That Old Chestnut

[Guest post by Sharon Levisohn]

Mother came home from hospital on Friday, having been in over Christmas and New Year. She has advanced COPD (emphysema) and had a respiratory virus that resulted in pneumonia.

However, her lengthy stay was not due to her illness – a week of steroids and antibiotics settled that insofar as it could be – but the inability to plan a discharge to meet her ongoing needs. The hospital wanted to send her home with three (local authority funded) home care visits plus daily district nurse calls. The social worker could not authorise the home care package without it “going to panel” and of course there would be no more panel meetings until January 7th. Then the hospital suggested a nursing home placement but, despite full-time oxygen dependency and limited mobility, my mother did not meet the criteria for a funded admission. Next they suggested a short admission to a cottage hospital. That was rejected as they thought, frankly, that the journey would kill her. Plan D was to be discharged home with the support of the (health-funded) Re-enablement Team; however, she was not open to this as her condition was too far progressed for rehabilitation. All this time, Mother was in an acute bed – one of those infamous bed-blockers – on a ward with confirmed Norovirus, while the family and I rode the Waltzer of uncertainty and conflicting updates, always aware that she might just give up the long battle with COPD.

What is the point of this personal anecdote of woe over the festive period? I suppose it is not a unique case; even on the ward there were several other patients unwillingly playing the Cherchez La Femme game of discharge co-ordination. How many patients and families in how many hospitals were going through similar experiences? What vexed me – and as a former nurse I am not criticising the frontline ward staff – was that the hospital did not seem to know what qualifying factors were applied to the various options – one might have assumed that they had confirmed Mother’s eligibility before informing her and the family only to dash their hopes. The other bugbear is the responsibility for funding. Surely, if a risk assessment has shown that a frail elderly terminally ill patient has been assessed as needing input from various agencies in order to be at home with the people and dogs and personal touches she loves, which give her a little quality of life, and if we believe that it is better for the elderly to live at home so far as is possible, surely then the funding needs to be provided? Or shall we simply abandon that principle as practically unviable?

Hospitals and Respect

The Care Quality Commission has reported today on a series of unannounced inspections that it has undertaken in Hospitals over the Spring which deduced that, of the 100, 45 met the standards required for nutrition and dignity, 35 met both standards but needed to make improvements (which makes you wonder around the standards if they are not ‘absolute’) and 20 did not meet either or both of those standards.

The National Report is available from the CQC site here (PDF).

The headline reports have been covered well by the national press so I thought I’d read through the report to see what ‘dignity’ and ‘nutrition’ actually meant in terms of the inspections which were carried out.

The report explains who the survey was undertaken in that two wards in a particular hospital were chosen on one day of the year.

Regarding respect for the patients the issues most commonly found to be lacking where call bells which were either placed out of reach or not responded to, attention to language in that condescending or dismissive tones were used towards patients and attention to personal private space regarding curtains being pulled around beds, for example, was not well-respected.

Regarding nutritional intake the most common problems were that patients were not given the help needed to eat, interruptions during meals so meals could not be finished and a lack of monitoring of food intake.

The inspections were carried out by one or sometimes two CQC inspectors, a practising nurse and an Age UK ‘expert by experience’.  The inspections took place between 9am and 4pm including one mealtime.

It’s very easy to berate a lack of compassionate nursing and I have no doubt that issues such as the way that condescending language is used is a matter of staff skill and training. Unfortunately our society as a whole tends not to value the older person and the less able person.

I am shocked myself at some of the language I hear people use in reference to older people – even (perhaps this shocks me more) colleagues who work in other service areas who seem to think of ‘the elderly’ as a homogenous group of people who no longer have individual identities that we can relate to when they cease to be economically viable.

That is a matter of training, training again and instilling attitudes in a work culture. Management culture drips down to individual practitioners and staff, that’s one thing I’ve learnt from working in the care sector. You might get the odd ‘bad apple’ but if the work culture is positive, they will be routed out. If the work culture is bad, bullying will dominate and the bullying of staff invariably leads to the bullying and mistreatment of patients.

I do though think there is a fundamental ‘acceptability’ of ageism in our culture which makes these reports less surprising than they should be.  Thinking back to my own social work training, which focused heavily on children and families (it’s a generic qualification so it is important that all age groups are covered well) the amount of time we spent talking about the needs of older people was below a minimum acceptable standard (one lecture in two years and most people didn’t turn up to it as it wasn’t compulsory)  and the course itself seems to adopt an ageist approach by not covering the needs of older people to a sufficient or acceptable standard.

If that is what is happening in the universities that train our professionals then we have to work harder and improve and push respect far higher up the agenda.

The other issues relate to staffing levels and the costs of providing a well-staffed ward. While I think every professional who is registered by a body which oversees them has to remain responsible for their own actions there are systemic failures in a management culture which does not allow sufficient staffing to deliver basic respect, dignity and nutrition.

The report itself says

The key theme was around the lack of time staff had to spend with patients to attend to their individual care needs. Reference was often made to certain times of day or night when staffing was inadequate.

Equally in the section regarding nutrition it says

A lack of time to deliver care (due to short staffing, persistent high demand or excessive bureaucracy) can prevent staff from making sure that people’s needs are assessed and they are given the right support to eat.

Poor practice may also result if there is a culture in a hospital that does not place an emphasis on treating people with dignity and respect. This might explain why needs assessments do not seem to be a priority in some hospitals, and the habit of talking across (rather than to) patients by staff.

As we see from the post about the Stafford Hospital inquiry, blaming nurses is too simplistic. The management should not be able to get away with this. Why do they push these targets and maintain poor staffing levels? Because money is haemorrhaging and needs to be saved by the Trusts. The brutal truth is that the fantasy of efficiency savings remains a fantasy while people are not being fed properly in hospital and while management cultures do not focus on staff training and development but allow understaffed wards to operate.

It’s a useful, if somewhat depressing report but there have been similar reports over the years and the key thing is for the findings to be acted on and not filed away. The ‘usefulness’ of the report relates to the way it  might move beyond the news headlines and affect funding decisions and management decisions in all hospitals, not just those that weren’t forced to make changes.

It’s interesting to see the CQC be a little more proactive though, particularly around the need for unannounced inspections. Now, if it can manage it with hospitals, it should be able to manage the same with nursing and residential homes?