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Care and compassion in the NHS

Jocelyn Cornwell
Jocelyn Cornwell
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The Health Service Ombudsman’s report on ten investigations into NHS care of older people has provoked an understandable, but wearingly familiar, wave of shock and media outrage. The Ombudsman is not known for emotive language, but she says her ‘harrowing’ findings, reveal ‘an attitude which fails to recognise the humanity and individuality of the people concerned and to respond to them with sensitivity, compassion and professionalism’.

If the language in the report is new, the findings are not. We know that poor care occurs in healthcare systems everywhere. The fact that all too often it is older people who suffer may reflect wider societal values, but from our work we know that it can happen to anyone. The fundamental problem is that the quality of health care is not reliable: the more vulnerable the patient, the greater the risk.

The media always focuses on ‘what has gone wrong in nursing?’, but the Ombudsman’s stories are not just about nurses: they feature a wide variety of medical, nursing and support staff, in hospitals and in general practice, and many are about lack of continuity and coordination between hospitals and primary care.

The report is a clarion call to think much more deeply about how and why vulnerable people suffer at the hands of the people there to look after them. The failings in the Ombudsman’s report point to something more than callous attitudes on the part of a few ‘bad apples’. The stories are about personal and institutional failure. Reliable quality cannot be achieved by single individuals acting alone. If we have learned anything in the past decade about providing safe, high-quality care, it’s that it requires sustained, continuous effort and focus over a period of years: it cannot be fixed overnight.

So what kind of practical actions could prevent the harm occurring in the first place?

First, we should stop thinking and acting as if ‘patient-centred care’ and ‘patient experience’ are different from clinical quality and patient safety. The cases illustrate perfectly that it is nonsense to do so. The care these patients received was unsafe (falls and bruises), clinically ineffective (failures to diagnose, poor prescribing, lack of pain relief) and neglectful.

At senior level, board and executive team members should be out and about, talking to patients, visitors and staff and seeing for themselves what goes on in wards, waiting areas and clinics. In the best organisations, senior leaders demonstrate by word and deed that quality of care is non-negotiable, and take an active interest in what is required to deliver it.

Staff don’t need more blame and condemnation; they need active, sustained supervision and support. In the high-volume, high-pressure, complex environment of modern healthcare it is very difficult to remain sensitive and caring towards every single patient all of the time. We ask ourselves how it is possible that anyone, let alone a nurse, could ignore a dying man’s request for water? What we should also ask is whether it is humanly possible for anyone to look after very sick, very frail, possibly incontinent, possibly confused patients without excellent induction, training, supervision and support. 

We need to develop much more systematic approaches to supporting staff who are delivering care, helping them to re-connect with patients and avoid ‘case-hardening’. On The King’s Fund’s The Point of Care programme1 we are currently working with one such practical method called ‘intentional rounding’ in a number of wards and hospitals. Instead of waiting for patients to buzz for help, with intentional rounding nurses take the initiative and visit the patients’ bedside every hour to do whatever the patient needs and see if s/he is alright.

The regular anticipatory ‘rounds’ at the bedside reassure patients they have not been forgotten and, tellingly, result in an overall reduction in patients’ demands. More importantly, by being ‘patient-focused’ rather than task oriented, staff can find themselves re-awakened to the needs of their patients as people. Rather than increasing workload as they had feared, the intentional rounds have encouraged productive relationships between families and carers and improved communications, leaving staff feeling more positive about the care they are able to offer.

Jocelyn is Director of The Point of Care programme at The King’s Fund.

Note
1. The Health Foundation’s Hospital Pathways programme is run in partnership with The King’s Fund as part of The Point of Care programme and works with patients, families, healthcare staff and hospital boards to improve the patient experience.





 
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Comments
This is such a complex area. My experience is personal, very limited and not recent. It comes from helping to look after my father and then my mother-in-law, between 1994 and 2002. In both cases, when the time came for institutional care (how we wished we were wealthy!) the same problems appeared.

One main concern was the lack of training given to hospital staff for what were then called EMI patients. Even basic understanding of their problems seemed missing. Without such understanding –common sense, really – on the part of staff, patients suffer all sorts of low-level deprivation such as lack of enough to drink, safe spaces around them and easy access to tissues and the like when in bed.

Another was communication, at a very basic level. Staff often seemed not to understand simple queries and would simply disappear. Any kind of question beyond the simply practical might elicit a guarded response. For many staff from overseas, understanding more than a simple factual question was difficult; answering it, impossible. This is not to criticize those staff who are doing their best, but has anyone helped them improve their spoken English? I was born in India and am not making any kind of racist slur.

Basic courtesy often seemed missing. Talking about someone in front of them, loudly calling their forename as if they were naughty children, and ignoring obvious needs was not uncommon. I took my father away from a brand new nursing home when I found him slumped horizontally over the side of his chair in a lounge while a staff member sat opposite him, chatting to the only other resident. It took a few seconds to make my father more comfortable, but the staff member chose not to help. The owner of the home, a local GP, never contacted me about the departure after 13 days of his first resident.

A very quiet, polite request to a passing nurse, if nurse she was, to reposition a nasal tube that had slipped across an elderly relative's mouth resulted in her simply walking away without speaking. The relative told me not to ask her again as it was better not to bother her.

Intellectual stimulation in the two care homes we chose for our parents was almost non-existent. Blaring television cartoons filled the lounge in one from early to late. When I pointed out that my blind, intelligent father might prefer a more suitable environment, a quiet lounge was offered where he could sit alone. I then put together some music tapes, provided a radio cassette and made a list for staff of the radio programmes he would enjoy. I hope they used them.

Both our parents eventually found good homes, but the process was not easy. We are articulate, motivated people and we tried very hard to make the best arrangements we could for them. Their stays in hospital were not good, and would have been much worse had we not been around almost daily to help with feeding and the like.

There is so much that could be done to make the lives of our frail, elderly people much better than they are. Ultimately, human will and intelligence will always determine the result. Policies, strategies and training can all be useful, but without the right staff, enough of them, courtesy at all levels and motivated management, no framework can be more than that.
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