed more times than I can say, discharged haemorrhaging or with raging infections, I’ve been left months untreated, left lying in my own blood for hours, I’ve watched old people die from dehydration because no-one held their drinks….. I could GENUINELY go on all day. Alternatively, you could read my blog http://diaryofabenefitscrounger.blogspot.com/ from mid November (Day 1) and read exactly what it’s like to be an in-patient. Sorry, but you clearly have no idea, and as a doctor you should.

This is not now and then – it is every day in every hospital and almost every patient. Not just the elderly, but the chronically ill and others.

If we never accept the NHS has faults it will never change.

Not only is patient care often rubbish – and yes, sometimes it’s because nurses ARE lazy or doctors ARE arrogant and incompetent – but it’s dangerous. Every day. Anyone working in the NHS knows that. They need to start speaking out.

Clearly, the first line should say DISAGREE.

I must admit to have felt some scepticism due to the timing of this report.

I have seen elderly patients in wards apparently neglected, but as I was in an opposite bed I could also see the poor buggers needed almost continuous, one-to-one care. How is any health service going to provide that in an ageing society without costs going through the roof?

This is an easy area in which to attack the NHS, but the failings are wider. The NHS is being asked to do the work that familes and the community might have in the past. If we want to do better we should not be considering cutting or privatising healthcare, we should be looking more seriously at what the needs of the elderly are in the last years of their lives.

19. the a&e charge nurse

[16] “They need to start speaking out” – as well as developing a keen interest in gardening – sadly, the lot of an NHS whistleblower is seldom a happy one.
http://www.independent.co.uk/life-style/health-and-families/health-news/millions-spent-on-doctor-gagging-orders-by-nhs-investigation-finds-2041209.html

Two thirds of nurses have raised concerns about care, more than one in three claimed no action had been taken – nurses are worried about the consequences of whistle-blowing despite having formal protection under the Public Interest Disclosure Act.
Eight in 10 said they would be concerned about victimisation for speaking out, while a fifth reported they had been actively discouraged from reporting concerns.
One nurse who spoke out against poor care told the union: “There are some managers who still marginalise me and make it clear that I am persona non grata. I have been told I will never get on in the trust because I don’t go with the flow.”
http://news.bbc.co.uk/1/hi/health/8038735.stm

Fair point a&e charge nurse.

As for this just being 10 ombudsman cases how about this#

http://www.guardian.co.uk/society/2010/nov/11/nhs-hospital-care-elderly

http://www.bbc.co.uk/news/health-11889342

And many, many many more. In fact when someone’s bothered to do a study have they EVER found that care was acceptable???

@19 quoted this: “There are some managers who still marginalise me and make it clear that I am persona non grata. I have been told I will never get on in the trust because I don’t go with the flow.”
http://news.bbc.co.uk/1/hi/health/8038735.stm

There are persuasive professional reasons for “not rocking the boat”. Try this from the annual earnings survey of the Office of National Statistics:

“The full-time occupations with the highest earnings in 2010 were ‘Health professionals’ (median pay of full-time employees of £1,067 a week); followed by ‘Corporate managers’ (£757); and ‘Science and technology professionals’ (£704). The lowest paid of all full-time employees were those in ‘Sales occupations’, at £287 a week.”
http://www.statistics.gov.uk/cci/nugget.asp?id=285

According to this survey in 2005, British doctors are among the best paid in Europe:
http://www.timesonline.co.uk/tol/news/uk/health/article758105.ece

Which perhaps isn’t too surprising because the number of practising physicians in Britain per head of population is low as compared with most other west European countries:
http://www.oecd.org/dataoecd/53/12/38976551.pdf

One important question is how come we have so few physicians per head of population compared with other west European countries?

22. alienfromzog

There are two separate but very important points here:

Firstly neglect of patients is always entirely unacceptable and I would never defend it when it takes place.
Secondly, the evidence from the ombudsman report does not show this is widespread – the methodology used, inevitably selects for unusual cases.

If you want to argue that neglect is commonplace across the NHS then you need different evidence to this.

Neither point should negate the other.

Furthermore the idea that the NHS as a state-monopoly is the cause of the problem is very dodgy logic. It is not surprising that within care systems all over the world, elderly abuse of various forms takes place. The elderly are often very vulnerable and often very unlikely to complain or be able to advocate for themselves.

You want to argue that care of the elderly needs improvement? I will back you all the way.

However, the link of these cases to ‘systemic failings in the state-run health service’ is just ideological nonsense. In the UK, much more neglect occurs in private nursing homes. In other parts of the world similar problems are well known. Why? Because the elderly are often very vulnerably and often very unlikely to complain or be able to advocate for themselves.

And, for me, the killer is this: – the Lansley reforms will make things worse for the vulnerable. And the Tories dare to use the vulnerable as a justification for the reforms.

AFZ

http://diaryofabenefitscrounger.blogspot.com/2010/12/to-assume-makes-ass-of-u-and-me.html

Doctor, if you don’t read ANY of the other links, I really really hope you read this first hand account of patient care.

I agree with much of that post.

It’s not just elderly care though. ALL patients are vulnerable or they wouldn’t be on a ward. Spend more than 4 or 5 days as a patient and you’ll experience bad care (dangerous or lazy or even cruel, not “rushed”)
Spend four or more years and you’ll be lucky not to be left with mental illness. That’s not histrionics or hyperbole but evidenced by the high levels of PTSD found amongst this group not to mention other phobias or anxiety disorders surrounding their care.

My medical ward most recently was appalling. The surgical ward however was good. The ward managers couldn’t have been more different in attitude and it pervaded everything. On one “expert patients” are desired, on the other, welcomed. On one, HCAs were proactive, on the other reactive. On one there was a feeling of them and us, on the other we were all in it together.

i agree that THIS test can’t prove that patient care is systemically bad, but ALL the studies can taken together. Every year for at least three years, from charities, focus groups etc. a study has told the same story, and every time it has been ignored.

Nurses know exactly what the score is. They know they’re overworked sure, but they also know they often have to “carry” incompetent or lazy or uncaring colleagues, they have to put up with managers who don’t run a good ward, they have to put up with obstructive systems and impossibly chaotic scheduling and pharmacy delays.

Of course the good nurses and other staff know it – the bad ones just deny it.

Tut, “desired” should read “despised”

@22: “Furthermore the idea that the NHS as a state-monopoly is the cause of the problem is very dodgy logic.”

Really? Try this instead:

“Its rigid pay policy makes it easy for the NHS to recruit and keep good nurses in poorer northern regions but hard to hire and retain them in the richer south. Hospitals in the north gain from a more stable pool of nurses. Southern ones have to lean on temporary agency nurses, who can be paid more but tend to be less experienced, less familiar with the hospital and less productive. Do southern patients suffer as a result?

“The economists look at the proportion of patients aged 55 or more, admitted to hospital after a heart attack, who die within 30 days. They find a strong link between this ratio and local private-sector wages. The higher the private wage, making it harder to get good nurses in the NHS, the higher the death rate: to be precise, if the private wage is 10% higher in one area than another, the death rate is 4-5% higher.”
http://www.economist.com/world/britain/displaystory.cfm?story_id=E1_TDVGGRSS

This paper by LSE researchers was the original source: Can Pay Regulation Kill? Panel Data Evidence on the Effect of Labor Markets on Hospital Performance
http://www2.lse.ac.uk/intranet/LSEServices/divisionsAndDepartments/ERD/pressAndInformationOffice/PDF/CanPayRegulationKilll.pdf

That pehaps offers insights into why other west European countries avoided the state-monopoly option for their national healthcare systems. On the evidence, they seem to believe that there is much to be said for decentralised administration and competition between service providers..

Credit for starting a national welfare state must surely go to Count von Bismarck, first Chancellor of the German empire (1871-90), who launched not only state pensions for the aged but, in 1883, a social insurance scheme to cover personal healthcare costs:

“The Health Insurance bill . . was passed in 1883. The program was considered the least important from Bismarck’s point of view, and the least politically troublesome. The program was established to provide health care for the largest segment of the German workers. The health service was established on a local basis, with the cost divided between employers and the employed. The employers contributed 1/3rd, while the workers contributed 2/3rds . The minimum payments for medical treatment and Sick Pay for up to 13 weeks were legally fixed.”
http://en.wikipedia.org/wiki/Otto_von_Bismarck

Whatever else, Count Bismarck had no leftist inclinations. Quite the opposite, in fact.

Incidentally, does any one here know where the “£20 billion efficiency savings” comes from? I mean, it couldn’t just be made up, could it?

No. It comes from a report compiled by McKinsey. In this they list areas of the NHS where they think that money can be saved. (Selling off land appears to bring in a lot of money in their report – I wonder if they have any property developer clients? – but it is hardly an “efficiency saving” since it can only occur once.)

Anyway, McK say that nurses are not productive enough. They say that the NHS can squeeze extra productivity out of them and save £0.7-£1.1bn. Great, eh? But how?

Well the problem is that, according to McK, hospital nurses spend 16% of their time “Psychosocial care of patients” and McK says that if this is removed the NHS could save loadsamoney. Hmmm, what was it again that the Ombudsman was complaining about?

McK also says that Community Health Services can have 11-15% fewer staff (!money saved!) if they make community nurses see more patients every day. So let’s see: same working day, more patients = less time with each patient. Hmmm, I wonder what the Ombudsman will say about that?

The “efficiency savings” recommended by McKinsey will result in worse care. Nursing staff will simply not have enough time to get everything done. The “£20bn efficiency savings” is not optional. It has to be done because the budget will be cut by £20bn. Oh, sorry, to satisfy the pedants: there will be more work, equivalent to £20bn worth, but the NHS will not get the money to pay for it, they will have to find the money by visiting more patients every day, and not having the time to talk to patients on the ward. Nice one McKinsey!

Frankly, this Ombudsman report will be the “tip of the iceberg” because it will seem minor compared to the volume of complaints that will occur when the cuts start to bite.

“I’ll cut the deficit, not the NHS”. Bollocks.

27

Brilliant – completely ignore the points made in 16, 20 & 24 & absolutely show that 10 is right – you’re all in denial.

Thank god I don’t have to depend on Dr.afz & R Blogger for (well, anything really).

You deserve everything you get.

@27

Try this news story of 3 September 2009 – well before the May 2010 general election – about the McKinsey report on the NHS in the Health Service Journal:
http://www.hsj.co.uk/news/finance/dh-is-told-137000-nhs-posts-must-go-in-next-five-years/5005782.article

A further news story in the same journal, a week later, gives more detail:
http://www.hsj.co.uk/news/policy/nhs-spending-mckinsey-exposes-hard-choices-to-save-20bn/5005952.article

The BBC story about McKinsey – with a graph showing the increase in staffing:
http://news.bbc.co.uk/1/hi/8234841.stm#graph

The Labour government shelved the report but Lansley published the McKinsey report slides in June last year:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_116521.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_116521.pdf

This story was a blatant propaganda piece planted by Coulson and/or Oliver to support the narrative that the NHS is failing and only massive restructuring and privatization will sort out the problem. There was a similar story that had top billing on the BBC a few weeks ago about the pay of NHS consultants which was obviously the same propaganda.

Personally, I’ve always found the clinicians in the NHS to be pretty good, except for one GP who was a total c**t and I could happily beat her to death but strangely enough she seems to be leading one of the new “consortia” and is practically creaming over the tories plans on her surgeries website.

@30: “Personally, I’ve always found the clinicians in the NHS to be pretty good”

As was said to me by a patient of about the same age as myself whom I met recently when on convalescence: the medicine is usually fine but the quality of nursing is often variable.

Her recent healthcare experience included not only similar orthopaedic surgery to myself – and by the same surgeon – but an earlier period of intensive care at the local NHS hospital after she contracted pneumonia. Unprompted, she too said she had noticed the neglect of patients showing early signs of dementia by nursing staff.

If you speak with real patients, I think that you’ll find NHS hospital physicians – and surgeons – are not usually the problem in care of the elderly. The care issues come mainly from the way some nurses care for elderly patients – and, on talking with patients, to my personal horror, there seems to be a fairly wide popular consensus about the ethnicity of nurses likely to be the most culpable.

The evidence of mistreatment of elderly NHS patients is substantive and can’t and shouldn’t be dismissed out of hand. It’s not just right-wing propaganda pushed out by the demonic Tories.

Oh for goodness sake Chris, what nonsense!!

They don’t get much more tribally labour than me – oh! It appears they do!!

I really want to shout in caps, but will restrain myself and say wake up and smell the coffee! Reports like this are coming out ALL the time – Lab Gov, Con gov or coalition – everyone just ignores them and more people suffer or die.

Well Bob, we tried, but I don’t think we got far :((((

My mother was killed by the NHS and our doctor recommended we take action, but I was physically and mentally exhausted after her death. I wonder how many others feel the same. She went into hospital with pneumonia, was put on oxygen. Then she was prematurely transfered to another hospital for the elderly. The oxygen was supplied by cannister, which kept running out. I had to measure the time it would run out and telephone the ward to remind them to change it. Her mental stability was terrible as a result of the oxygen imbalances. They could not locate any sides for her bed. She wandered in the night and fell, breaking her hip…. except they this was denied for 9 days and she was forced to have physiotherapy to walk. I would go in before I went to work… she would have poured her tea into her porridge and put her teeth into the porridge as well. She was not fed unless I fed her. I returned after work for the evening. She was frequently dirty. I tried to make few representations because I was frightened that the nurses would take it out on my mother. They seemed so angry and aggressive. There was no care, no kindness, no respect and I suspect she would have died in there, but for the care I gave her. She came home, but never recovered from this nightmare. I hope and pray that I never get old enough to have to suffer such misery, such… cruelty… because that is what it was. His was 6 years ago. Most people do not complain and I am sure that the Ombudsman cases are just the tip of a gigantic iceberg.

@33 Sue: “Well Bob, we tried, but I don’t think we got far (((”

Sadly, no. I’ve debated healthcare issues on various online forums for more than a decade – really – and the debate lines just keep repeating.

Because I’m an old codger now, I can recall reading essays about the NHS from the 1950s by the high priests at the LSE. The standard line was the NHS is truly wonderful – look how awful the American system of healthcare is. And sure enough, because lots of business people, politicians and journos had visited America and, importantly, because they also spoke and wrote English over there, that had an instant resonance. The American system of healthcare was and is truly awful.

Only since the report on national healthcare systems by the the World Health Organisation is 2000 have academia and think-tanks here taken much notice of healthcare in other west European countries:

“Taken together, the World Health Organisation, in 2000, ranked the provision of healthcare in the United Kingdom as fifteenth best in Europe and eighteenth in the world.”
http://en.wikipedia.org/wiki/Healthcare_in_the_United_Kingdom

As I keep posting, credit for starting a national welfare state must surely go to Count von Bismarck, first Chancellor of the German empire (1871-90), who launched not only state pensions for the aged but, in 1883, a social insurance scheme to cover personal healthcare costs:
http://en.wikipedia.org/wiki/Otto_von_Bismarck#Chancellor_of_the_German_Empire

Briefs on a selection of national healthcare systems from the Civitas think-tank can be found here:
http://www.civitas.org.uk/nhs/health_systems.php

As best I can tell, the Netherlands is currently rated as having the best system in Europe:
http://en.wikipedia.org/wiki/Healthcare_in_the_Netherlands

@28. max

Brilliant – completely ignore the points made in 16, 20 & 24 & absolutely show that 10 is right – you’re all in denial.

Thank god I don’t have to depend on Dr.afz & R Blogger for (well, anything really).

Do you completely lack any powers of comprehension?

What I wrote in #27 can be summarised as “if you think care is bad now, then you won’t believe how bad they’ll be when the McKinsey recommended cuts in staffing are applied”.

::Sheesh:: some people have to be taught how to think.

35 Bob B
I don’t want to sound as if I’m attempting to dismiss your claims Bob, but from the link you provide, the Netherlands spends more per GDP on its’ healthcare system than does the UK.
IMO, the problems with the NHS started with Thatcher/Major’s idea to attempt to carry-out market style management within the framework of a bureaucratic system, this, in effect, created the need for more bureaucrats.
With particular reference to the elderly, The Community Care Act changed the financing of residential care from central to local governments, which caused an enormous amount of bed-blocking within hospitals as budgets ran out. A further problem was the tendancy of social-workers to have people with assets such as houses, admitted into residential homes although they could have been cared for in the community, but placing people into residential care meant that they would have to fund themselves, which saved money from budgets.
The upshot of this is that many elderly people are left on wards for a long periods but hospital wards on not designed for ongoing care and neither are they staffed to accommodate it
This, of course, does not justify some of the less than satisfactory care that has been reported.

35. Bob B

“Taken together, the World Health Organisation, in 2000, ranked the provision of healthcare in the United Kingdom as fifteenth best in Europe and eighteenth in the world.”
http://en.wikipedia.org/wiki/Healthcare_in_the_United_Kingdom

The paper is not measuring ‘ best.’ They are measuring efficiency within a specific framework. If you think Greece has better healthcare than The Netherlands and Sweden- Columbia better than Germany and Morocco better than Denmark then I am afraid you are barking.

@37: “I don’t want to sound as if I’m attempting to dismiss your claims Bob, but from the link you provide, the Netherlands spends more per GDP on its’ healthcare system than does the UK.”

So what? America spends about 15+% of national GDP on healthcare, about half of which goes on public funding for healthcare services.

No other country spends as much in total as America does on healthcare as a percentage of national GDP but few believe that the average American citizen gets as good healthcare as the average citizen does in most west European countries even if private healthcare in America is excellent.

Prior to the Obama reforms, 46 million Americas had no insurance cover for healthcare costs and unpaid healthcare bills were the most frequent reason for personal bankruptcy.

Evidently, national spending on healthcare isn’t everything and we need to compare not just spending between countries but patient outcomes – such as 5-year survival rates for patients diagnosed with cancers. We need to look too as to why Britain has so few practising physicians per head of population as compared with most other west European countries – see the link @21.

40. Laughing Gravy

For the last fifteen years of her professional career as a nurse, my wife was sister-in-charge of a long stay geriatric ward. She had been trained and worked under the ‘old’ culture of nursing. Each patient had a care plan, under the supervision of one of the registered nurses on the ward. The bulk of the day-to-day care of each patient may have been carried out by nursing assistants – but the supervising nurse was responsible for the implementation of the plan. My wife checked every patient, every day to ensure that they were being properly cared for according to their personal plan. Initially, she was assisted by registered and enrolled nurses and this regime worked well. Later she was assisted by newly registered nurses plus assistants. When she retired, after forty years, she was not sad to go. The job had become harder because of the attitudes of the newer registered nurses who would not be managed, and did not like to take the responsibility for indiviual patients, and because of the attitudes of nursing assistants who were slovenly, ill-educated, and disobedient. The fact that my wife regularly checked the state of the patients was seen as interferring and an implicit criticism. Fundamentally, what has gone wrong is structured ward management of patients is failing. The cases mentioned by the Ombudsman are extreme examples – but anyone who regularly vists NHS wards (not only geriatric wards) see minor and major examples of the same failings. There has to be a reintroduction of the management responsibility and authority of ward sisters otherwise these scandals will continue. It is not rocket science.

@38: “The paper [on UK healthcare] is not measuring ‘ best.’ They are measuring efficiency within a specific framework. If you think Greece has better healthcare than The Netherlands and Sweden- Columbia better than Germany and Morocco better than Denmark then I am afraid you are barking.”

– Several subsequent independent assessments of healthcare services in Europe following the WHO report in 2000 have rated UK healthcare services as relatively mediocre from a consumer’s perspective:
http://www.healthpowerhouse.com/files/Index%20matrix%20EHCI%202009%20091001%20final%20A3%20sheet.pdf

– @35: “As best I can tell, the Netherlands is currently rated as having the best system in Europe”:

“The standard of healthcare in Netherlands is reasonably high and probably one of the best in Europe. ”
http://www.amsterdamtips.com/tips/healthcare-netherlands.php

“The Netherlands was ranked first in a study comparing the health care systems of the US, Australia, Canada, Great Britain, Germany and New Zealand.”
http://en.wikipedia.org/wiki/Healthcare_in_the_Netherlands

As for Greece, average life expectancy at birth there is marginal longer than in the UK but shorter than in most other west European countries according to this OECD chart for 2007 – and btw UK life expectancy at birth is longer than in the US, which is surprising seeing as how the Americans spend so much more on healthcare as a percentage of national GDP than any other country:
http://www.oecd.org/dataoecd/22/36/45270718.pdf

40
I don’t know where your wife worked but care-plans were not the old style of nursing they are the new way, most older nurses never did personal assessment or wrote a care-plan, care was determined initially by the matron and carried-out by the nurse-in-charge, there would hardly be any entries made in the patient’s notes and then it would be only the matron who made entries. Now there has to be at least one entry per shift and that is undertaken by the primary or named nurse.
If your wife constantly checked the patients designated to primary or named nurses they would probably feel as if she was interfering as those nurses were trained in the new way ie they are personally responsible and accountable for their practice. No nurse in charge or matron to direct them.
Yes I agree that the job is much harder, partially due to individual care-planning and partially due to the fact that wards are staffed at the same level as when your wife initially started nursing, but this was at a time when care was basically the same for all.

@40 Laughing Gravy: “The job [of nursing geriatric patients] had become harder because of the attitudes of the newer registered nurses who would not be managed, and did not like to take the responsibility for indiviual patients, and because of the attitudes of nursing assistants who were slovenly, ill-educated, and disobedient. The fact that my wife regularly checked the state of the patients was seen as interferring and an implicit criticism. Fundamentally, what has gone wrong is structured ward management of patients is failing.”

Many thanks for that. You’ve focused on something very important IMO and which reflects – sadly in one respect – on fundamental changes in the career opportunities for young women, which are almost certainly irreversible. And btw I’ve heard similar reports to yours from retired nurses/ward sisters so this is not another of those observations which can be dismissed out of hand.

I’ve talked with nurses who “trained” in the 1950s and 1960s – or to several of their husbands who were my senior line managers in the civil service.

In the 1950s and 1960s, there were usually steeper entry requirements to be accepted as a trainee nurse, especially in the famous and esteemed London teaching hospitals which could demand and get A-levels from applicant trainees. But labour markets and job opportunities for young women have evolved radically since then.

You’ve probably read about girls getting better results than boys in the school leaving exams – GCSEs and A-levels. This is one of the consequences:

“WOMEN university students now outnumber men across all subject areas, from engineering to medicine and law to physical sciences.”
http://www.timesonline.co.uk/article/0,,2-2356965.html

And this is another:

“For the first time ever, more women than men graduated from medical schools.” [July 2002]
http://cdnedge.bbc.co.uk/1/hi/in_depth/health/2002/bma_conference/2091015.stm

Entry to nursing will shortly be changed to degree level, this is because the nurses of the 1950s and 1960s were totally directed by a matron.
Furthermore, care has become more complex, especially for the elderly, where life-extending interventions are now commonplace. Now a newly qualified staff-nurse is expected to do personal assessments and implement the relevant nursing interventions, in fact, s/he is taking on more than the average matron was qualified to do.
Also, far more males are now entering nursing just has many more women are going into medicine and pharmacology.
The world has changed since the 50s and 60s, and the stereotypal ‘carry on nurse’ weilding her bed-pans is now only part of ‘a golden-age’ which I doubt if anyone, nurse or patients, would like to return to.

@44

A “lively” topic of debate among my friends – many of whom are far more knowledgeable about practical health and social care issues than I am – is about whether making nursing an all-graduate profession is an unwelcome, bad move.

I say not so – because, besides boosting the theoretical knowledge of qualified nurses, young women now have many and increasing opportunities to go into higher education for all sorts of (exciting and challenging) degree courses.

It’s crucial IMO for nursing to be able to offer a career route with a similar kudos – and importantly, to broaden the later career options of women who may want to opt out of nursing, or even healthcare, further on, perhaps after marriage and children. They are likely to feel a non-graduate SRN qualification won’t be treated seriously outside the healthcare industry and so opt for degree courses which offer wider career choices and opportunities with the implication that they will be lost to nursing altogether.

The counter view – powerfully articulated by its exponents, believe me – is that qualified nurses in a course of regular working must expect to do all sorts of very practical, basic nursing tasks, such as dealing with bed pans and the like, which graduates will regard as demeaning and will neglect. The contention is that the end result of turning nursing into an all-graduate profession will be to reduce the effective standard of practical nursing care on wards.

And there the argument rests, unresolved. As said before, I claim no expertise in HR management of hospitals so my views don’t count for much in my circle of friends.

45
The sort of jobs that nurses traditionally have done such as emptying bed-pans and assisting people to use the toilet requires very little knowledge, that is why it is mainly left to nursing assistants. It isn’t about being ‘too posh to wash’ it’s about optimizing staff resources in a rational and cost-effective way.
Meanwhile, staff nurses are carrying-out patient assessments, implementing care-plans and ensuring that patients are receiving the planned care, many nurses are now prescribers and have to have a similar knowledge of medicine as doctors. Are there poor nurses – yes of course there are, just as there are poor doctors, teachers and police, accountants, solicitors and cleaners.

@46: “many nurses are now prescribers and have to have a similar knowledge of medicine as doctors.”

From what I’ve read in blogs and forums, I think qualified physicians would dispute that nurses after a 3 year undergraduate course will know as much or have as sharpened diagnostic skills as a medical school graduate will – or should have – have after a minimum of 6 years.

48. Laughing Gravy

@42
My wife retired ten years ago. Personal care plans were well established at that time though I cannot say when they were introduced. Nevertheless, my basic point still applies. Registered nurses may be professionals (I do not quibble at that), but in all walks of life professionals work within managerial structures of other professionals. My son is a chartered accountant but he works within a structure which is headed by his Chief Financial Officer. If his boss came to check or query some piece of work he had done he would not take that as interferring. Another son is a solicitor – his work is constantly under supervision by senior partners. Professional nurses should learn to work within a structure of supervision and direction – that seems obvious to me.

47
Many nurse prescribers hold higher qualifications in pharmacology than most newly qualified doctors, in fact the title of ‘doctor’ is an honorary title while many nurses actually hold a phd and are able to use the title of ‘doctor’ quite legitimately. This may give you a clue as to why physicians are often derogatory towards nurses, they too still hold stereotypal views about the role of the nurse.

48
There is a difference between managing a ward and constantly checking upon nurses who are doing the job they are paid to do and highly qualified to do it. Best address the attention towards staff who are not doing their jobs.

@49: “Many nurse prescribers hold higher qualifications in pharmacology than most newly qualified doctors, in fact the title of ‘doctor’ is an honorary title while many nurses actually hold a phd and are able to use the title of ‘doctor’ quite legitimately.”

Any data on what percentage of nurses do have PhDs? And btw the quality and significance of PhDs is very variable – a PhD subject may indeed be original but it can also be very narrowly focused.

FWIW my impression, gained from experience, is that in Britain prescribing pills is done too lightly and with scant regard for recognised potential side-effects. A hospital consultant has already taken me off one pill, prescribed by my GP, because it was associated with a recognised cardiac risk.

Quite often, people of a certain age are taking daily an assortment of pills as the result of serial prescriptions handed out by various consultants, GPs and prescribing nurses. Some of us are inclined to wonder just who is checking up on adverse potential interactions and side effects? The worry is that medical ethics usually inhibits physicians from questioning the prescribing judgements of other physicians so patients unwittingly go on taking the same collection of pills every day regardless.

50

I have a report by the RCN dated 2005 which states that 370 nurses have a phd.

51 As far as over-prescribing goes, I agree, but as you have pointed-out, this is something which all professions who are prescribers need to look at.
In fact, nurses are a leading force in talking therapies such as Cognitive Behavioural Therapy, and most large GP surgeries offer this intervention.
Most mental health trusts now employ nurses as clinical specialists providing talking therapies, these nurses usually practise on a Msc, post-graduate diploma or a degree.

@52: “I have a report by the RCN dated 2005 which states that 370 nurses have a phd.”

As compared with how many tens of thousands of SRNs?

“As far as over-prescribing goes . .”

No, those aren’t the prescribing problems concerning me here and now – which are the often cavalier attitude of medication prescribers to potential adverse medication interactions and side-effects. Friends of a similar age tell of similar concerns – this is usually a problem which compounds with ageing as the number of serial prescriptions from various prescribers accumulates.

Just who looks after this when medical profession ethics inhibits prescribing clinicians from questioning the judgements of other clinicians?

With rare exceptions, prescribers have hardly ever mentioned to me potential side-effect risks of prescribed drugs so I’ve come to rely on what I can find on the internet by googling and that’s occasionally hair raising. On reading the warnings posted by the US Federal Drug Administration (FDA) about one mooted course of long-term medication suggested to me, I responded by saying absolutely no way.

I sense that some clinicians have come to regard me as a pain in the neck.

53
I have no figures to compare the percentage of nurses with a phd or indeed the number of GPs, surgeons, registrars and politicians

Under NHS guidelines, patients should be given education with regard to their medications, including potential side-effects, clearly you are concerned that you have not received that information. How many nurse prescribers have not given you the required information?

55. the a&e charge nurse

[48] “Professional nurses should learn to work within a structure of supervision and direction” – they already do – the problem is not so much structure but the mismatch between resources and clinical need not to mention unrealistic public expectation (conditioned by too much Holby City or the slightly sexier ER or House, perhaps?).

You say your son is a solicitor – imagine his boss dropping numerous briefs on his desk then insisting he complete them ALL by the close of business while at the time the office phone rings literally none stop with frustrated clients ask for regular updates.

No solicitor would accept such conditions – for example, a relatively straightforward probate case initiated by a relative of mine is still not settled two years down the line. Any letter has a price and it goes without saying that the solicitors will still get the same cut no matter how long it drags on for.

Anyway it won’t be too long before the corrosive and moral sapping atmosphere that exists on many wards will no longer be attributable to the ‘failing NHS’ because the NHS will no longer exist – oldies will continue to suffer terribly but many will do so behind closed doors because a market led system will simply not have sufficient financial incentives to provide for them all (and what we don’t don’t know doesn’t hurt us, eh?).

Perhaps we could adopt “Dying behind closed door” as an exciting strap line for Dave & Andy’s shiny new health care system?

Aand amp You are wrong about solicitors! OK, yes for private practice, but those in, for instance, the Crown Prosecution Service, cannot turn away work. I have worked in both. And it is a lack of basic kindness and compassion which is now built into so much of the NHS. I listened to groups of nurses chatting away for lengthy periods… in the same ward where my Mother suffered from a lack of basic needs… like cleanliness, oxygen and food. Does occasional pressure desensitise nurses? Or have they gone into a supposedly caring profession without a jot of compassion or empathy? But I agree, it does not bode well for the future.

57. the a&e charge nurse

[56] slagging off nurses seems to have become the de rigueur nowadays – but perhaps we should blame ourselves for putting up with so much shit in the first place?

Imagine groups of parents invading the classroom morning, noon and night to interrupt the teacher every few minutes – add in a phone that never stops ringing while disapproving relatives harrumph because a teacher is not on hand to field hundreds of calls.
Teachers would rightly never countenance such a dysfunctional environment in the same way that solicitors rationalise the volume of work and speed (usually very slow) at which they do it.

Fact is NHS bed occupancy and patient throughput has increased dramatically over the last 20 years. There is no evidence to suggest that NHS ward level staffing has improved. An ‘average’ NHS ward has 24 beds, 97% of which
are filled, and during the day is staffed with 3.3 RNs and 2.2 support workers.
Skill-mix has become more dilute. In 2005 NHS wards typically had 65% RNs
http://www.rcn.org.uk/__data/assets/pdf_file/0005/353714/003860.pdf

Of course the public just see a uniform and assume they are all nurses but 6 years ago this figure was 65% and now is almost certainly even less.

It is well known that patient care is being compromised by inadequate staff levels
http://www.telegraph.co.uk/health/healthnews/8186658/Patient-care-compromised-by-nurse-staffing-levels.html
Not least because the public would be unwilling to accept the exorbitant cost of guaranteeing sane staff-patient ratios (of 1:4) for acute medical beds – after all it is far easier to moan and blame the nurses rather than address the blatantly obvious structural short comings.

Just think how labour intensive, and time consuming it is looking after frail, bed bound, demented and acutely unwell oldies – yet sometimes the level of ignorance from relatives is simply breath taking (perhaps because they can only think about their own needs rather than all of the other things going on on a typical crowded NHS ward).

For those, like Bob B, who long for BUPA-world the solution is straightforward.
* Higher costs to pay for more for realistic staff-patient ratios.
* Regulate patient throughput so that bed occupancy remains at a safe 85% and do not admit anybody, no matter sick, until they have been swabbed pre-admission to reduce risk of any resistant organisms (MRSA, etc) being imported into the clinical environment.
* Curtail the flow of relatives that daily swarm all over the wards, or at least introduce a booking system so that the constant interruptions could be managed more effectively.

In BUPA-world the wards would look lovely and care would be much better but the price we would have to pay for offering only the best would be an end to both universality and comprehensiveness – or as Dave & Andy like to call it, “Dying behind closed doors” for those that never get in?

58. the a&e charge nurse

Oh, and just to add – let’s not forget that the vast majority of NHS staff will have their own experience as USERS of the NHS (in one way or another) as well as being providers.

In other words many of us will have watched OUR relative die while being cared for on a busy NHS ward – looking at it from this perspective I must say I found the behaviour of some relatives rather less than gracious on a number of occasions.


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