Practice team blog
It seems the tide may be turning on the way older people are treated in the NHS, with the need to develop and improve this important area of care at last being acknowledged and acted on. There were two announcements this week that gave me hope that change is coming.
One is that the first national programme for nurses to develop specialist expertise in the care of older people has begun. The Older Person’s Nursing Fellowship at King’s College, London is open to band 7 and 8 nurses, and the initial course has launched with 24 places.
The fellowship, funded by Health Education England, is being seen as the first initiative of its kind to develop highly skilled nurses with specialist expertise in the care of older people. It is an acknowledgement of the complexity of the care this group needs.
In the same week the NHS Confederation announced it is launching an independent commission on improving urgent care for older people. Leaders and experts from across the acute, primary, community and social care sectors, commissioners, patient groups and older people’s advocates will together put forward patient-centred, evidence-based solutions to be practically applied in local health and care settings.
The commission will look for examples of best practice to inform development of its report and recommendations. The final report will be published at the end of the year, with the confederation then rolling out a programme of practical activities to implement the recommendations at local level.
These are small but essential steps on the road to ensuring that care of this complex group is given the recognition it needs and is delivered by those who understand its complexities and have the knowledge and expertise required.
It was not a big surprise to me to read that mental health budgets have fallen by 8% in real terms during the term of this government.
But I was surprised to hear care secretary Norman Lamb’s reasoning around this decline in funding. According to the BBC, he explained that budgets were “not the full picture” and that “mental health care is given through a range of services including the voluntary sector.”
True, voluntary services such as mental health helplines offer invaluable support for people when they are at crisis point and do a fantastic job. But funding has been cut here too.
How can he possibly imply that volunteers are now providing mental health care so therefore it’s okay to cut budgets?
“The voluntary sector offers services that are vastly helpful to service users”
The voluntary sector offers services that are vastly helpful to service users but they cannot replace the work done by a community mental health team or by regular psychiatry appointments. Voluntary services should supplement care, not replace.
It is reassuring to hear that new standards for mental health services are being introduced and will be underwritten with some investment. But Norman Lamb’s comments give a worrying insight into a future where volunteers are relied on more and more to provide the type of care that should be given by healthcare professionals.
I don’t watch Top Gear, and perhaps my dented and increasingly rusty Ford KA explains why. But I am interested in the Jeremy Clarkson affair because until now he has been one of the “untouchables”.
It is interesting to note that it took several days for the incident to be brought to the attention of BBC managers – and it was Clarkson himself that raised the issue.
Why did it take so long? And why did no one else report it? Do employees of the BBC fear the repercussions of raising concerns against the rich and famous?
“Do employees of the BBC fear the repercussions of raising concerns against the rich and famous? “
Who can blame them when the prime minister is happy to make light of the incident on national TV while voicing concerns that his children will be denied their Sunday night entertainment, and over 600,000 people signing a petition to have Mr Clarkson reinstated.
Over the years I have met “untouchables” in the NHS who were never challenged about their behaviour.
Mr Clarkson’s suspension reminded me of a surgeon back in the early 1980s, who was brilliant at the technical aspects of his job but incapable of conducting a ward round without a temper tantrum. He was known to hit nurses on the head with clip boards if fluid balance charts were not up to date. His ward rounds were miserable and everyone was frightened of him, but his behaviour was excused as the actions of a perfectionist, and he went unchallenged.
What interests me about Jeremy Clarkson is not the future of Top Gear, or even his relationship with the prime minister. I am interested in why the incident was not reported earlier.
“It takes a lot of courage to blow the whistle”
It takes a lot of courage to blow the whistle, particularly when you are challenging people in power. There are numerous blogs on our website that are testament to the implications for staff.
Jennie Fecitt, lead nurse at Patients First, wrote “Seven years ago, as a senior nurse at Manchester Walk-in Centres, I blew the whistle on patient safety issues. I was bullied, victimised and received detrimental treatment from colleagues; my health and family suffered terribly. My NHS employer could and should have done more to protect me as a genuine whistleblower”.
Over two years ago we hoped the Francis report would bring about a change in culture in the NHS, but only yesterday I took a call from a nurse who was in despair about poor care in her workplace. She was too frightened to give her name or place of work, and was even concerned that I might track her call. How terrible that the only person she felt she could approach was a section editor of a magazine.
This is clearly not an isolated case. This year the results of the NHS staff survey revealed that nearly one third of NHS employees still do not feel secure raising concerns about unsafe clinical practice.
There is hope for the future. Sir Robert Francis QC’s new report “Freedom to Speak Out” offers 20 recommendations to support staff to raise concerns, and the Kirkup review presents clear challenges for maternity services.
“Perhaps it is time for a petition supporting those brave individuals who stand up and speak out when something feels wrong”
If the allegations against Jeremy Clarkson are proven he has to lose his job. This will send out an important message to people who think bullying from a position of power is acceptable and should have no consequences.
Perhaps it is time for a petition supporting those brave individuals who stand up and speak out when something feels wrong, whether that is the NHS, the BBC or any other organisation. Bullying cannot be an inevitable part of working life.
Find out about Nursing Times’ Speak Out Safely campaign
I like to think that one of the reasons we love the NHS is that the general population in the UK has a sense of fairness that is largely independent of where individuals stand on the political spectrum. We may argue about the finer details but the overwhelming majority of us agree that a healthcare system that is free at the point of need is fair.
Where there are arguments about fairness in the NHS they tend to focus around who ‘deserves’ care, and there are a number of easy targets. Common focuses of frustration and disagreement are ‘health tourism’ – non-UK citizens receiving free care; the ‘undeserving’ sick – people whose lifestyle choices may have caused their ill health; and the ‘frivolous’ patients – those who want treatment to enhance their life rather than cure ill health.
While there are many arguments about whether it is fair that one group or another should receive free healthcare, in another area there seems to be an overwhelming consensus that fairness means ever-greater funding. Many new drugs coming onto the market that advance treatments in life-threatening illness are eye-wateringly expensive. Yet when NICE says it can’t justify the expense for the benefits patients will receive, it is regularly vilified as denying hope to dying people.
As we read the undeniably sad stories of individuals being denied a drug that may give them an extra two months of life, of course we sympathise – and empathise. We want them to have the drug, and the chance of that extra couple of months. But the drug will be paid for from the finite resources of the NHS, so it will mean denying other people other treatments. The reason we don’t get as agitated about those people is that we don’t have their story, or a picture of them because they aren’t an identified individual. They are a group affected by a changed target or policy, and rather than dying earlier, they may just have to put up with pain and immobility for a while longer, a cheaper and less effective treatment, fewer community nurse visitis or fewer sessions of a much-needed therapy.
I wouldn’t like the job of deciding where the fairness line should be drawn, and I am certainly not suggesting that funding for expensive new drugs should be routinely refused. But a research report from the University of York recently suggested that, far from being miserly when it comes to approving expensive new drugs, NICE is actually too generous in the amount of money it recommends spending per quality-adjusted life year.
The report recommends that spending decisions look not only at the QALYs that may be gained by individual patients who receive expensive new drugs, but also at the QALYs likely to be lost elsewhere in the system in additional deaths, life years lost and poorer quality of life for the ‘unknown’ people. That sounds fair to me – what do you think?
The topic of when and for how long relatives and friends can visit on hospital wards has long been a much discussed topic. Open visiting versus fixed-hours visiting? Should it be the same for every ward and department? Can children visit? How many visitors should be allowed at one time?
The discussion continues around and around because at the root of it all is the problem that not one size fits all. No one blanket policy will suit every patient and every ward.
“No one blanket policy will suit every patient and every ward”
I was really heartened to see that one trust has developed an innovative approach to the question of hospital visiting. The new system focuses on the individual needs of patients and assesses whether they would benefit from having the freedom to be visited by family and carers 24 hours a day.
Imperial College Healthcare Trust has developed “passports”, which are issued to family and carers of vulnerable patients or people with dementia across the five hospitals within the trust. The card allows them to visit whenever they want.
The cards were developed by nurses, which is no surprise as they are the ones who spend their time debating the visiting issue with patients and their loved ones.
“Having a card means families can support their loved ones who are in hospital”
Having a card means families can support their loved ones who are in hospital, which can be a difficult and destabilising experience. Doubtless this measure will help the wellbeing and recovery of these vulnerable groups.
Where possible acknowledging that individual needs are met is the root to the best quality healthcare and the optimum patient experience.
When the idea of launching a Nursing Times app was floated a few months ago I was cautiously excited.
The need for an app was obvious. Since becoming online editor a year ago, I’ve watched as the number of you accessing nursingtimes.net on phones and tablets has dramatically increased.
But I’ve worked in the NHS and know that although a needed change might be obvious to the frontline, it doesn’t always filter up, in any organisation. So I held back on my optimism until the moment we actually pushed the button and made the app live.
I wouldn’t be surprised if many of the people reading this have felt the same at some point in their nursing career. It doesn’t take a genius to see that those on the frontline will be the first to spot potential patient care improvements, yet how often are they involved in the decision making?
That’s why we got involved with the Change Challenge.
The Change Challenge, or “Challenge Top-Down Change” to give it its formal title, aims to use crowdsourcing to give everyone working in the NHS, or using one of its services, a chance to put forward their ideas for implementing change within the health service.
Even those without a ground-breaking idea were able to vote on others, resulting in a set of ideas already peer-reviewed. The campaign has so far had a massive 7,500 contributions, giving us the first ever socially constructed roadmap for change in the NHS.
The next stage is to collect stories of change and experimental ideas on how to apply the changes put forward in stage one. You can get involved and make your voice heard on the Challenge Top-Down Change website.
Going back to our big change, the Nursing Times app hit both the App Store and Google Play last month and I’m delighted to say our wonderful readers have proved me right by downloading it in droves.
Subscribers can now download the app on Apple and Android absolutely free as part of their subscription, and access a whole range of content including rolling news and the latest practice. Just log in with the same details you use on the website. If you’re a subscriber but you’ve never used the website you will need to activate your subscription, a two-minute job that will give you access the thousands of practice articles, plus our range of online learning units on fundamental nursing topics.
The revelations of the Francis Inquiry into care at Mid Staffordshire hospital two years ago made shocking reading. How could something like this happen in our NHS?
Today Sir Robert Francis sought to answer this in the Freedom to Speak Up Review, which explores the problems staff experience when they want to raise and escalate concerns. While reading through the summary of the report I was reminded of a quote from Marie Manthey, a pioneer of the primary nursing movement, which captures simply what our priorities should be:
“Patients matter most but staff matter too”
What Sir Robert has demonstrated is the difference between a culture that nurtures staff and one that sees both staff and patients as commodities who can be pushed through systems based on industrial processes rather than the principles of humanistic care.
It is difficult to read Sir Robert’s account of talking to people who tried and failed to raise concerns in organisations designed to care. He says:
“It is difficult to read Sir Robert’s account of talking to people who tried and failed to raise concerns”
“The genuine pain and distress felt by contributors in having to relive their experiences was every bit as serious as the suffering I witnessed by patients and families who gave evidence to the Mid Staffordshire inquiries. The public owe them a debt of gratitude in the first place for speaking up about their concerns, and secondly for having the courage to contribute to this Review”.
There are 20 recommendations, which have all been accepted “in principle” by Jeremy Hunt, but my concern is how these will be implemented. I can already see chief execs reaching for a pad trying to work out a to-do list, but as Sir Robert makes clear:
“We need to establish everywhere a culture in which all staff feel safe to raise their concerns.”
My concern is that while we talk a lot about culture and openness and honesty, this winter we have seen meltdown in many parts of the NHS. There has been a mantra in the NHS over recent years that you don’t need more money – you just need to do things differently. But the winter crisis in A&E has indicated that many NHS organisations have been pushed as far as they can go.
“Francis has laid out a framework for ALL staff to raise concerns”
Nurses struggle day in and day out to provide the bare essentials of care to patients. They are forced to cut corners and compromise because they have neither the time nor the resources to do otherwise.
Yes, NHS managers need to facilitate a cultural change that allows staff to raise concerns. But in return these managers need adequate resources so they can support their staff to do the best job they can.
Francis has laid out a framework for ALL staff to raise concerns. Politicians now need to be ready to deal with the reality of providing care in a service that is underfunded and run on the goodwill of staff.
Storytelling has been a cornerstone of education and culture across the world for centuries.
In preliterate times stories were used to pass on the important knowledge and cultural norms and values that sustain communities.
While storytelling has retained its significance in many cultures in the developing world, in the West it became seen as largely for entertaining or educating children. But the value of storytelling in education and training has been increasingly recognised in the UK over the past few years, and this is a welcome development.
We all love good stories - I remember far more of the stories I read as a child than the academic texts I read as an undergraduate. That’s because stories engage us, take us on a journey, and show us the world from a different perspective. So I’m delighted that storytelling is increasingly used in healthcare education and practice, as our articles on the use of stories in NHS organisations and nurse education demonstrate.
There can be few areas with such a wealth of powerful stories as healthcare. These may be from patients, families or staff, and can range from the tragic to the triumphant. Appropriately used they can offer staff - and patients and their families - the opportunity to look at life through someone else’s eyes. These stories should be used to help health professionals to improve their abilities to offer patient-focused care.
In healthcare nothing stands still or stays the same.
And if you look in the opposite direction for too long something will happen behind you. An example of this is tuberculosis. Once nearly eradicated, it has crept back into our lives, slowly and insidiously over the last 15 years.
The UK currently has the second highest rate of TB among Western European countries and, if the current trend goes unhalted, England will have more TB cases than the whole of the United States within two years.
Last week the government announced a new strategy to tackle the rise in the number of TB cases. The £11.5m investment announced by Public Health England and NHS England will deliver a 10-point action plan, the Collaborative Tuberculosis Strategy for England 2015-20.
This will include improving access, treatment, diagnostic and care services. And it will focus on tackling the disease in difficult-to-reach groups and improving screening and treatment for new migrants.
This is welcome news indeed, but in many ways overdue. The increasing incidence in hot-spots like London, Leicester, Birmingham, Luton, Manchester and Coventry has been clear for some years. Let’s hope that this new funding and strategy will now tackle this as a national issue, rather than the job being left to localities, and we will work towards eradicating this disease.
Last week, I received an email from a student nurse wanting to ask the Student Nursing Times community for some advice.
We host a regular feature on Student NT for our readers to discuss problems and offer advice, so this email was nothing new. But its content struck a chord with me.
Victoria started her email by saying that the nurses on her placement “weren’t very nice”. She was told to “get on with it” and “find your own learning opportunities”, she felt ignored and it sounded like your classic too-busy-for-students ward.
But her main concern wasn’t for herself, but for the patients the ward was meant to be looking after. As an outsider looking at the ward culture from a fresh perspective, Victoria saw how patients were ignored and she noted “there seems to be a massive lack of compassion and respect for patients”.
We know that there are wards out there run by individuals who are burnt out or so overwhelmed with paperwork and stress that they can’t see the wood for the trees. But every person who responded to Victoria seemed to have experienced the same:
“Sorry to hear that you are experiencing this. I too had a similar problem at one of my placements”
“I can really empathise with your situation as I have been there too”
“Had a similar experience myself in my mental health placement”
“I too had this, so I can completely understand where you’re coming from”
“What you describe is not unique to where you are. Indeed, I have experienced the same scenario both as a student and as a qualified nurse”
“Victoria, this sounds very much like my first MH placement in first year…and looking back on it I recognise it was something of a baptism of fire.”
Thankfully, many of the commenters suggested Victoria raise her concerns and I hope those who could empathise with her had already raised theirs. But with so many student nurses reporting similar experiences, I had to wonder, do student nurses feel able to take their concerns further? And when they do, is something done about them?
Raising concerns doesn’t need to mean getting staff into trouble. But it does mean management are made aware that the culture on that ward, for whatever reason, isn’t working.
Are you surprised to hear student nurses reporting these experiences?