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    The pace of change in health visiting over the past few years has been hectic, traumatic at times and stressful, but have the rewards promised been delivered?
    Health visitors welcomed standards and national recognition but the next phase is not certain at all. We, as with our School nurse colleagues transferred to Local Authority Commissioning this year. We have worked hard to ensure commissioners were ready for us and know what we do, how we respond to populations and need. Lots of good standards have been written down but sadly this is where I fear the wheels fall off.
     Government cuts have hit Local Authorities. Hard. The honeymoon period has been short for our school nurses who now find themselves an expensive service that no one wants. Commissioning is looking at getting a complex professional service but finds there is not the money to pay for dedicated, well educated  professional SCPHNs.

    Is this the future also for Health Visiting?

    Currently many health visiting services are finding that managers are looking at how they deliver the service that is being “paid for” and “counted” rather than the comprehensive complex relationship building, nurturing service that health visitors are trained to do. Yes I celebrated the enshrinement of the 5 mandated contacts and the 4,5,6 model but this is a bare minimum, what if a provider interprets that as a set service delivery standard? Do we continue to anticipate need? A core principle of health visiting is the search for health needs

    I’m a Health Visitor in the NHS. My job is to provide a universal service to children until they go to school that will monitor their health and well being and safeguard them

    The safeguarding of children depends on so many factors. But it’s not just the job of health visitors to protect children, it’s the role of families and families currently are under massive pressure.  Cameron’s government talked about Troubled Families but those of us working day to day are finding families in trouble, they have more stress than ever before. Mums and dads are working 2/3 part time jobs. We are there to support them.
     These children and their parents have little expectation of us. They become lost to services and when, as we have heard so much recently, they are living in fear there is no one to trust, no one to support them. Safeguarding children does not start with social workers, it’s about visible children supported in their communities but we need commitment to maintain universal services from Health Visitors and School Nurses to ensure our children are never unseen or unheard.

    No one else will

    So, we move forwards to the here and now.
    health visitor
    Is this is it? I’m in consultation phase and I’m at risk of being down banded or made redundant. So too are my colleagues across England.  So have we lost the fight? Do we give up now, go back to our areas and tough it out, having our own individual battles? When it’s done do we reflect on when things were good, what we could have done who’s at fault?
    Just the sound of this is too awful to imagine.
    So what do we do?  We look for inspiration. Whether it be current or past. The Practice teacher that inspired you, the mum that fought against the odds for her child, women like Marie Stopes, the women that started us off in 1862, those that went on to do their bit for women’s suffrage.  We take their example and adapt, we owe it to our children and communities to stand up and fight these cuts to a service we built for them.
    It’s not just a job. It’s a service that will disappear unless we shout out. We are the invisible support. There’s a presumption we will always be there from our colleagues in Health and Social care and by the public.
    In Worcestershire recently we raised the “What if” question and were bombarded by mums and families asking what if their health visitor had not been there, asked, enquired? They showed how much health visiting affects families.
    Last week I heard stated that we shouldn’t worry about the lack of follow ups a and chasing contacts. She cited the example that “no one else does, a GP wouldn’t call to see why an appointment is missed”. But that’s exactly the point. No One else does. The under 5s are too easily invisible and we have seen again and again the tragedy of invisible children, lost from the eyes of their neighbours.  Women with post-natal depression are not wont to shout for help, we know that often unless the health visitor asks no one else does. The Domestic Abuse question, so vital to women and children, if no health visitor who will ask? No one.
    I could go on, but I think I’m preaching to the converted.  I know you get the importance and significance of the job. So how do we go forward?
    The only way I know is by raising awareness, sharing experiences and campaigning.  We are not reinventing the wheel. So many nurses have had to fight for services in the past.  Health visitors fight daily for housing, safeguarding, GPs to listen to concerns they raise. This should be simple for us. Why so careful?
    We have leaders who have given us inspiration, Professor Dame Sarah Cowley spelled it out for us and continues to do so, Dame Elizabeth Anionwu coins the phrase the Radical Health Visitor. It’s my belief that if we aren’t radical we aren’t fulfilling the job description!  They weren’t Dames when they did their work, they were you and me, turning up, doing their best. Use the resources you have, your voices and your Union as so many before have done. No one does this alone.
    Support each other, speak out, speak up, challenge, organise and don’t give up. It’s a nothing to lose moment, were in good company with the rest of our NHS and Local Authority colleagues.
    So, I’m at the March in London on March 4, I want a block of red ❤️YourHealthVisitors up front – indulge me!  If we don’t fight this No One will.
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    Students applying for nursing or midwifery courses in 2017 will already be aware that they are no longer eligible for government bursaries, which have been scrapped by the Tories in a bid to save £800m of public spending. While this change will result in financial uncertainty for many students, the removal of bursaries could spell even greater uncertainty for the National Health Service in the next few years.

    Under the bursary system, Health Education England funded a fixed number of places based upon local ‘workforce plans’, designed to fulfil the needs of the NHS locally. The government argues that by removing a cap on the number of funded places, the removal of bursaries could result in an increase of 10,000 places by 2020. Yet some experts disagree. Estimates by London Economics suggest that because of the removal of bursaries, nursing admissions could fall by 6-7 percent in the first year alone, leading to “a significant increase in staff shortages in the medium term”.

    There is a distinct shortage of nurses and assistant health practitioners within our health service – a shortage of 15,000 to be precise – so it seems counter-productive to be cutting investment at a time when we should be attracting applicants to study nursing. It is hard to see the logic in shifting the financial burden from the taxpayer to individual students, considering that, on average, 70 percent of students never fully repay their loans, meaning that the taxpayer ultimately foots the bill anyway.

    But even if the government’s forecasts turn out to be correct, there is no telling what types of nurses and allied health professionals are likely to be trained under the new system. Without the financial guarantee which bursaries provide, universities may be tempted to cut the numbers of less popular, specialised courses like child psychology, while expanding upon popular courses such as physiotherapy. HEE warns that,

    If the commissioning of education is not efficient and effective, then attrition potentially goes up, people leave the courses or graduate with the wrong attitude…this impacts on the tax payer in a number of ways.”

    By replacing workforce plans designed to meet the needs of the NHS with a system driven by market values, it is possible that an unfunded system could result in a shortage of highly valued and specialised nurses and AHPs, while unneeded specialities become flooded with new graduates. As none of this training will have occurred with specific vacancies in mind some graduates may find themselves struggling to find a job, despite having incurred thousands of pounds of student debt.

    The political choice to detach recruitment from the needs of the NHS runs the risk that many graduates may end up taking jobs elsewhere. One particular weakness of government-funded places was that graduates could take up jobs within the private sector or abroad, with absolutely no obligation to work within the NHS after they graduated. But whilst the bursary system was far from perfect, the new system does even less to incentivise people to study nursing in the first place and to pursue careers within the health service.

    What is particularly uncertain is who exactly will be responsible for meeting the workforce needs of the NHS once funded places have been completely abolished. If HEE remains ultimately accountable for NHS staffing, it will have to look at other non-financial incentives and soft ‘nudging’ to convince people to take up nursing in spite of the associated debts.

    While the rest of the NHS is supposedly getting to grips with Sustainability and Transformation Plans and the devolution of healthcare, the removal of nursing bursaries seems to relinquish some of the control which would make local workforce plans easier to plan and carry out. The full effect of these bursary cuts will not be felt until 2020, when the first cohort of students who enrolled in 2017 will finish their courses. If Labour were to win the next general election, therefore, they could find themselves having to explain an NHS workforce crisis conceived under the Tories.

    This was first published by the Fabian Society in Anticipations winter 2016

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    In 1987 Brian Turner wrote a seminal text detailing the sociology of the para-medical professions. Whilst some of his work would be contested in a contemporary context (e.g. Nursing may no longer associate itself as para-medical), some of his work still applies. Namely, his assertion that the non-medical health workforce undergoes a process of professionalization. One modern day exemplar of this may be the role of the Ambulance service Paramedics.

    Arguably this has been a quiet revolution. One generation of workers has seen the shift from the traditional ‘ambulance man,’ promoted from driving council vehicles, to the graduate profession who now have a place in primary care to assess, prescribe (legislation pending), treat and maintain a patient in their own home. This places them on a par with Nurse Practitioners and other professional such as Physiotherapists and Pharmacists who define themselves as Advanced Practitioners.

    There is little to critique in term in terms of the efficacy of these roles. There is widespread consensus that many clients can and should be treated at the right place and right time, rather than taken into a hospital environment. However, there is the wider question of how these roles have emerged and in whose interest do they serve?

    A benefit of health policy from 1997 was the principle that each area of the UK can seek to review its own specific health needs and meet these through local health service specifications. This included workforce planning. However, there is a need to undertake this with a view to the longer term and not, as we assert, to fill a void perpetuated by the current Governments Neo-liberal approach to health policy.

    There is a notable lack of regulation for all roles that describe themselves as ‘Advanced’. Nurse Practitioners in both secondary and primary care have been arguing for their roles to be recognised through regulatory frameworks for well over a decade.

    Without nationally agreed regulation of Advanced Practice (as we do see in Scotland and Wales), Governance will not keep pace with changes in practice. Without Governance, organisational structures will continue to struggle to understand the distinction between roles that specialise and those that are advanced. This debate is not one of semantics, but a very real and distinct method of health care practice.

    Whilst the neo-liberal approach to policy in this field (ie a lack of), then there will continue to be a plethora of health professional titles across the sector. To again use Ambulance Paramedics as an example, a quick review of literature finds that Paramedics use the same ‘Advanced’ title if they specialise in trauma and intubation or if they practice in a primary care setting seeking to see, treat and maintain a person in their own home.

    Not only is this true in the context of Advanced Practice, there is an emergence of new professional roles such as Physicians Assistants and Primary Care Pharmacists which is adding to the confusion around roles and responsibilities. This crowded primary care environment with a plethora of illegible titles, professions and roles is hard enough for those working within the profession to keep pace with. How then should the wider public, let alone those who are unwell and their families and carers understand this picture? Whilst there may be more areas and professions to seek care from, it may be suggested that there are more professions who may turn clients away for ‘not meeting their criteria’.

    The more crowded and confused the landscape becomes, then the more professions may lose sight of their primary purpose. Turner (1987) commented that with the process of professionalization also comes the ‘rise and fall’ of competing professions. Clearly a neo-liberal landscape may be a catalyst for this. We would argue that this is counterproductive and not in the public’s interest. We would seek for professions to focus on their primary aim, the delivery of care for their clients and wider community and not have to be in a position whereby they have to compete for professional space. This competition not only detracts from our professional imperative, but also leads to short term planning through a race to be the first to meet the next policy agenda.

    This is not a call for nurses and paramedics etc. to ‘know their place’; we do assert that all health professions should be involved in the wider political context. But rather an argument to seek an end to the competition between professions and to plan for practice in the longer term, practice that is carefully underpinned by socially just principles.

    See Turner B, 1987, Medical power and social knowledge, Sage London

    Paul Mackreth is a District Nurse and Senior Lecture in Community Nursing at Leeds Beckett University

    Fiona Needham – who also contributed –  is a Senior Lecture at Leeds Beckett University and Course Leads a Programme for Advanced Practitioners

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    Buurtzorg (“care in the community”) is what would be called in the UK a social enterprise which was established in Holland in 2006 as all parties involved started to realise that the demand of providing care by nurses/carers in the community,  caring for the clients in their own home environment, was significantly  increasing. This created a situation in which the nature of providing care  subsequently started to change too.

    “Buurtzorg” is in essence a home care organisation working with small and flexible teams; a community nurse and community carers providing care to the clients within their own living environment or house. E.g.  clients being subject to ill health, clients returning home from hospital  or on behalf of their GP; injecting insulin, caring for surgery wounds and dealing with pain relief. Supporting in palliative care is also possible. Each client is allocated a personal nurse/carer. The nature of this “Buurtzorg” is to promote the client’s independence and to increase the opportunity to remain living in their own home as long as possible.

    The fully autonomous teams work throughout the Netherlands and all have the authority to take any decision for whatever issue that may arise during their daily involvement with their clients. They therefore have the ability to organise the job without too much management involvement and unnecessary bureaucracy.  Decisions are taken by the nurses/carers working closely with the clients. Although there is one office only within the organisation dealing with administrative issues for the whole of all the teams throughout the Netherlands.  The staff are well-qualified and undertake activity personally which is in other systems are often delegated to unqualified people. This reduces the number of different staff involved in the care of an individual.

    The consequence is that the nurses are challenged to have the courage to take the responsibility in taking tough decisions and that working hours are irregular. The nurse/carer is in a direct contact to the client’s GP, (hospital) specialist, or social worker; whoever as professional is involved.

    Clients do not pay for “Buurtzorg”. This is funded by general funds within the Dutch healthcare system.  A study by KPMG in 2015 showed that care provided in this way was not more expensive. Care appeared to be higher quality and much more satisfying for staff.

    Differences with regular care and general characteristics of “Buurtzorg”;

    • Nurse/carer and client actively work on creating the best possible solutions within their own (professional) support network that results in increasing the client’s independence and quality of life.
    • Providing care is the responsibility of the carer/nurse.
    • Professional care is based on professional standards and is all evidence based and  monitored.
    • Providing care is based on achieving the maximum of effectiveness; care delivered within the exact the time needed; not more and not less time spent and custom made and custom offered care based on the client’s wishes.
    • Hardly any overhead costs.
    • Nature of the care provided is often practical by nature, therefore the provided care is “transparent, visible and measurable”.
    • Aim-purpose “Buurtzorg”: to create the opportunity for clients to live in their own home as long as possible and to avoid that they have to be cared for in elderly homes or hospitals.
    • “Buurtzorg” is highly focused on the client’s availability of (professional) network in the community.




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    The truth about the quality of care provided by some private hospitals has been well documented: “Investor-owned hospitals have higher costs, despite spending less on clinical personnel than do non-profit facilities. Death rates and postoperative complication rates also are higher at investor-owned hospitals, and nurse staffing levels are lower. Investor owned health maintenance organizations have worse quality scores and spend less on care and more on administration and profits than do not-for-profit plans” (Harrington et al. 2001). Then, why the much repeated myth that care in a private hospital is necessarily superior to that given in a public facility? This certainly was not the case for the 3,000 patients treated by the BMI owned Mount Alvernia Hospital in Guidford, where the Quality Care Commission (CQC), in unannounced inspections (December 2012, January 2013), found untrained staff being left to care for very sick children. “Staff were untrained and had very limited experience of caring for sick and post operative children. The hospital management team were dismissive of concerns and blocked action to improve the situation,” the CQC report said; adding that correspondence between nurses and managers “showed that the hospital management were made aware that the use of untrained staff was putting patients at risk and contravened all published guidance.” It can be added that the QCQ report also highlighted a surgeon refusing to let women patients have chaperones during intimate examinations. Another did not wash his hands between patients. A consultant sedated patients and left them without adequately trained staff to look after them. The same consultant would talk on the phone during surgery! – beats driving whilst doing so! One patient had a nerve block on the wrong side of his body! Resuscitation team members had failed to attend emergency calls.

    Animal Farm

    BMI Healthcare is owned by General Healthcare Group (GHG), which is £2bn in debt. GHG was acquired in 2006 by Apex Partners, a private equity company, which borrowed to finance its takeover by securing its debt against properties (private hospitals), with an extra £222m of debt secured against the profits generated from these hospitals. (See Who Owns Care Homes?). BMI manages 72 hospitals owned by GHG (that is, in reality, owned by lenders such as Barclays, Mitzuho, and Pfandbriefbank), in partnership with the NHS and such private providers as Bupa. GHG is not able to meet its debt repayments, and an option for their lenders is to seize GHG’s properties. This is unlikely, in that it would be a major ‘spoke in the wheel’ of the state’s propaganda machine, which extols the virtues of the private sector; though such ‘news’ would undoubtedly be relegated to those late night tv slots which are not primarily concerned with the drivel given out about the twin entities of royalty and celebrity. That concentrating the minds of the masses on escapist trivia is paramount is shown by the comparative lack of publicity given to the acquisition (July 2013) by Bain Capital of 80% of Plasma Resource UK, a government owned asset, which is a major blood plasma supplier to the NHS. Bain Capital was formerly run by Mitt Romney, the Republican Party presidential candidate.

    Jennifer Rankin ( 2013) reported: “Lord Owen, a former Labour health minister in the 1970s, who created a service to make the UK self-sufficient in blood supplies, said it was “hard to conceive of a worse outcome” than the £200m sale of an 80% stake in the Hertfordshire-based company to private equity … A privatised company posed risks of contaminated plasma, he suggested … The worldwide plasma supply line has in the past been contaminated … We in this country should do everything in our power to avoid being reliant on open market tendering processes for NHS patients.” Rankin added:  “Professor Allyson Pollock, professor of public health research and policy at Queen Mary University London, said there was “not a shred of evidence” to support government claims that private firms would boost innovation in plasma treatments. Where is the evidence that when you use venture capital such as Bain Capital that they invest and they don’t asset strip? …  The sale illustrated “why we are concerned at the way that NHS and NHS associated products are being denationalised and privatised and put out to the market place as a source of profit rather than responding to patient needs … The sale of the 80% stake adds to the growing list of privatisations now underway, including the Royal Mail, Search and Rescue, which will be taken over in 2015, and a tranche of the student loans book.”

    Future of health care

    What of the future of health care  in this neoliberal utopia of privatisation? To some degree this question is relatively easy to answer, for whatever model of care provision prevails in the USA will be adopted in the UK, as surely as the adoption of the same foreign policy. A model of paying for care currently receiving attention in the USA is Direct Primary Care (DPC). This is a scheme in which companies or unions pay a monthly fee per member, from which future health care costs are met from an aggregated fund managed by a DPC company, which charges a management fee. The self employed who are not in a union will be encouraged to take out private health insurance. Mount Alverna – here we come! It is claimed that such schemes will be cheaper than private insurance. The DPC company will source the most ‘economic’ (cheap)  service available for each individual participant’s needs, thus creating a ‘market’ in which the most inefficient (costly) providers go out of business – ‘Darwinising’ health care provision. Such a process would lead to fewer and larger types of provision, with the ill, for instance, having to travel considerable distances to ‘super’ surgeries or ‘super’ hospitals, no doubt being owned by private equity firms.

    It is reasonable to assume that any costs bore by companies will be factored into wage rates. In essence, workers will be paying for their care in the form of accepting lower levels of disposable income.

    Those individuals who can not afford a monthly fee – the unemployed; those not in a union or employed by a participating company –  will have it ‘credited’ to them by the government, probably being taken from benefits (including in-work benefits), rather than being additional to them.

    Generally, DPC providers claim they will be able to address 80% of the most common diagnoses, with the remainder, including such expensive to treat conditions as cancer, needing to attract additional fees.

    Companies which participate in this type of scheme gain benefits – the worker becomes their captive, being willing to accept poor pay and conditions through fear of  losing their job and its attendant provision of health care, for both themselves and their family. Unions would have similarly docile members, who would not question their union’s acceptance of company’s business objectives. In this regard, consider the RCN’s statement concerning its ‘corporate relations’ – “We understand your business, your issues and motivations and we can help you achieve your business objectives” (RCN 2012). Thus, the RCN is indistinguishable from those who exploit its members –  “the creatures outside looked from pig to man, and from man to pig, and from pig to man again; but already it was impossible to say which was which” (George Orwell 1945).

    The lie will undoubtedly be spun in the UK that health care is still free, not having to be paid for as the need arises, but its costs will have been pre-paid, in terms of lower unemployment and disability benefits, lower wages, and unrelenting servitude, in which even those who have little will cling to what they have in fear of becoming as one who has less.

    This is the road to the soup-kitchen. I conclude with the advice given anonymously in a notice posted in the market place of Hitchin in 1800: “Advice to all poor tradesmen and labourers. With one consent lay all work aside and meet together in a body and see what is to be done in this case; for your work, all you can do, will not support you or your family. Your vile oppressors, see how they use ye, what yoke of bondage you are brought under. Be not afraid of horse nor standing arms but come forth with courage and resolution. If you give way to those villains you will always be bound under these chains wherein your liberty and freedom is entirely lost. Nothing’s to be done without you take this step” (Hammond and Hammond, 1949).


    Hammond JL, Hammond J (1949) 1st pub 1917. The Town labourer (1760-1832). Volume ii., p. 118. Guild Books.

    Harrington C,   Woolhandler S,   Mullan J,   Carrillo H,  and  Himmelstein DU, MD Journal: American Journal of Public Health – AMER J PUBLIC HEALTH , vol. 91, no. 9, pp. 1452-1455, 2001.

    Nightingale L (2013) Who Owns Care Homes

    Orwell  G. (1945) Animal Farm. Secker and Warburg

    Rankin J (2013) Bain Capital Bus Majority Stake in Plasma Resources UK., 18 September 2013.

    RCN (2012) Model Recognition Agreement

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    Recently there was a case in the press of  a nursing home manager jailed due to poor care arising from short staff. So what could or should she have done?

    Stonedale Lodge Residential & Nursing Home

    Stonedale Lodge Residential & Nursing Home

    Whilst it may still be due to staff sickness or holidays; it seems to have been a regular occurrence. This may mean that she has tried bank staff and none available. Has she tried agencies? Too be honest, it is more  difficult to obtain care assistants from agencies. I have actually known  a  care home which paid  an agency nurse to work as a care assistant, so it is not all bad. But then, the regular staff need to assist them as they are unfamiliar with the  establishment. Whether or not she rang agency, depends if her regional manager( in this case it was a company home) allowed her to ring them. Sometimes they do but use delaying tactics when it is too late to get anybody. However, by delaying, sometimes they do save  a couple of hundred pounds because a usual member of staff finally decides do work overtime. So what proof would she have of this?

    Managers- always keep emails and keep replies. If this keeps happening, it is your DUTY as registered manager to inform the CQC. They will monitor the staffing levels. However, it has been known (anecdotal) for some homes to invent the names of staff and display them on the off duty-. There are also cases of dependency levels of patients in hospital or care home, being falsified since they indicate the required staff level; the Francis report gives us published evidence of this. Yes you also need to be  in a union but according to the Francis report (2013) and anecdotal evidence, they too may not be effective. Indeed anecdotal evidence, nobody will publish it nor write it, tells us that some staff are dissuaded from joining a union.

    This is the difference to an NHS hospital- the care home manager is REGISTERED. Yes there is a dilemma between beds, budget and quality of care. But get your priorities right. Yes I know you may lose your job if you ring the CQC- but it is better than going to jail. Although why that should be the major factor I do not know. Yet today, everybody does need to work I know. Consider also dilemmas faced by overseas nurses. I explore this elsewhere.

    On a hospital ward of course, the ward manger or person in charge would ring round other wards who may have somebody but not always. So then you alert the manager. Again if it keeps happening, keep records and inform even higher managers. Yes you too may need to approach the CQC.

    Evidence is crucial. This is not just for managers. Keep incident forms (take a copy) of shifts when staff levels are low. note what tasks you are unable to do due to low staffing such as baths, how can you bath in an EMI home with 3 staff and 30 residents? Otherwise, you have no clear record of why these tasks were not done on your shift so you are in trouble. If it is  a certain resident /patient you cannot meet the needs of, note it in the care plan. Also put a note in the diary. Today there were only 3 staff on not 5, so we could not bath residents.

    Talking to staff and students I am constantly amazed when they say you can do nothing about it. Students need informing of what to do in these situations in preparation for their qualification. Let us not forget senior care assistants in a care home. I am going to end with a scenario because it makes me smile and we all need to smile. At an interview once, I was asked by the higher manager, if I told you to use less staff than the inspector recommends what would you do? He did not like my answer and I am proud to say, I did not get the job. Wrong person, wrong question. Remember- there are no actual specified staffing levels. We do feel that if  a minimum staffing level was established, whilst many may solely meet that and never go above it, it would be better than the present levels.

    In this case the relatives informed senior managers , it is not indicated whether or not the manager informed them, so they too are involved. The question always is, do the regional mangers act alone- to what degree are they representative of the company? We do know that many companies pay managers a bonus for not spending the budget.. We do know that there have been cases of managers (and staff) being pushed out for failing to adhere to company ways. We also know that there is good practice and not all poor care is due to low staffing levels.

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    Care Homes in the UK are increasingly being controlled by private equity businesses, as witnessed by the acquisition of Four Seasons Health Care by Terra Firma, a private equity group which agreed a £825m takeover. Four Seasons had debts which totalled £1.6bn in 2009. The Royal Bank of Scotland took a 40% stake in the company in return for nearly halving its debt.  Acting on behalf of pension funds, insurance companies, and rich clients, private equity groups manage companies on behalf of their investors.

    Nurse Warrior

    Image copyright Keiren Robertshaw

    Why should nurses, patients’ relatives, and the taxpayer be concerned by such developments? After all, the world of high finance does not claim the interest of many, as it is seen as the prerogative of highly educated ‘city types’ who can grasp its perplexing intricacies.

    Firstly, then, allow me to put in simple terms what it is that private equity businesses do:

    They acquire a controlling interest in companies with a large proportion of debt relative to equity. The acquisition is leveraged, that is, it is financed by borrowing money against the acquired company’s assets and future stock market performance.

    The aim is to increase the stock market value of the company by hoping the market reacts positively to changes in management, which are often accompanied by bullish statements about future performances. When Terra Firma acquired EMI in 2007, it issued statements about its troubled past and better future: EMI lacked “business discipline”, and wise investors would appreciate “the significant potential for transforming the business”. Compare this with this statement by Peter Calveley, CEO of ‘Four Seasons’, “We have now got in place a stable long-term capital structure that means we have got confidence in our position”.   This came after ‘Four Seasons’ was acquired by Terra Firma in a £825m. deal underwritten by Barclays and Goldman Sachs. £700m was in the form of loans, and the balance of £125m was raised from investors. In the ‘Four Seasons’ example, if its stock market value increased to £1bn., the return to investors will be £1bn. – £700m., that is, £300m., representing a return on investment of 140%.

    This form of speculative business model depends on rising stock markets to enable selling on at a higher valuation – such businesses only buy to sell on. When stock markets are in decline, the exit strategy becomes problematic.

    This business model differs from venture capital partnerships that usually invest in start-ups, and do not take a controlling interest in the acquired company. The speculative model distributes cash generated by the acquired company to investors on a contractual basis, that is, they do not act like the majority of companies, which pay discretionary dividends. The speculators also charge a per annum management fee, usually of between 2-3%. They can also claim a share of profits when the company is sold; in the above example, this could be as much as 20% of the £300m ‘profit’.

    This business model relies on the availability of cheap and ‘flexible’ borrowing, with interest paid flexibly during the term of the loan. Banks securitize their lending, so that it does not appear on their balance sheet, which increases their ability to lend more. Loans can be on very ‘easy’ terms, often with clauses that allow default on repayment at least once without incurring penalty.

    It is a vast commission generating merry-go-round in which the elderly have become a commodity.

    What’s more, it is speculation that cannot fail; consider the case of Southern Cross, which the private equity firm Blackstone bought for £162million in 2004, selling it three years later at considerable profit, which it achieved by selling off the company’s homes (45 to ‘Four Seasons’), and forcing Southern Cross to lease the properties back. This arrangement contributed to Southern Cross going into administration, with the government immediately pledging to use public money to ensure affected homes would stay open, amid warnings that moving vulnerable patients might lead to their deaths. It is like going into a bookmakers and placing a bet than cannot lose; the tax payer will return all losing stakes. ‘Four Seasons’ eventually acquired (by debt finance)140 care homes from Southern Cross.

    The private equity model (scam) borrows at high levels using the asset they’re seeking to acquire as collateral on the debt; indebt the company further on the promise of ‘performance improvements,’ pay off their major creditors, and relying on the tax payer to pick up the bill. In the case of ‘Four Seasons’, this increased indebtedness is underway, it’s acquiring 17 care homes from Optimum Care, which operated under the Avery banner, owned by Graphite Capital, another private equity investor (Healthinvestor  11 April 2013).

    Investment banking revenues increase from underwriting private equity debt finance and charging fees for setting up deals, but the mechanics of these deals can easily collapse. As private equity partners face debt repayment deadlines they may need to sell parts of their investment, or seek re-financing deals at higher cost to finance existing debt.

    What of the quality of care provided under the aegis of such companies? Helga Pile, Unison national officer for social services, said: “Private Equity takeovers are noted for looking at ways of maximising profits. The elderly care sector by contrast is woefully underfunded and cannot afford to lower the quality of care by cutting staff or depressing the training and wages of people who work in it.”  Regarding the training and wages of workers, Peter Calveley lamented that ‘Four Seasons’ needed to recruit “several hundred” nurses from elsewhere in the EU, principally Spain, Portugal and Romania.

    They are mainly what are described as PRN nurses, that is, qualified nurses currently undergoing NMC registration, who can be employed as nurses, but who will start off as senior nursing assistants or senior carers while waiting for their registration to be completed. These nurses need to apply for an accession card which ties them to their employer. “Romanian and Bulgarian immigrant workers might be unwanted by the British public, but they are in high demand from British employers, with almost 48,000 UK jobs offered on a careers website in Romania last year. Recruitment agent Brindusa Deac, of Tjobs, Romanias largest foreign jobs website, said: “I don’t think an employer in Britain minds what nationality they employ, they want the best candidate for the cheapest wage legally possible. And Romanians will probably earn less than a Briton in the same position. Around 40% of the jobs offered on the website are for healthcare staff, most for elderly careworkers for both private and state-run care homes. The government has confirmed it will not seek to extend temporary curbs on 29 million Romanian and Bulgarian nationals’ right to live and work in Britain, which are due to expire in December” ( Elgot,  2013).

    Many of these workers are offered accommodation by their employee, often within or attached to the place of work, for which they are charged, and are on-call at all times, with nurses often being asked to cover for ill carers. Of care assistants: “These are hard working reliable individuals looking for work as a carer, they may not have care experience but will undergo the normal 2-5 days training as required by care home providers. While these positions are mainly live out, employers who do not have staff accommodation are expected to help migrant staff to find suitable cheap rooms in the local area and possibly cover the first few weeks rent for them until they start getting paid ( 2013). Yet the CQC requirement in the England, is for a course based upon Skills For Care.  The duration of this course and its exact content  is not specified, and it is assessed by the registered manager of the establishment .

    It is within this business model that: “UNISON has reached a landmark recognition agreement with Four Seasons Health Care along with the GMB and the Royal College of Nursing”. Perhaps this statement by the RCN may summarise what use the unions can be to ‘Four Seasons’ – “we can help you to achieve your business objectives” ( February 2012).Surely a role of any Union is to support members when raising issues of patient care in addition to supporting demands for greater pay and conditions- which would fly against the business objectives actually.

    Why does it not matter that newly qualified UK nurses are not being recruited in sufficient numbers into the private care home sector? The answer: because they will never be able to compete in terms of cost and ‘flexibility’ with EU nationals, and this is a portent of what will become the guiding principle of all areas of nursing within the UK. Nurses face the same prospect as call centre workers, whose jobs went to areas of low labour cost.

    Nurses, like Boxer, the workhorse in George Orwell’s Animal Farm, described as the farm’s most dedicated and loyal labourer, are being sent to the knackers’ yard in a van owned by private equity firms and driven by unions. The £15bn care-for-the-elderly market is expected to grow at 3.1% a year for the next 10 years. Everyone wants to be a part of it.

    Finding out who owns a nursing home should be easy. According to a new Government Accountability Office report, it’s not. Private investment firms have been buying up nursing homes in recent years, creating a complicated trail that makes ownership difficult to pinpoint. This lack of transparency makes it difficult to know who is ultimately responsible for care in a home”

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    I am distressed about the idea of solving the horrors of Mid Staffs and potential future problems by suggesting that nurse training must be prefixed with a year as a health care assistant.

    I am an ex nurse who is well retired but can also say that I am well tuned into the current situation as I am a volunteer with my local hospital, a member of my PPG and also attend Clinical Commissioning Group meetings .I am also an active member of my local voluntary community as well being involved with setting up our local Healthwatch. So I can say I am an active citizen.

    Nurses have a very valuable status and are a respected profession. To go to university and get a qualification has changed the status of the profession and quite rightly They are now doing work that junior doctors used to do, so leaving much of the” hands on” work to an unqualified well meaning task force. Giving the unqualified health care assistants competences is one thing, but what do they do with the result of that work? They do not understand what the consequences are for example a raised  blood pressure recorded but they could be unaware of implications for the patient if not reported So the result may be left on the chart without being acted upon.

    So I show my age and ask why we demean the future of nurse training by suggesting that they would have to do a year on the wards.??? Student nurses spend a large proportion of their training time on the wards now.

    State enrolled nurses used to be a valued part of the ward team who were trained to a lower non graduate level and why have they disappeared? Patients in hospital now are there for shorter stays and many have more complex needs, so they deserve good quality care from qualified competent staff. I am sure it would be agreed that the patient deserves that quality of care and trained personnel. We would of course have to pay more for SEN’s who delivered care for the patient and in a time of reducing budgets –well need I say more.

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    The response of the Socialist Health Association (SHA) Cymru Wales

    1. Purpose

    This deliberately short paper responds to the invitation to submit comments on the forthcoming Bill proposed by Kirsty Williams AM to ensure safe nurse staffing levels within Wales. It draws upon consultation with the membership of SHA Cymru Wales which culminated with a meeting of members on September 3rd 2014 at which four speakers from different perspectives explained in detail some of the issues that need to be considered.

    2. The SHA

    SHA Cymru Wales is part of the UK Socialist Health Association which has over 700 individual members (and many affiliated organisations). Many members have some expertise in, or knowledge of, health care. It is affiliated to the Labour Party. It believes that health care systems should operate on the basis of meeting the needs of the population through a national, publicly owned, planned and delivered, system of care. SHA Cymru Wales has about 40 individual members, and several affiliated bodies that share its aims.

    The response has two parts. The first offers comments upon aspects of the Bill. The second raises queries that arise from a reading of the Bill which it is hoped will be addressed as the Assembly undertakes its work upon the Bill.


    3.1. SHA Cymru Wales understands the motivation for the Bill and has much sympathy with its aims. The best defence that the NHS can have against its detractors is that of offering consistently high quality care to its patients and their families who would be expected to be in the front line of defending the NHS from those who see it as an impediment to the relentless march of the alleged efficiency of profit- driven insurers and deliverers of health care. However, SHA Cymru Wales is not entirely clear how the precise legal vehicle chosen to ensure defined staffing levels will operate in practice.

    3.2. Safe staffing levels must be a pre-requisite in ensuring that standards of care at all times meet all legal and professional requirements. Nurse staffing levels in particular have received much attention as a result of recent enquiries – notably the Francis Enquiry related to Mid Staffs. However, SHA Cymru Wales would see the need for safe levels of staff to apply across a range of care professionals. In this regard we would wish the Bill to be so crafted that other care professionals would be brought within it purview as evidence to underpin required staff ratios / levels becomes available.

    3.3. Even if the Bill is confined to nursing levels, determining what a safe nurse staffing level is at any point in time in different care settings (an acute “on take” medical ward or award caring for elective surgery) has to take into account the severity of the patient load and the needs of those patients. Thus the nursing staff that ought to be available for a given setting have to be adequate both in quantity and in quality (skill). As ward setting become increasingly specialised it is important that staff have detailed knowledge of the care needs that arise from the precise clinical work being done. Nurses that have great experience of nursing patients recovering from major surgery may not be fully au fait with the needs of, say, elderly patients recovering from a stroke.

    3.4. It is understood that there is some evidence base for different ratios of staff to patients in different settings, but some of that evidence is from outside the UK. It is not clear whether the evidence base being cited is totally transferable to the UK / Welsh context. If the research that underpins specific ratios comes from non UK care settings, these may, or may not, generate similar care needs and nursing requirements for similar numbers of patients. It It is requested that great care is taken to understand the extent of the transferability of research data from any overseas settings.

    It is less clear whether the evidence base in regard to skill levels is sufficiently well developed in all nurse settings but it would be hoped that the Bill would prompt urgent research to identify appropriate levels across all hospital and community settings.

    3.5. It is noted that the safe level would apply on a shift by shift basis. It is not clear how sudden surges in workloads are to be accommodated within this legislation. Three very different approaches might be intended.
    a) Is it intended that such surges would be met by deploying a “reserve” of trained staff (with the inevitable implication that current total levels of staff would need to be increased to maintain such a reserve?
    b) Is it intended that “manageable” workloads would be adjusted to allow for the surge in unmanageable demand – with the result that elective work would act as the safety valve in the system?
    c) Is it intended that calculated “safe levels” would be explicitly relaxed when high levels of sudden demand are placed upon one part of the hospital system – and if so how would this be permitted?.

    We would expect the Bill to recognise the possible reactions that the service would need to take.

    3.6. The Bill is silent with regard to the financial implications. SHA has received some views that the measure may be “self funding” in that any higher staff costs arising from the Bill will be covered by shorter lengths of stay and better outcomes. SHA Cymru Wales would have major concerns if this is indeed the expectation for it is reported that the Welsh average nurse: patient staffing ratio is currently 1:10 and the intended ratio is 1:8. This represents an increase in staffing of about 20% and thus an increase in cost of about the same percentage for a large part of the total nursing budget. Worse, were the predicted reduced lengths of stay to occur, far from releasing funds to pay for the higher staffing levels, there is every probability that this would lead to an increase in workload, rather than a reduction in cost unless very tight controls over admissions were introduced and the “spare capacity” gathered together in such as way as to allow it to be closed.

    3.7. Following on from 3.6. a major concern of SHA Cymru Wales is that the Bill will lead to unintended consequences if NHS funding remains tight. If legally binding staffing levels are established, these will be high on the agenda of Boards, professionals and managers. Such staffing levels will be protected at all costs. In straightened times, staff cost centres that are not so protected will inevitably become prey to cost reductions. Medical staffing levels have some protection – as do the services that are outsourced and are protected by commercial legally binding agreements.

    There is thus concern that other staffing levels that are not well protected – for example ambulance services, community staff, rehabilitationists, and diagnostic staff – will bear the brunt of providing funding to support nursing areas to which legally binding levels of staff apply. This may, perversely, drain staff from the very support services that assist nursing staff, so that nurses then find themselves undertaking tasks that were once the preserve of others.

    3.8. It has been noted that the evidence that links safe nurse staffing levels to good care (using reduced mortality and other measures as evidence of such care) has been interpreted as emphasising the staff : patient ratio as being the main feature. It is accepted that if good staff levels are maintained, then staff might feel more secure and settled, leading in turn to lower staff turnover and high team spirit.

    However, members believe that great importance should be attached to the continuity of care that a settled ward staff can deliver. Merely ensuring a defined staff : patient ratio in itself will not automatically provide for the same nurses to care for patients throughout their stay. Indeed, if the impulse becomes one of staffing wards to a given level, then there is a risk that the use of transient agency staff and staff re-deployed from other areas will be increase.

    We would wish further work to be undertaken to understand what impact continuity of staffing has on care outcomes.

    4. Questions

    4.1. The Bill is clearly titled so as to refer to “nurse” staffing levels. SHA Cymru Wales assumes that this wording intends specifically to apply to registered nurses only and not to staff sometimes seen as part of the nursing workforce at ward level, but who are not professionally qualified.

    Is this understanding correct and if so, could this be made explicit within the Bill?

    4.2. Again, in relation to the wording used, SHA Cymru Wales assumes that the Bill does not seek to bring midwifery staffing levels within the scope of the legislation. If so, SHA Cymru Wales is not persuaded that the omission of midwifery for any length of time can be justified. First, it is felt that the adequacy of staffing levels in this field can be predicted and assessed to a level similar to the (wider) range of nurse settings using an evidence base of comparable utility. Second, safe levels in this care area are just as important as in general nursing – especially given the nature of the care that is to be given to both mother and baby, the tragedies that arise from poor care, and the extremely high costs and that fall to be met by the NHS when avoidable harm arises from inadequate care. Third, workload in midwifery has some element of predictability that should aid the service in arranging adequate staff levels.

    Could the Bill please allow for the inclusion of this service within its scope?

    4.3. SHA Cymru Wales understands that much of the debate around the Bill has focussed on nursing care in acute hospital settings. SHA Cymru Wales however, would wish to see any “safe” level applying in all psychiatric care settings and would wish to be assured that this is so. In respect of 3.7. above SHA Cymru Wales would wish to see firm safeguards that protect investment in psychiatric settings and ensure that nursing levels here are set using appropriate metrics.

    4.4. It is not clear whether the Bill intends that the safe staffing regime is to be applied to:
    • NHS facilities operating in Wales only
    • All health care facilities operating in Wales – public and private
    • All health care facilities which provide services to Welsh patients as commissioned by the Welsh NHS.

    SHA Cymru’s reading of the Bill as drafted is that Welsh health bodies would need to apply the provisions of the Bill both as providers of NHS care and as commissioners of NHS funded care. Further, the logic of the Bill should also apply to ensure that all privately provided nursing care operating in Wales is “safe”.

    Clearly, if the Bill passes, NHS Wales should operate its own services in line with the Bill’s requirements. However, NHS Wales as a commissioner of services (whether from the English NHS or the private sector) will then be expected to ensure that any services it acquires for its patients also operate to safe standards. Further, for privately funded nursing care, it would seem unwise to allow a two tier level of staffing to operate within the public and private sector; if safe levels are required, they must be required in both.

    Could the Bill please make clear the application of its provisions to health providers serving Welsh patients – whether publicly or privately funded?

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    A recent report  quoted Attorney General Eric T. Schneiderman: “Nursing home residents are among our state’s most vulnerable citizens, and the perpetual neglect in this case is shameful”, whose comment pertained to 8 nurses and 9 certified nursing assistants who were sacked following a New York state investigation that showed neglect of duty and making false records.

    The investigation used hidden cameras to show that a highly dependent 56-year-old male resident, who suffered from Huntington’s chorea, was not routinely given pain medication, liquids, and incontinence care at Highpointe on Michigan Health Care Facility, with charts and nursing notes routinely claiming he had.

    The 17 accused appeared at Buffalo City Court, facing various charges of wilful violation of health law, endangering the welfare of an incompetent or physically disabled person, and falsifying business records. Endangering this patient is a charge which is a felony and carries a maximum prison term of four years.

    Schneiderman commented: “The charges filed send the message that my office will not tolerate anyone being neglected by those responsible for his or her care. We will use every tool in our arsenal, including hidden cameras, to ensure that nursing home residents receive the care they need and the respect they deserve.”  This follows the New York authorities arresting 22 people in 2010 after hidden cameras revealed maltreatment of patients in two facilities.

    The use of hidden cameras to record instances of poor nursing care has been a constant theme in the American press. Jan Hoffman  reported a hidden camera catching a nursing assistant stuffing latex gloves into the mouth of a ninety six year old patient, as another taunted her and tapped her on the head. Once thrown on a bed, one of the nursing assistants assaulted her with heavy-handed chest compressions. Their treatment was accompanied by laughter.

    Jeremy Pelzer reported that in Ohio new legislation would enable nursing home patients the right to install hidden cameras in their rooms. Cameras can be installed by relatives, the only requirement being consent. States such as Ohio and New York are single consent jurisdictions, so if a patient or their legal representative consents to the use of a camera, no other consent is needed. A prosecutor can install a hidden camera without a court order or subpoena. The nursing home or hospital need not be told about the surveillance camera. Other States are expected to follow this trend.

    The laws in other States may vary. Many nursing homes have installed cameras in common areas and hallways, but they cannot install them in the patients’ rooms. In the case of patients with enough mental faculty to make an informed decision, courts may act to prosecute a relative for invasion of privacy if they install a camera unbeknown to the patient. Nursing facilities in some States may instigate legal proceeding against those installing cameras clandestinely.  They may use ant-surveillance detectors. They may ask patient to leave a nursing facility if cameras are discovered. Patients or their representatives on admission to a nursing facility may be asked to sign an agreement not to use a surveillance camera.

    The power of business interest to block the use of cameras in nursing homes is evidenced by the vote in the Senate Medical Affairs Committee concerning the right of families to install cameras in South Carolina’s nursing homes. The committee was evenly divided, with a 7-7 vote, meaning that it will not progress. Adcox  quoted the sponsor of the bill, Sen. Paul Thurmond, “This is really about empowering an individual who’s in a nursing home. The older generation is fraught with neglect and abuse.” They also quoted committee member Sen. Brad Hutto, who commented on the opposition of the nursing home industry to the bill: “They are concerned this is a ploy to catch them doing bad things to patients. That’s not what this is about. This is empowering families to take care of loved ones.” He added, “Generally, people with cameras on them behave better.”

    Abuse recorded by hidden cameras is not confined to the elderly: A Canadian report commented on the case of a teenage girl who was bound and hooded, and was forcibly injected by nursing staff with an antipsychotic drug, despite the fact that she appeared calm. This girl had entered the world of prison nursing at the age of 14 for throwing crab apples at a postman. She subsequently killed herself. The footage of the injection was the subject of court action by the Canadian government, which sought to block it. The same report states: ‘In Canada, mandatory video surveillance in prisons is designed to protect both inmates and staff.  However, elderly citizens in Canadian hospitals and nursing homes have no such protection. Instead, unlike the U.S., Canadian governments and courts vigorously prohibit video surveillance inside the hospital and nursing home rooms of elderly people’. The report claims that criminal charges and convictions have ‘increased substantially’ in States like New York since they licensed the use of hidden cameras.

    The situation in Canada was also commented on in a CTV report  which highlighted the case of a hidden camera in a Toronto nursing facility recording an elderly resident being roughly manhandled as her incontinence pad was changed, having a soiled wipe shoved into her face; an employee wiping his nose on her bed sheets; employees having sex in her room as she lay in bed. Four employees were sacked, but did not face any legal charge.

    Abuse of patients has been caught on hidden cameras in the UK. David Brindle reported, ‘Inspectors have been called in to private hospitals that care for people with learning disabilities after exposure of a regime of shocking abuse by staff at a unit run by one of Britain’s leading care companies’. Another report gave details of footage of an Alzheimer’s patient being repeatedly beaten in a care home, which was later screened on TV. Helen Nugent reported an 89-year-old woman who was suffering from dementia being dragged across her bedroom floor, as she scream in pain, and was then threatened with violence.

    Such abuse is the UK is not as isolated as some reassuringly make out. As in America, there has been a constant flow of reports of abuse, which begs the question, how much more abuse would be discovered by using hidden cameras? Exactly what lies under the ‘tip of the iceberg’?

    The continuous reporting of abuse in American care facilities led to the passing of the Elder Justice Act (EJA) in 2010, which established  mandatory reporting requirements for those suspecting abuse in long-term care facilities (EJA, Funding for training and certification, 42 USC, sec. 1397, 2010). All employees are required to report reasonable suspicion of abuse to the Secretary of Health and Human Services and law enforcement agencies. Failure to report can result in harsh financial penalties of up to $300,000.

    The need for a debate on the use of hidden cameras in nursing homes was made by the Care Quality Commission (CQC) in its document A Fresh Start for the Regulation and Inspection of Adult Social Care (2013), which states: “We would … like to have an open conversation with people about the use of mystery shoppers and hidden cameras, and whether they would contribute to promoting a culture of safety and quality.” This produced a similar reaction from the care home industry as it had in America, with claims of patients’ privacy and staff moral being under threat. These claims are seen as a ‘red herring’ by some in America, with the care home industry more  “concerned this is a ploy to catch them doing bad things to patients” ( Adcox 2014), i.e. employing too few and inadequately trained staff.

    The issue of patients’ privacy is addressed in certain American State legislation (Ohio etc.) by linking it to consent to use hidden cameras, by the patient or their representative. If the patient has requested the use of a hidden camera, or one that is marked by a notice on their door, then all that can be objected to is their choice to do so. If a relative makes this choice, what can be questioned is their right to make a choice based on a knowledge of the patient and their likely wishes. What cannot be objected to is a person’s right to make an informed choice, even though that choice may be anathema to others. That is, people should have the same right in most instances to not have a camera in their room as others do to have one. The qualification in most instances seems an important one where abuse is suspected but can only be proved by a hidden camera. In this instance, should authorities have the duty to override the wishes of a patient’s relative?

    To the charge that cameras, whether hidden or otherwise, lower staff morale, should it not be asked, which staff? If nursing staff do their job, and do it with a caring manner, what have they to fear? Your every step along the High Street or shopping mall is recorded, which will trigger a response if you mug someone. Your right to privacy is being infringed, yes, but the general right of people to be protected from mugging is enhanced. Would some staff, too intimidated to report abuse, welcome the use of cameras that would instantly stop that abuse? Would some staff welcome cameras that showed the good care they gave?

    Ethical issues surrounding the use of cameras in nursing facilities have previously been debated, the BBC reporting: ‘The use of hidden cameras in hospitals to spot child abuse by parents is legal and ethical, says a report. The technique was used most controversially at North Staffordshire Hospital where researchers suggested some cot deaths were the result of child abuse. A specialist advisory committee in paediatrics was set up as a result and raised reservations and objections concerning the procedure, which is only used when abuse is suspected. But another study, published in the Archives of Disease in Childhood, the journal of the Royal College of Paediatrics and Child Health (RCPaed), says hidden cameras, monitored by nurses or other health staff, should continue “in the absence of any viable alternative”. The research, conducted by Dr Neela Shabde, one of the doctors on the advisory committee, and Professor Alan Craft, a vice president of the RCPaed, says medical staff have a legal duty under the Children Act 1989 to intervene to protect the best interests of the child.

    If it was deemed that hidden cameras had a role in protecting a child from an abusive parent under the Children Act of 1989, then why do they not have a similar role today in protecting such as the elderly from an abusive or neglectful nurse or nursing assistant?

    The whole issue is a contentious one. Who would review camera and audio footage? What guidelines would be issued that defined abusive or neglectful care? What rights would there be to appeal?

    I suggest that the debate about the use of cameras should be extended to include NHS and private hospitals, local authority and private homes for the elderly, and those with learning disabilities. It should also be extended to all those who work in these facilities, nurses, nurse students, and assistants. The debate should not be between committee members, or be dominated by those with the loudest ‘voice’. It should be a debate in which opinions are sought, discussed, and form the basis of action. The following questionnaire is suggested as a means of initiating this process.

    Answer yes or no:

    • Hidden cameras should be used in care facilities.
    • Patients in care facilities are abused and there should be camera to catch the offenders.
    • No one should get paid to abuse our older citizens who deserve respect for their contributions to society.
    • Serious physical abusers should be fired and reported to the police.
    • Hidden cameras should not be allowed in care facilities.
    • Elderly patients are humans that have rights to privacy.
    • It is morally wrong to constantly watch the elderly in care facilities without their prior consent or their knowledge.
    • Neglectful or disrespectful abusers should be suspended and reported to the Nursing and Midwifery Council.
    • Do people with cameras on them behave better?
    • Would cameras show low levels of staffing hindering care?
    • Should patients have the right to install hidden cameras in their rooms?
    • Should relatives have the right to install hidden cameras in rooms?
    • Should relatives have the right to install cameras if a notice of this is displayed on the door?
    • Should care facility managers have the right to install hidden cameras in rooms?
    • Should all people have to declare in the National Census if they would like cameras in their care facility rooms?
    • Should cameras be installed in common areas in care facilities, such as hallways and nursing stations?
    • Should it be compulsory for nursing staff to report abuse or suspected abuse?
    • Should there be severe penalties for those who do not?
    • Have you witnessed nursing staff not giving care, but writing in notes that they had?
    • Do you think this is a common practice?
    • If a camera is installed, should it have an audio capability?
    • Should cameras be mandatory in all areas of care facilities?
    • Should cameras be mandatory in all areas of care facilities, allowing patients or their relatives to opt out?
    • Would nursing staff who did their job, and in a caring manner, have anything to fear from cameras?
    • Would cameras show nursing staff to be hard working and caring?
    • Would cameras protect ‘good’ staff from more dominant ‘bad’ ones?
    • Would cameras increase the public’s confidence in nursing
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    Around this time of year NHS Hospital Trusts will be preparing their annual Quality Accounts (QA).  These are public documents aimed at enabling professionals and the public alike to be informed about the quality and safety of services provided across the organisation.  Introduced in 2010 by the Department of Health, QA’s are part of the national drive to increase transparency of NHS health service providers in England.

    Are QA’s any better that previous ways of improving quality and safety of nursing care?  A look back over the history of nursing may help to answer that.  Florence Nightingale gave the profession a great start by using statistics to evaluate patients’ progress.   The shocking death rate of young soldiers in hospitals during the Crimean War prompted her to compile monthly statistics on the causes.  Six months of figures revealed that almost three quarters had died of illnesses they acquired in hospitals, far more than from wounds.  Her campaign for reform began, underpinned by systematic data collection to identify root causes of deaths.  Some causes lay outside the hospitals’ control, namely unsanitary water supplies due to contamination from animal carcasses and blocked sewers.  Once these were remedied the mortality rate from disease dropped sharply.

    Florence Nightingale

    Over a century later, in 1972, a landmark change in nursing was brought about by the Briggs Report which put nursing onto a ‘research-based” footing from which it has become increasingly evidence-based, to the undoubted benefit of patients.  The learning from Florence Nightingale was clear – that statistics brought about positive changes in social policy.  Similarly, the change to being a research-based profession ensured that patients would be no longer subjected to ‘traditional’ ineffective (or worse, harmful) methods of care.

    Since then, awareness of the influence of nursing politics has increased.  Two books, The Politics of Nursing (1985, Jane Salvage) and Nurses: Power and Politics (1987, Trevor Clay) pointed out the key role of nurses in leadership positions in creating environments in which good nursing care can flourish. Both authors emphasised the need to have patients’ feedback at the heart of any service developments.  In contrast with this ethos, the top-down nature of targets and funding streams in the NHS over two decades means that financial management has dominated all else, as is aptly described in a book NHS SOS published last year (Ed Davis J, Tallis R).

    QA’s can reveal annual data on patients’ experience and outcomes of care in hospital.  This presents a real opportunity for nurses, or anyone else interested, to see factual evidence on selected aspects of care in their local hospital.  Priorities for improvement are decided by an inclusive process involving staff, patients, key stakeholders and the public.  Common priorities for improvement include pressure ulcers and complaints.  The Francis Report recommended that QA’s  “..should no longer be confined to reports on achievements as opposed to a fair representation of areas where compliance has not been achieved.”   As regards complaints, he points out that the nature and detail of complaints is more important than numbers alone.

    A real strength of QA’s is that they are open to scrutiny by Local Authority Overview and Scrutiny Committees, Clinical Commissioning Groups and Healthwatch Groups which can see the draft version of QA’s, and to make comments which are then included in the published version.  While there is some way to go in achieving ‘the perfect QA’, evidence is emerging that requests and comments from Scrutiny Bodies are being taken on board.  Examples include increased clarity and jargon-free reports, and a change of emphasis in dealing with complaints to encourage increased reporting by patients, but with the aim of having lower levels of severity of patient harms.

    Such improvements reflect well Florence Nightingale’s search for “facts not impressions”.


    Clay T, Dunn A, Stewart N (1987) Nurses Power and Politics

    Salvage J (1985) The Politics of Nursing, Heinemann, London.

    Tallis R and Davis J (2013) NHS SOS: How the NHS Was Betrayed – and How We Can Save It.

    A shorter version of this article is published in Nursing Times

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    Student doctor, pharmacist and nurse from Wythenshawe Hospital explain what working in an NHS hospital is like today.

    Wythenshawe Forum with Andy Burnham and Mike Kane

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