Anne Milton: 'We need to raise the bar'
The Public Health minister used to be a nurse herself. To conclude our series, Christina Patterson challenged her for a candid view of her former profession
Christina Patterson is a writer, broadcaster and columnist. She writes about politics, society, culture, travel, books and the arts. She has interviewed writers and artists ranging from Martin Amis to Eddie Izzard and Werner Herzog, and did the first interview after he left office with Gordon Brown. A former director of the Poetry Society, and literary programmer at the Southbank Centre, she has written for the Observer, the Sunday Times, the Guardian, Time, the Spectator and the New Statesman. She’s a regular commentator on radio and TV news programmes, a regular reviewer on the Sky News press preview, and a regular guest on The Review Show. She has campaigned to improve standards in nursing in a series of articles in the Independent, by speaking at conferences, and in programmes she has made for Radio 4 and The One Show. Christina is the only woman on the shortlist for the Orwell Prize 2013. She has now left The Independent, but can be contacted via her website, www.christinapatterson.co.uk .
Saturday 14 April 2012
It isn't easy to get someone from the Government to talk about nursing. It isn't easy to get their press officers to answer emails, or return calls. I first contacted the Department of Health press office in September, to request an interview with Andrew Lansley. I also wrote to him, but never had a reply. In February, I was told that I couldn't interview him, but I could, if I was prepared to wait a few weeks, interview the Public Health minister, Anne Milton. The day before the interview, I got a call to say it had been cancelled. When I was asked when it would take place, I was told it wouldn't.
Someone told me a decision had been made "higher up" to cancel, but that I could email a few questions, and get them answered "in her name". Someone who was "higher up" told me it was simply a matter of a "diary complication". It wasn't "conspiracy", he said, just "cock up". I don't know if this is normal in an area that actually calls itself "communications", but I do know that cultures are set from the top. If this is how nurses feel they're treated by their bosses, I'm not surprised that they're fed up.
But when I finally got to meet Anne Milton, in a pub in Guildford, with a member of her policy team, and someone from the press office, which was, after all the angry phone calls, a bit embarrassing, she couldn't have been more charming. Guildford is her constituency, and also where I grew up. She goes jogging, she told me, down the street where my mother lives.
Anne Milton clearly takes health seriously. But then she probably should. Health isn't just a government portfolio she inherited. It's been the central focus of her working life. She trained at Barts in 1974, and then worked as a district nurse in Hackney. It was only in the early 90s, after working as a medical adviser for social housing providers, that she "suddenly" decided to go into politics. "It's a long time since I've worked on a ward," she said, "and it's a long time since I've been a district nurse. So I was very determined that I wouldn't say 'well, of course, in my day'. I don't hark back to it, but everyone else does".
Well, as she says she doesn't say, of course. When you tell anyone of a certain age about bad experiences of nursing, the first thing they usually say is "bring back matron". But matron had already gone by 1974. And whatever's gone wrong with nursing, it's going to take a fair bit more than "bringing back matron" to put it right.
But perhaps Anne Milton doesn't think anything has gone wrong? Or perhaps, as a former nurse who's currently in charge, or practically in charge, of 330,000 nurses, she doesn't dare say?
"So," she said, reminding me that she's a politician, "it's important to find out our areas of agreement. I think I was enormously lucky to train at a hospital that had some of the best standards. But even there, it wasn't all perfect. I think it is the case that some of the out-of-London hospitals weren't necessarily up to much. And I think there was a picture of patchiness that still exists today. Some hospitals are good, and some are bad. Some wards are good, and some are bad. Some nurses are good, and some aren't as good."
Well, as I now keep wanting to say, of course. But what about her friends? She must have friends who still work in hospitals. What do they think?
"So," said Milton again, stretching out the word as if taking time to think how honest she can be, "I went back to the Barts League of Nurses at their AGM quite recently, and the story from people I trained with is probably 'it's not like it used to be'. It is," she said, in tones that make you absolutely sure that they wouldn't have dropped under her, "about standards." But when she trained, she said, "society" was "a different place". There weren't, she said, "the opportunities for young girls". We are, she said, "recruiting from a different pool". What she was saying, in fact, but so carefully that you could almost miss it, is that the calibre of nurses recruited has gone down.
And does she, as a pre-Project 2000 nurse, whose peers clearly think that post-Project 2000 nursing standards have dropped, think Project 2000 was a good or a bad thing? Or, I added, remembering the need for circumspection, neither?
The answer, not surprisingly, is "neither". "I think," she said, "one of the impetuses behind Project 2000 was about nurses not being handmaidens of the doctor. I was brought up," she said, "and trained in a hospital that never for one minute led me to believe I was a handmaiden of anyone. I always perceived," she said, and I don't think anyone could doubt it, "that I was a professional in my own right."
And what about the theory/practice split that came about with the shift to university-based training? Student nurses still get to spend 50 per cent of their training on hospital wards, but they're no longer part of the work force. Some, I told her, say they spend a lot of their time standing around. Is this her impression, too?
"I need to choose my words carefully," said Milton, as if she usually doesn't. "When I trained, student nurses were not supernumerary. We were the work force. So, we were left in charge of wards it was inappropriate, and unsafe, to leave us in charge of." Being "supernumerary," she said, is "a good learning experience", as long as you learn the skills you need to "make the leap" to being a qualified nurse. "What often happens," she said, "is that the baby tends to go down the plughole with the bath water, so I think we're now in a situation where the gap between the academic learning, and the practical learning, has got too wide."
So she has said it, the thing that pretty much everyone says about nursing these days, the thing that makes so many older nurses despair of their profession. But what, if anything, can Government do about this?
Milton stirred her skinny latte and took a delicate sip. "I don't think," she said, "the NHS is involved enough in recruitment, and necessarily recruiting the right people. Similarly," she said, "possibly the universities aren't aware enough of the skills that are needed for the NHS." The Government, she said, is doing a lot of work "around higher education", to make sure that "we have a workforce with the skills and academic training that future employers want". It also, she said, is working to encourage "continuing professional development". Not just "tick boxes", she said, but the recognition that training doesn't end with a degree.
It's also, she said, about leadership. "It's leadership," she said, "in the academic professions and the service, coming together to make sure that we recruit the right people. We need leadership at a ward level, but you also need leadership in outpatients, and leadership in the community, because for many people today it's the care they receive in their own home, or as an outpatient, that's important."
This is true. Of course it's true. But what can Government do about this? "The first thing," she said, "is that you have to spell out what's important. So when the Prime Minister launched the nursing quality forum, it's saying 'these things are important, and that has to trickle down'." She's talking about the "nursing and care quality forum" that David Cameron announced he was setting up in January, on a day when he said he wanted the whole approach to caring to be "reset". There are, she said, some "simple tests" you can introduce, like asking patients if they'd recommend their hospital to their friends and family. "We'll need," she said, "to raise the bar. Nothing but the best will do."
When David Cameron announced the launch of the forum, he said "nursing needs to be about patients, not paperwork". But surely a lot of that paperwork – or, to use the more popular Tory word, "red tape" – is about safety? Which bits, exactly, can be cut?
"Evidence," said Milton. "To make sure that any paperwork that's kept has got a good evidence base for keeping it. One of the points of spreading best practice is to say 'actually, this really works'". This, again, is clearly true, but NHS trusts are independent, so what can Government actually do about the ones that are letting their patients down?
"OK," she said, with the kind of nod that makes you wish she was running every hospital and every ward, "well, Government can set standards. And part of the care quality forum is about setting standards. But actually satisfying me, the Government, that you're meeting a minimum standard isn't quite what I want. I want you to say, 'not only do we reach your minimum standard, but this is the best. We are the best.' I think the changes in commissioning – and I know the health and social care Bill has been controversial – will have people saying 'you know, that's not good enough, we're not going to go there any more'."
Ah yes, the health and social care Bill. I promised the press office I wouldn't talk about it. If you want things to be "simple", it's quite hard to see how a 473-page Bill is the answer. But if "good commissioning" does lead to better care for more people, I'll eat the words I've written about the Bill, and swallow my pride, and give Andrew Lansley, if I can ever get to meet him, a slap on the back.
When it comes to poor standards, says Milton, "there have to be opportunities for people to blow whistles". The Government, she said, has made changes to the NHS constitution, to change the balance in whistleblowing from "a right" to "a duty to report", and thinks anonymous helplines might also help. She thinks healthcare assistants do need "some basic training", and that "if you employ people, you ought to employ people with the skills to do the job". She thinks this also applies to overseas employees. "Anybody employed to do a job," she said, "should have the language skills to do it, whether they're a doctor, or a nurse."
And when I asked her whether she approved of "intentional rounding", where nurses check on patients every hour, and which David Cameron has said he wants to see on every ward, she said this: "I think," she said, in tones I wouldn't want to hear if I was a nurse on a ward she ran, "I'll be honest for a minute and say that I'm somewhat surprised that the nurse in charge wasn't going round the patients. I think David Cameron is absolutely right. I think it's as basic as telling an architect how to draw a straight line."
I showed Anne Milton the "manifesto for better nursing" I'd drawn up. She read it carefully, ticked most of the points, and added a few notes. "I don't want more reports," she said. "I want somebody to say, in three or four years' time, that something happened. I want this forum to be the culture shift."
So do I. I think it could. But to make this happen, I think all of us who get ill, or have relatives who get ill, which is all of us, need to keep the pressure up. I believe that the 10 points in my "manifesto" could help. If you do, too, then write to the chief executive of your NHS trust, write to your MP, and write to Anne Milton, or Andrew Lansley. Let's show nurses, and their bosses, that we care, too.
Special report: A crisis in nursing
* Day One: Six operations, six stays in hospital – and six first-hand experiences of the care that doesn't care enough
* Christina Patterson: More nurses, better paid than ever – so why are standards going down?
* Leading article: What can and should be done about nursing
* Day Two: Reforms in the 1990s were supposed to make nursing care better. Instead, there's a widely shared sense that this was how today's compassion deficit began. How did we come to this?
* Day Three: How can a profession whose raison d'être is caring attract so much criticism for its perceived callousness? Does nursing need to be managed differently? Or is the answer to develop a new culture of compassion?
* Day Four: The nurses who taught an ailing hospital how to care
* Day Five: My 10-point plan for change by Christina Patterson
* 'Nurses do not wake up each morning intent on delivering poor care...'
* Anne Milton: 'We need to raise the bar'
* Leading article: Manifesto for better nursing
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