The NHS was forged from care, not box-ticking

At Stafford hospital, the guidelines were fulfilled, but patients died needlessly
Click to follow
The Independent Online

Very occasionally something comes on the radio that makes you stand still in rapt attention. It happened the other day as the MP Ann Clwyd spoke about the death of her husband six weeks ago in the University Hospital of Wales in Cardiff. He died, she said, from hospital-induced pneumonia because "cold and callous" nurses did not keep him warm or care for him. The rawness of her grief burst the dam of self-control and she wept.

Earlier that day, the Chief Nursing Officer for England, Jane Cummings, had called for nurses to focus more on compassion. That was what prompted Ann Clwyd to make her private grief public. "Nobody should have to die in conditions like I saw my husband die in," she said. He died "like a battery hen... crushed against the bars of his hospital bed with an oxygen mask so small it cut into his face and pumped cold air into his infected eye". Such treatment is now commonplace, she said, complaining of a "normalisation of cruelty" among NHS nurses.Can this be true? Or do hard cases make for skewed judgements?

The Health Secretary, Jeremy Hunt, has been speaking of a "crisis in standards of care". The scandal at Stafford hospital three years ago, where hundreds of patients died after inadequate treatment, has now been followed by a Care Quality Commission (CQC) report, which said last month that 27 per cent of hospitals and care homes are failing to meet minimum standards. In response, the Chief Nursing Officer has called on nurses to focus on "six Cs": compassion, care, competence, communication, courage and commitment.

Nurses, on their websites, are outraged. One talks of beds in her one-to-one care unit increasing from 9 to 15 with no increase in staff. Another says the "just-in-time delivery" system of a privatised service left no clean linen available in her hospital. Another criticises David Cameron for claiming the ratio of nurses to beds is rising without explaining more nurses are part-timers. Another attacks Jeremy Hunt for claiming the NHS budget has increased when the UK statistics authority says the opposite. Nurses offer their own list of "six Cs" which includes cuts, contempt, crossness and crap.

So who is right? Compassion is determined by two things: the way you are and the amount of time you have to spend. There is no doubt that spending cuts lessen the amount of time available for compassion. But have our nurses changed the way they are?

Certainly their job has changed. Once nurses spent their first three years doing the washing, bum-wiping and basic health care now done by health-care assistants. That early training taught nurses something about compassion or about themselves as they decided the job wasn't for them. Today, nursing is more academic, which self-selects a different kind of applicant. Nursing used to be an apprenticeship; now it's more a course of study. Talking to patients has been replaced by communications training. Making sure someone is warm isn't on the checklist.

The Government speaks with a forked tongue. "They say they want more compassion," one consultant says, "but they are very focused on us ticking all the boxes on the CQC guidelines, Clinical Negligence Scheme for Trusts guidelines and Nice guidelines." Guidelines have become a self-perpetuating industry in which the tail wags the dog. "The more rules you have to regulate care, the less caring people have time to be. All the paperwork, the risk assessments and care plans reward staff for the wrong things." The nurse who does the job and forgets to tick is disciplined: the one who ticks without doing it is rewarded, unless a catastrophe finds them out.

The old-style nursing sister is now a ward manager who may have zero patient contact. At the lower end of the scale are increasing numbers of "bank nurses" – temps who are the equivalent of supply teachers. "They don't know the patients, the care plans, or where the blankets are kept," another consultant said. "Wards are understaffed, over-tasked, and shorn of the time needed for compassion. Contrast that with private medicine – whether it's a private consultant or a reflexologist: they spend time with you. You don't feel rushed; you get an hour, not five minutes for the consultation and three to fill in the paperwork afterwards." One CQC report found cleaners had more time than nurses for small acts of kindness.

Yet CQC inspectors say they see unacceptable care on well-staffed wards, and excellent care on under-staffed ones. Good hospital management ought to be able to address that issue. Yet the more senior managers the NHS has – 40 years ago it had 500 compared with 70,000 today – the more they seem to spend their time sending out emails about "quality" issues when, as one nurse put it, "the wheels on the bus are flat and the engine is out of oil". The problem at Stafford hospital was that senior managers put cost-cutting and targets before care. All the guidelines were fulfilled but hundreds of people needlessly died.

More managers? More targets? Insanity, Einstein is alleged to have said, consists in doing the same thing over and over again and expecting different results.