NHS Care of Older People

Alison McGovern Excerpts

Thursday 27th October 2011 Westminster Hall

[Alison McGovern (Wirral South) (Lab)]

The hon. Lady’s final point before she reached her conclusions and recommendations made some quite clear criticisms of the values in society. Will she add to that list how she would like the values in society to improve?

[Margot James]

I welcome that intervention because whenever one is preparing for a debate such as this, one is conscious of how much more there is to say than one has time for. I was not intending to draw too many conclusions on what needs to change in society. I was concentrating on what needs to change in the domain that we are discussing, but perhaps the hon. Lady would care to call for a debate on the topic to which she has referred. I am sure that we could fill an afternoon with such a discussion and I should be delighted to take part.

[Margot James]

I thank my hon. Friend. That is a very good point. The integration of health and social care should, with the weight of joint commissioning behind it, make quite a difference. My speech has concentrated on care in hospitals, but I hope that other hon. Members will bring out issues to do with care at home and other aspects of what the NHS delivers.

I shall go through my list of recommendations briefly. On nutrition, the Age UK report, “Still Hungry to Be Heard”, advocated that ward staff needed to be “food-aware”. Training should include nutrition and the importance of assistance with meals when needed. I agree with these recommendations. Older people should be assessed for signs of malnourishment on admission, during their stay and on discharge. Hospitals should introduce protected mealtimes. Where they are using a red tray system, which involves a red tray being given to patients who require assistance with eating, staff should be trained in how to use it. It sounds as though that system works well where it is used properly.

[Alison McGovern]

I thank the hon. Lady for her generosity in giving way to me again. Does she question, as I do, the red tray system, in that if nurses and nursing staff understand the needs of a person, surely they should understand what their nutritional assistance needs are without the use of a red tray? Surely they should know patients well enough already. Is that not a question that we should ask?

[Margot James]

I thank the hon. Lady for her excellent point. In an ideal world, I would strongly agree with her. I agree that what she has suggested is to be desired. The trouble with relying on that is that the throughput of patients through wards these days is quite fast, the rostering system for nurses is very complicated and the continuity of care is certainly not as good as it used to be. Many nurses work intensively for a week and then have a substantial amount of time not working. Therefore the personal relationship, which is so desirable, has been compromised to the extent that we can no longer rely on it to ensure that patients’ nutritional needs are met. That is why I believe that the red tray system is useful. However, I am very concerned that people could easily think, “Oh well, that sorts the problem out,” and not feel that they need to relate to the patient in the way that the hon. Lady suggests.

I come now to accountability. I realise that this is not something that the Government can mandate, but chief executives should come on to the wards regularly—every day that they are in work. Nurses used to be accountable to a matron, who would turn up unannounced to check on standards. We must replicate that discipline again, and I recommend starting at the top.

Managers need to ensure that budgets are used wisely to support front-line staff and that front-line staff are not distracted by other, non-patient-care “priorities”. I looked at nurse blogs when I was preparing my speech and I sympathised with one nurse who said that nurses are

“at the beck and call of so many departments who wish to give work away and have no qualms in ‘getting the nurses to do it’. Loan stores, training, HR, to mention a few who seem to have forgotten that their role is to support us—not the other way around.”

I have sympathy with busy nurses who are pulled in all directions.

--- Later in debate ---

[Alison McGovern (Wirral South) (Lab)]

I congratulate the hon. Member for Stourbridge (Margot James) on securing the debate and thank the Backbench Business Committee for timetabling it. There are few issues that mean more to me or make me more angry than the poor treatment of older people, especially by our NHS. Therefore, it is highly important that we focus on that today.

I shall begin where other hon. Members might not have had time to go—by questioning our values. The hon. Member for Stourbridge listed societal problems as being one of the causes of indignity in hospitals and, when I intervened to ask her about that, she said that she did not have enough time to go into the subject. I hope I can assist her by taking us on that journey.

I am afraid that I shall start by disagreeing with the hon. Lady. I find it hard to believe that there is a lack of moral value or preference in society. Part of the problem is that those values are not made explicit often enough. We have talked much about dignity today. That word is often used, but rarely explored. I question and doubt the point made by the hon. Member for Truro and Falmouth (Sarah Newton) about older people being treated differently in other countries. If that is the case, it is incumbent upon us as politicians to make our values absolutely clear. In many ways, the national health service is, for Britain, an expression of our moral choices and preferences. Whether or not we talk about the NHS in those terms, that is what it is.

Let us begin by asking what we mean by “dignity.” It means inherently respecting the other person because of their humanity. In practice, that means demonstrating they are listened to, cared for and thought of, no matter who they are or what their personal circumstances are. Let me quote from the CQC report to give an example of what I mean and why it is so important that we make that absolutely explicit. In the report’s overview by Dame Jo Williams, she mentioned that they found cases where they believed that staff stripped patients of their dignity. She says:

“People were spoken over, and not spoken to…left without call bells, ignored for hours on end, or not given assistance to do the basics of life.”

When we talk about dignity, that is what we really mean. I find it hard to believe that we live in a Britain where most people would walk past, look the other way or not consider the needs of somebody who is extremely vulnerable and stripped of the basic necessities of life. The vast majority of people in our country would consider that situation to be utterly intolerable.

The question is: what is going on in the health service that leads us to see cases in our surgeries and examples among our families where people are bereft of their dignity? Given that we set such high moral value by the appropriate respect given to people because of their inherent dignity, what is going on in the health service that allows such a situation to occur? I accept other hon. Members’ points about the level of frequency and the commitment of staff by and large, and I was also most taken by the remarks of my hon. Friend the Member for Nottingham South (Lilian Greenwood), who is no longer in her place, about the best practice demonstrated to her. Given that we know what the right answer is, we need to consider what happens when there is a failure.

[Dr Coffey]

I strongly endorse what the hon. Lady is saying. What is even more extraordinary is how there are such different experiences within a single hospital. That is why local leadership is absolutely critical to getting this right.

[Alison McGovern]

I thank the hon. Lady, who spoke so well and so bravely earlier, for her intervention. I will come on to describe the differences within hospitals—a point at the heart of the debate.

Last year, the Wirral University Teaching Hospital Trust experienced some of the worst staff survey results in England. They were awful. The percentage of people who would recommend our local hospital to a member of their family was disturbingly low. I know I speak for other hon. Members in the area when I say that we are extremely concerned about this. The trust has a plan of action to try and put this right and there are many examples of the best quality of care being given to my constituents. However, some wards have been very poor. What we have observed locally relates exactly to the point raised by the hon. Member for Suffolk Coastal (Dr Coffey). Some wards are very good and some are extremely poor, and the CQC report also found that. Some of the places of most concern also had very good practice, so this is a problem.

We ought to ask the following questions about staff in the NHS, and I think that they should ask the same questions of themselves. The first question relates to the point that I started with: do they have the right values? Do they make the right moral choices? Do they have the right preferences? By and large, I think our answer would be yes. I do not believe that people in this country somehow just do not care—I think that that is wrong. The second question is: are NHS staff empowered to make choices in line with those values—the basic right to dignity and sense of humanity that we want them to? Are they empowered? Finally, in line with the points that have just been made, are they accountable if that does not happen? That is a crucial point.

The Front Line Care report is an important report written under the previous Government about the future of nursing. There is, perhaps, a missed opportunity. It covers, in detail, many of the questions that we have about nursing care. My mother was a nurse. Her line on nursing is that a nurse’s job is whatever the patient needs. That coheres entirely with both the Front Line Care report and the CQC report, which points out the problem alluded to by other hon. Members. Dame Jo Williams states that care seems to be:

“focusing on the unit of work, rather than the person who needs to be looked after.”

We need staff who are empowered to provide person-led care that looks at the needs of each person, and delivers for them what they need in the health service.

There is, of course, the question of targets. The Government have moved towards dropping some of the waiting list targets that were in place under the previous Government. Is this the kind of thing we can have targets for? I am not sure. However, I know that we know good quality when we see it. If the model of staffing for the dignified and respectful care of people is right, then that will drive up the quality of experience they receive. Leaving aside whether we have targets, quality of experience can definitely be monitored. There are some difficulties relating to monitoring older people, not least people who die in hospital. It can be very difficult to ask for feedback about the death of a loved one, but we need to find a way of asking. A good death is at the heart of what it means to be a dignified person. I encourage all hospitals to think carefully about how they ask for feedback from the relatives of a patient who has died. Even in the case of an older person with dementia, how do we get feedback on how the NHS has treated them?

As politicians, we need to back nursing staff and doctors. At the beginning of my speech, I tried to be very clear about the values that we espouse and I hope that they are shared across the Chamber. Those values give people absolute faith about what is expected. We can be clearer about the standards of care that we expect. I have concerns about systems, such as the red tray one, which rely on a tick-box culture, rather than saying, “Here is the standard that we expect people to live up to and it is your responsibility to do so”. How people in different wards meet those standards would be different, but they must meet them.

I would set the following test for the NHS. I believe in the NHS not merely through custom and practice, but as an article of my political faith. It is a fundamental expression of our values that everybody should be looked after if, through no fault of their own, they become unwell. Everybody should be taken care of. That means that if one person is not taken care of in the NHS—whether they are related to us, or nothing to do with us—in the way that we would expect for a member of our family, then that is not good enough. We should articulate that value. I hope—and know, in my case—that local leaders of hospitals share the belief that we should care for people in the NHS as though they were members of our family and give them the dignity to which they have an absolute moral right. We need to articulate those values and then make people empowered and accountable to living up to them in the NHS.

[Liz Kendall (Leicester West) (Lab)]

It is a pleasure to serve under your chairmanship, Mrs Brooke. I thank the Backbench Business Committee for allowing us to have the debate. In particular, I thank the hon. Member for Stourbridge (Margot James) for securing it. I also want to thank all other hon. Members who have spoken and given passionate, heartfelt and thoughtful contributions.

Hon. Members from all parts of the Chamber have spoken with one voice. It is completely unacceptable for any older person to receive the appalling standard of care that we have read about in the CQC report and in the ombudsman’s report. We have seen that appalling standard of care in our own constituencies. My hon. Friend the Member for Bolton West (Julie Hilling) has seen it in her own family. Although we may not have seen as poor a standard of care as she did, I am sure that many of us have been concerned about the care given to our own families. I would like to consider some potential causes of those poor standards of care, and talk about possible measures to tackle them and to ensure that every service matches the best standards.

It is important to look closely and carefully at this question and to avoid thinking that one issue, one group of staff or one set of problems is to blame. While there are some straightforward, practical steps that could be taken immediately, there will not be one simple quick fix that will solve the whole issue. There are deeper and more complex issues that are far harder to address. I will talk about five areas: staff levels and resources; staff training, which many hon. Members have spoken about; culture and leadership; the regulation of the NHS; and deeper issues that are very difficult to address.

Several hon. Members, particularly at the beginning of the debate, raised the issue of staffing levels and resources. If we talk to individual members of staff or organisations such as the Royal College of Nursing, they say that the issue is of concern. Staff to patient ratios were referred to by the hon. Member for Stourbridge and the hon. Member for St Ives (Andrew George). Peter Carter, who runs the RCN, gave me a stark example. The figures are rough and not perfect, but he said that paediatric and children’s wards have one nurse for every four patients, while in the wards that specialise in care for older people the ratio is around one nurse for every 10 patients. Elderly, dependent patients have different needs from sick young children, but in many ways they are just as challenging, so we need to look at that, particularly because, with an ageing population and some of the problems in social care, more sick elderly patients are ending up in hospitals, many with not only dementia but two or three other health problems. That co-morbidity issue will be important as we see hospitals with big financial challenges, which we will over the next couple of years.

On staff training, we often hear commentators or senior people in the NHS, frequently medics, who question whether moving nursing towards being a degree profession has been an entirely good thing. It is vital to get the right balance between academic and practical elements in nurse training. Degree courses have been around for many years—40, I think. As many hon. Members have said, we see differences between and even within hospitals that are using nurses with the same qualifications, often from the same universities, and some have their problems and some do not. We need to look at the balance, but we should not think that that is the entire cause of the problem. A lot is down to the culture created in wards, which I will say more about in a moment.

Concerns have been expressed by many hon. Members today, the media and NHS staff about health care assistants. Health care assistants in wards provide more and more of the care, some of which is intimate, such as feeding older people or helping those with continence problems, but it is a positive development. As other hon. Members have said, our staff have the right values, and that is partly about the training they get. I think the hon. Member for Stourbridge said that health care assistants do not get any training and are not regulated, but they do, or should, get training from their employer, the trusts. Such training can be patchy, and we need to look at that.

In 2003, I called for the regulation of health care assistants—as many people did, way before me—in a project I did called “The Future Healthcare Worker.” If nurses are to take on some of the more clinical roles, and health care assistants more care, we need to look at that issue. I had hoped for more progress on that under the previous Government. It would be interesting to hear from the Minister the current Government’s views on regulation. There are all sorts of issues around time and cost—for employers and individual staff—but it is something we need to look at.

Culture and leadership are woolly words, but in practice we know when we see good culture and good leadership. My hon. Friend the Member for Wirral South (Alison McGovern) made this point. What is it on the ward that matters above all? Yes, it is about how long it takes to be treated, whether operations are a success or whether medicine is taken on time, but it is also, crucially, about the experience of the patient, whether they and their families feel that they have been given enough information and the time to think about it. When the information is given can be important. We have all been in situations where the doctor has said something quite shocking and we were not prepared for it. What matters is the simple things such as whether the patients are covered up when they go to the toilet and cleaned effectively afterwards.

There are places where the patient’s experience is at the top of the agenda, not only of the individual ward but of the hospital as a whole. Simple and straightforward surveys, developed by organisations such as the Picker Institute, can help individual organisations and services to get that across.

Another thing about culture is a bit more tricky and concerns how we build a team and being open to questioning. In a team, staff should value each other’s different experiences. That might not be the case with some of the old-fashioned hierarchies in a hospital—doctor, nurse, care assistant—where they do not dare question one another. Teams need to value each other’s skills and experiences but also be open to questioning.

[Alison McGovern]

One of the best examples of quality of care that I have seen recently was in one of my local hospitals, when I was shown around a ward in part by the cleaner, because she was deemed to be so important to the good functioning of that ward.

[Liz Kendall]

That is absolutely right. It is not that everyone has the same skills and experience, but that all those different skills and experience are important. In a proper culture of learning, mistakes can be admitted, because we all want to learn from them to ensure that they do not happen again. We need to see not only the different health professionals as part of the team, but users and families too. Peter Carter of the RCN raised the issue of families being involved, and it was sad that all over the papers he was reported as saying, “Come in and care—it is up to you to care for members of your own family.” What we need, though, is for families to be part of the process, particularly if their relatives are elderly patients suffering from dementia. Family members know them best. We might not be able to hear what they are saying but their family will know how they react, and whether they like or dislike something.

Such a culture and such leadership need to be in evidence not only on the ward, but on the board—a point made by the hon. Member for Stourbridge. As the boss, the board should want to know what is happening on the ward and its members should be getting the surveys and patient feedback. As with Members of Parliament, hopefully, what they will most want to know is what individual constituents think of them. Accountability is vital, from the top down. Also, in particular for old people who might not have family members nearby, the idea of volunteers who can be advocates and part of the process is important.

On regulation and the Care Quality Commission, I am concerned about the issue. More could be done immediately. The CQC has an important role to play, but I want to be clear that responsibility for the quality of services lies with the providers and not with the regulator. However, people want to have confidence that, if the CQC says that somewhere is okay, it is okay and, if it is not okay, that the CQC will go back and ensure that it is sorted out. I am concerned that, almost six months after the initial inspections, the CQC has not been back to a third of the hospitals it said in its report were failing to respect and involve older people, and it has not been back to two thirds of the hospitals that were failing to meet nutritional needs. I have written to the CQC, which has not written back, but it said on the phone that it had received written reassurances. That is not good enough. It should be going back to those hospitals. I am keen to hear from the Minister whether he could take action to ensure that we know which hospitals have not had a follow-up and what the timetable for action is.

There are clear national guidelines for people who work for public bodies such as the council or the NHS. There are guidelines on raising the alert and referring a person immediately—within one day—if it is thought that they are vulnerable or at risk of neglect or abuse. I have asked the CQC whether it referred people, or whether it required the hospitals to do that. If someone has seen children at risk of neglect or abuse, action would need to be taken or they could face the legal consequences. I am concerned about that matter.

I have spoken longer than I intended. I want to finish by addressing what I call “deeper issues”: our model of health care, the nature of medicine and the way we as a society treat older people. When our NHS was established, our population had very different health problems. People needed episodes of care for acute conditions that could be treated and increasingly cured. Our health services were based on the model of individual district general hospitals. However, we have health problems now that are related to people living longer with long-term and chronic conditions. Improving health is no longer solely about needing episodes of acute care that seek to cure people. It is about increasingly helping people to manage their long-term health problem, and, when they are very old or suffering from dementia, helping them to live to the end of their days as comfortably as possible.

Our model of health care has not kept pace with changing needs. One third of hospital admissions are for people over 65, but, because on average they stay in hospital twice as long, two thirds of hospital beds have an older person in them. Hospitals are not the place to care for older people, but hospitals are where we care for them. We must change that situation, which means shifting services out of hospitals and into the community. We need to focus more on prevention and joining up with social care.

There is a big challenge for medicine. We have talked a lot about nurses, but not about doctors’ mentality. They are trained to cure. There is a big challenge for doctors as well as nurses as our health needs change. In too many places, doctors are still at the top of the hierarchy. They are the ones who help to determine the shape of care. It is important to look at their changing role, too.

I want to talk about how we as a society treat older people. I hope we will have a proper debate about that one day. I want to say two things. First—I think other hon. Members have mentioned this—we are not used to seeing people get so old. It is quite a recent thing to see people living for such a long time, often in pain, and it is very painful for families, particularly if they see people whom they love suffering with dementia. Society shuts older people away too often. We say, “You’re just getting old” or we prefer that they are not seen and not heard. In other countries, it is not like that. Older people feel more part of the community and they are perhaps more visible than in this country. I can give a simple example. Care homes in Spain do not have opening hours—they are simply open—and people see them as part of the community.

The issue is about how our services cope with an ageing population and how we treat older people. If someone is very old and slowly dying, including from something such as dementia, which is awful to see, we need to find a new way to deal with that.