Christina Patterson: More nurses, better paid than ever – so why are standards going down?

Respect for the nursing profession has been transformed – but not everyone believes patients are feeling the benefit

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Let's get one thing straight. There never was a golden age of nursing. Florence Nightingale wasn't Jesus, and nor were the people she recruited and trained. There was a report to a select committee, triggered by a scandal in poor nursing, in 1892. There was another one in 1932, and another in 1939. There have been scandals in nursing for as long as nursing has been around.

When Aneurin Bevan launched the NHS, on 5 July 1948, at Trafford General Hospital, a hospital stay was measured in weeks. Thousands of people died every year of pneumonia and tuberculosis. The average life expectancy was 71 for a woman, and 66 for a man. Nurses spent quite a lot of time dusting, and scrubbing bed pans. They wore uniforms that made them look like maids. They worked for a low wage because they were expected to have what Nightingale called a "vocation". It was a vocation which hardly ever seemed to hit a man.

But a sense of vocation, as the historian and Professor of Nursing Policy at the Florence Nightingale School of Nursing and Midwifery, Anne Marie Rafferty, points out, can be an excuse for exploitation. "Certain themes run through all the major reports," she told me, when we met last year. "A need to be freed up from the task of domesticity, not to be a skivvy, and not to be a thoughtless responder to doctor's orders." As far back as 1964, she said, there were attempts, in things like the Platt Report on nursing education, to "give due recognition" to nurses' clinical skills.

The result of these reports, and reforms, and changes in medicine, and changes in training, and changes in society, is that nursing has changed. Frontline Care, a report commissioned by Gordon Brown, which Rafferty contributed to, presents an almost Utopian vision. Nurses, it says, "will work as clinicians, managers, leaders, teachers, researchers, scholars and policy-makers". They will "encourage and embed innovation", "expand the profession's evidence base", and "act as green champions". A "new story of nursing is needed", it says, "to demonstrate that nurses are not poorly educated handmaidens to doctors". Nursing, it says, "will be perceived as a profession that offers worthwhile, engaging careers with high levels of responsibility and autonomy".

Which all sounds very exciting, if you're a nurse. If you're a patient, or what the report calls a "service user", you might be less concerned with "green champions" and more concerned with care. And it's the quality of nursing care, not the quality of the qualifications, that seems to be at issue. It's certainly different to how it was when nurses in starched uniforms scrubbed bedpans. The question, of course, is whether it's worse.

"That," says Jocelyn Cornwell, a medical sociologist who is now working with the King's Fund, "is really hard to answer. If you read accounts by nurses of nursing either before or after the war, right up to the Sixties or Seventies, there was no idea of delivering individualised care." She remembers, she told me, reading an autobiography of a woman who'd been a hospital matron in the Seventies, who wrote about the shock on the wards when nurses were told they had to use patients' names. "I think the idea that in the past there was this wonderful era when everybody was looked after as a human being," she said, "is probably wrong."

But Cornwell is clear about one thing. She thinks a high proportion of hospital care is "bad". Five years ago, she came to the conclusion that "there was a real problem in what's happening to patients in hospital". She thinks hospitals are places that "lack humanity". "If," she says, "you read Roy Porter's stuff on the history of medicine, he says that the perception of modern hospitals is that they're like factories. They're like that for the staff as well."

Katherine Murphy, chief executive of the Patients' Association, agrees. She has been involved with patient care for the past seven years, but thinks that over the past two years it has got noticeably worse. "In 2010 and 2011," she told me, "we had a huge increase in the calls to our helpline. We work out the top five calls we get every week, and poor nursing care is either the first, second or third. It never drops below a third."

Statistical evidence isn't easy to find. Dr Foster, a research firm which collates thousands of statistics about healthcare trusts every year, hasn't done individual studies on nursing care, but it has recently published a study saying that one in four patients think their local hospital isn't up to standard. Many patients, according to the study, thought that nursing staff "spent too much time clock-watching", and felt as if they were on "some sort of mass-production line".

Peter Carter, the director of the Royal College of Nursing, which is actually a trade union and not a college, insists that "the vast majority of patients express high degrees of satisfaction with the care they receive". But he also suggested, a few months ago, that families should go into hospital to help their elderly relatives eat and drink. "It is," he said, "about helping gran get out and to the loo."

Some of us thought we paid our taxes so that someone else could, at least when she's in hospital, "help gran get out and to the loo". And certainly, in the past 15 years, the NHS has had more of our taxes than ever before. Real health spending doubled while Labour was in power, and the number of nurses went up by a fifth. Pay went up, too. Newly registered nurses start off on about the average wage, but a matron can earn more than £45,000. Many nurses work three long shifts a week, and most get at least seven weeks holiday a year. It isn't a footballer's wage, but it also isn't slave labour.

It's hard, then, to understand why, with a bigger, better-paid work force, standards of nursing care seem, at least in certain areas, to be going down. If there aren't mass studies to provide the kind of evidence that people like Cornwell think is missing, there's certainly no shortage of reports. And what's coming out in the reports isn't good.

The first big one to hit the headlines was two years ago, into the Mid Staffordshire NHS Trust. It followed an investigation by the Healthcare Commission (which has now been replaced by the Care Quality Commission) which found that up to 1,200 more people died at Mid Staffordshire, between 2005 and 2008, than at other trusts. The report said that patients were so thirsty that they drank water from vases. They were also left lying in their own faeces, and urine. Families had to remove used bandages and dressings, and clean filthy toilets. Patients were "routinely neglected", "humiliated" and left "in pain".

When a report like this comes out, people always say that it must never happen again. The trouble is, it does. A separate report by the Health Service ombudsman a year ago described the experiences of 10 elderly patients throughout the UK. One of them, according to the introduction by the ombudsman, Ann Abraham, "enjoyed literature and crosswords". Another was writing a book. They were all, she says, transformed by poor care "from alert and able individuals to people who were dehydrated, malnourished or unable to communicate". Nine died during the events she describes.

One 82-year-old patient, unsure how to get home after surgery, asked the nurse to phone her daughter, but was told that this "was not his job". Another was discharged from hospital "dressed in unfamiliar clothing held up by paper clips" and "accompanied by bags of dirty laundry", which weren't even her own. Another was so dehydrated that he couldn't speak, or swallow. Another had nine falls in hospital, but only one was put in the nursing record. A number were left to soil themselves, and lie on sheets soaked in urine.

 

A report from Age UK last August found that patients still weren't getting help with their food. It said that 157,000 people left hospital malnourished in 2008, and a year later the number had gone up to 185,000. In 2007, it said, 239 patients actually died from malnutrition. Nearly a third of nurses, it said, admitted that they weren't confident that anyone would notice if a relative of theirs on a hospital ward wasn't eating, or even if they were suffering from malnutrition.

A report last October by the Care Quality Commission (which has had so many problems of its own that Private Eye calls it Can't Quite Cope) into "Dignity and Nutrition" found that large numbers of old people in hospital struggled to get either or both. About half the hospitals the commission visited gave its inspection teams "cause for concern". Twenty weren't even reaching legal standards of care. Two were providing care that "put people at unacceptable risk of harm". Patients, according to the report, were "spoken over, and not spoken to". They were "left without call bells, ignored for hours on end" and "not given assistance" to "eat, drink, or go to the toilet".

The Care Quality Commission found that one in five hospitals was giving care that "posed risks to the health and well being of patients". Since it only picks two wards per hospital, and visits on only one day a year, the true number is likely to be higher. Age UK's research shows that about 21 per cent of patients say they're not treated with "dignity and respect". A fifth of the hospital population, in a country of 62 million people, is an awful lot.

A report by the Patients' Association last November repeated the now familiar stories of patients left hungry and thirsty in urine-soaked sheets. It said that patients continued to "express no faith" in the way that complaints are handled in the NHS. Many, it said, say that they have to "jump through several administrative hurdles" before they even get to the point of having their complaint "considered".

Most of the official reports have focused on the care, and the failings in care, of the elderly. Certainly, the NHS doesn't seem to have adapted to the problems of an ageing population that's only going to get bigger. But complaints about nurses across the general population have, according to the Nursing and Midwifery Council, more than doubled in two years. Last year, they were up 139 per cent on 2008-09. And it looks as if the 4,211 grievances that were lodged in 2010-11 are just the tip of a massive iceberg. Most people haven't even heard of the council, and these are nurses who are in serious danger of being struck off.

It's the same story, again and again and again. It's buzzers not answered. It's sheets not changed. It's patients not washed. It is, in other words, what used to be called "basic care". "Very often," Murphy says, "when people come into hospital, the clinical care is good. It's the softer side, the nursing care, that lets them down."

"The evolution of the nursing profession," say the authors of Frontline Care, "has been a largely untold success story of the transformation of a traditionally subordinate, low-paid occupation into a competent, well-educated profession that respects human rights and values compassion." They're right about the pay, and the training, and the status. But higher status isn't the same as more respect.

It's the compassion that seems to be the problem. Plenty of nurses have it, but plenty, sadly, don't. It isn't clear whether this is coming from bad systems, or bad recruitment, or bad leadership, or bad training. But you can't have care that doesn't care. We need to sort this out.

Life on the ward: startling statistics

£45,000: The amount a matron can earn on a ward each year

185,000: The number of people who left hospital malnourished in 2008, according to a report by Age UK, published in August last year

239: The number of patients that Age UK says died from malnutrition in 2007

1 in 3 nurses would not be confident that family would notice if a relative was malnourished on a ward (Age UK)

4,211: The number of complaints lodged against nurses in 2010-11, according to the Nursing and Midwifery Council

139: The percentage that complaints against nurses (recorded by the Nursing and Midwifery Council) increased between 2008/09 and 2010/11.

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

 

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