NHS: Standards of Care and Commissioning

Lord Winston Excerpts

Thursday 31st March 2011 Lords Chamber

[Lord Turnberg]

My Lords, I am delighted to have this opportunity of opening this debate. I am pleased that so many noble Lords are remaining in the Chamber and are going to contribute. I look forward to hearing what they have to say.

I shall focus my remarks on recent reports of failures in standards of care, particularly for the elderly, but this is also a good opportunity to examine whether the commissioning arrangements proposed in the new Bill will have a positive or a negative effect on standards of care. Perhaps, too, we should look at how the Bill might be used to make things better.

I am someone who has spent most of his life working in the NHS and I bow to no one in my support and admiration of what it achieves. I see enormous advances being made every year, and patients who would no doubt have died are now cured and surviving into old age. Medicine has been transformed out of all recognition during my working life.

It is because I have this pride and huge admiration of the NHS and the people who work in it that I now feel a deep sense of shame. Despite these wonderful advances, in too many places we have been ignoring the common decency needed to care for the vulnerable, the sick and the elderly—and it is the elderly who are often the most vulnerable. As Ann Abraham, the Health Service Ombudsman, said in her report, there is a,

“gulf between the principles and values of the NHS Constitution and the felt reality of being an older person in the care of the NHS in England”.

That is why I am going to focus on the elderly, but they are not the only group where standards have slipped. I suspect that other noble Lords may speak about the mentally ill, and only the other day we had a report about failures in maternity services.

Of course, the media are quick to pick up the seemingly occasional horror stories of neglect in a hospital. You might want to hide behind the idea that these are rare incidents against a background in which 1 million people are looked after perfectly well in our hospitals and nursing homes every 36 hours, and that is absolutely true. But it turns out that it is not a rare or unusual event. It seems to be happening far too often, and stories of neglect are just too common for comfort: patients, usually in a geriatric ward, unable to eat the food left out of reach at the end of the bed and collected by staff seemingly unaware that it has not been touched, and too busy to notice that a thirsty patient is unable to even drink without help—or, worse, too busy to notice that a helpless patient, unable to get out of bed and incontinent, is sitting in damp sheets for hours or, the final degradation, soiled by faeces and unwashed for days.

Noble Lords might ask whether I exaggerate. Where is the evidence that this picture is not just a rare, occasional lapse in an otherwise acceptable system of care? Well, quite apart from the rather common anecdotes of many with elderly relatives, there is now the report of the ombudsman in which she describes 10 examples of the complaints she receives that emphasise just how bad it can get.

We cannot say that we have not been warned. In 1997 we had the report from Age Concern in its “Dignity on the Ward” campaign, describing failing standards of care. When it followed that up 10 years later, in 2007, it found that little or nothing had changed. The Commission for Health Improvement in 2003, the Healthcare Commission in 2007 and the Care Quality Commission in 2010, despite regularly changing their names, came up with the same message. Now there is the book that has just been published, Michael Mandelstam’s How We Treat the Sick, which brings all this together in a devastating way.

The scandal at the Mid Staffordshire hospital of a year or so ago turns out not to be an isolated example. Every time we have a disastrous fall in standards we have another report or inquiry. I will not list all the hospitals or nursing homes that have been the subject of criticism but they range from Cornwall to Rotherham, from Tameside to Southampton and from Oxford to Bolton. There are just too many, and it is clearly not a new phenomenon. It went on under the past Government and the one before that, so I do not want to make any political points here. But how can we have tolerated this neglect of our most vulnerable citizens for so long? No one can afford to be sanguine—not the doctors, not the nurses, not the managers and not the Government. I want to say a few words about why and how this is happening and suggest what we might do about it, because we certainly cannot allow it to go on.

Let me apologise for starting with the nurses, for whom I have the greatest admiration and to whom I owe a great deal of personal gratitude. However, at the end of the day, it is the nurses who patients look to first for their personal care and empathy. It is always tempting to look back to a golden age that never was, but one thing that is clearly fixed in my mind is how high the standards of nursing care were on the medical wards where I worked in the 1950s and 1960s. Those were the days when the sister in charge of her ward really was in charge. She was usually a mature woman in a career job who made absolutely certain that everything ran efficiently and well. I admit to running scared of her; as, indeed, did the patients.

However, those were the days before the revolutions in nurse management and nursing education. One of the unintended consequences of the upward drive to better educated nurses with university degrees has been the development of a generation whose aspirations are set high. They quite reasonably expect to have a career in which they can practise their skills to a high standard. Who can blame them? They do a great job with all the caring attitudes you can wish for. However, that has left a gap at the more basic and, to many, less attractive level of the general and geriatric ward where there is greater emphasis on the basic needs of patients: feeding, washing, help with movement, going to the toilet and so on.

Those are the wards where staffing levels are often lower per patient in the belief that they do not need the more intensive, one-to-one care of the specialist units. So they are often understaffed and sometimes come to rely on temporary, or “bank”, staff, who constantly change. Continuity of care is damaged as patients, already a little disorientated by being removed from their familiar environment, are faced with a bewildering series of new faces.

It is not only the nurses who are constantly changing. Confusion is compounded by the way the rotas for the ward doctors are arranged to fit in with the European working time directive or as they rotate through yet another experience to chalk up on their training programme. So there are new faces at every turn. These wards do not have the champions that the specialised departments have, who can put pressure on management to protect them from cuts. Not much wonder that nurses in training pass through those experiences quickly on their way to higher things. Nursing sisters in charge may not stay long enough to be able to stamp their authority and, in any case, are distracted by paperwork or, nowadays, putting stuff into their computers—care plans and the like.

I fear that these changes have created a situation in which we have two starkly different standards of care. On the one hand we have highly trained, highly professional and caring nurses in well staffed specialised units—intensive care, coronary care, chemotherapy units and the like—and, on the other hand, poorly staffed wards, rushed nurses, falling morale, falling standards and poor supervision. These are the staff who are struggling to cope with patients whose vulnerability makes enormous demands for the care and attention that the nurses have neither the time nor the patience for.

Of course, this picture is not true everywhere and many, probably most, wards and hospitals are very good indeed. It is just that this picture is too common for us to take any comfort from it.

So what is to be done? Here it is clear that there is a need for a multifocused set of actions which no one profession or body can shirk. First, we must have someone at ward level who takes full responsibility for ensuring that patients are properly looked after with the respect and dignity that they deserve. That is absolutely key. I hope that my nursing friends will forgive me for saying that we should be making this job, the ward sister or charge nurse, a career post and rewarding those who do it accordingly.

[Lord Winston]

Hear, hear!

[Lord Turnberg]

My Lords, there has to be some continuity in that post to make it an attractive alternative to the lofty pastures of the specialised departments.

Then there is the issue of too few carers on the wards. What happened to all those state-enrolled nurses—SENs—whose roles were predominantly in the caring world and who did not aspire to higher degrees? They disappeared in project 2000. Is it possible for us to resurrect the SEN grade and make it attractive again? I hope that some thought can be given to that.

That leads me to the medical profession, who cannot absolve themselves—ourselves—from responsibility for the neglect we are now discussing. They, after all, must see the way their patients are being cared for and, I am afraid, have not raised their voices loud enough. They should be leading the charge for proper staffing levels on their wards. They should be pressing hard on the managers of their hospitals. Of course, they really must do something about these disruptive rotas that are destroying the continuity of care that patients need and deserve.

The managers must make themselves much more aware of their responsibility to ensure that there are sufficient staff on these wards to cope with what is one of the most demanding areas of a hospital. They should know that these wards cannot be among the first, for example, to take cuts. Then there are the responsibilities of the trust boards. Board members have to be rather more hands-on and need to know what is going on in their wards. Many obviously do, but it seems that there are too many who do not.

Finally, I come to those bodies who will be commissioning services in the bright new tomorrow, the GP consortia, and the responsibilities that we should be placing on them for standards of care in the NHS, under the Health and Social Care Bill coming through the House—in whatever form that Bill survives. To paraphrase Aneurin Bevan, there are bed pans clanging on the floor all over the country and, in the rush to devolution to the local level, important though that is, devolved responsibility must also mean some central accountability.

As these services are commissioned, we must make sure that the Bill places a duty on the GP consortia to make sure that high standards of care for the elderly, at least, are a contractual obligation on the providers. Furthermore, we must have a robust system of monitoring so that we can have some confidence that this care is actually being provided. Perhaps the proposed commissioning board can take this on, but only if it has the capacity to monitor what is going on in hospitals and nursing homes, and has a mechanism for action when standards slip.

We have been through too many years in which we have seen indifference punctuated by intermittent reports and wringing of hands. It has to stop. The time for action is now.

--- Later in debate ---

[Lord Winston]

My Lords, the points that I shall make are no criticism of the Government; indeed, they are not faults induced by them. If there have been faults, they have been those of healthcare professionals and the management of the health service. I hope that the noble Earl will be able to respond by saying how we can build in these suggestions. This is a strong echo of what the noble Lord, Lord Turnberg, said. He spoke with nobility, dignity and humanity and his points were very well made.

Some weeks ago, I brought to the attention of the House my experience at a leading hospital, where I was faced with a woman in her postnatal period, four days after delivery, with a dangerously high, life-threatening blood pressure, which no one was dealing with—she had not seen a doctor in four days. There was no continuity of care on the ward. When I tried to speak to the nurses, they were busy at their computers and with their paperwork.

I want to talk about the loss of continuity of patient care in the hospital service. The noble Lord, Lord Turnberg, talked about halcyon days. Although we may not want to return to those days, the old-fashioned firm system in medical practice was very good: the idea of consultants working in tandem, usually two at a time with the same secretarial support, followed by a senior registrar, a registrar, house physicians and house surgeons, was a good way to ensure continuity. Nowadays, we do not even have the privilege of interviewing the staff who come on to the team. Because of political correctness, they are often appointed. That means that we lose a valuable kernel within the health service.

There used to be flexibility about time off. We did not go off when a patient was really sick. We had a detailed handover when we went off, if we had to. We would make sure that the person to whom we were handing over understood what was going on. We were still responsible, as junior doctors, when we were off, and would expect to be informed if critical decisions were being made about those whom we regarded as our patients. That ethos and that culture have been lost, partly because of the European working time directive, although that is not the only reason. The restrictions on working time, which we have previously encouraged the Government to think about, have had a massive negative effect not only on training and experience but on morale and continuity. A “watch the clock” attitude has been engendered.

There used to be general ward rounds for the whole team, at which the ward sister would be an important person, together with the general practitioners. Often, general practitioners came to the wards, which meant continuity in society afterwards. Nowadays, we do not have the same attitude towards the hospital in which we work. We have no hospital nurse, no medical porters and no dedicated bedrooms. There is no staff dining room. That may seem a ridiculous point, but the disadvantage is that, in terms of morale, we cannot replace the staff dining room, where we used to discuss individual patients with other consultants in order to learn. In science units, restaurants and coffee facilities are in every research lab, but they are no longer in hospitals. We should think about that. I have to say that I learnt my haute cuisine of Indian cooking in such messes. We felt valued members of an institution in a way that we do not now.

As the noble Lord, Lord Turnberg, said, there is no leadership on the ward. Without ward sisters, individual nurses do not feel responsible for all the patients in their care on the ward. Doctors now normally do ward rounds without the sister present; indeed, it is difficult to find a nurse who is free.

I make one final point. Basic nursing has been lost: cleaning patients, caring for them, listening to them, trying to feed them occasionally. Yesterday, I met a paediatric nurse at one of the best nursing schools in the country. She said: “I got an A in hospital management and NHS management in my essays, but I cannot change a paediatric colostomy bag, and that really worries me”.