NHS Care of Older People

Margot James Excerpts

Thursday 27th October 2011 Westminster Hall

[Margot James (Stourbridge) (Con)]

It is a pleasure to serve under your chairmanship this afternoon, Mr Betts. I thank the Backbench Business Committee for allowing us to have the debate this afternoon, and I am grateful to colleagues on both sides of the divide for supporting it. I look forward to hearing the views of other people who have a great interest in the subject.

We are here because of troubling reports about the care of older people in the NHS. I was prompted to confine our debate to the NHS by the report from the Care Quality Commission two weeks ago, which studied 100 NHS hospitals. The report was by no means an isolated study; it came on the heels of the ombudsman’s report in February and Age UK’s “Care in Crisis” report in May.

That we have a worrying problem is beyond doubt, but I hope to bring a balanced view to the debate. It is important to note that even when reports give cause for serious concern, there are significantly more examples of good and acceptable care than there are of bad. Indeed, the ombudsman’s report stated that the overwhelming majority of patients say they receive good care. I will return to the balanced view that I promised, but first I will outline the concerns raised by the latest findings of the CQC.

The Secretary of State commissioned the CQC to undertake a series of unannounced inspections in response to the ombudsman’s report. The inspections focused on outcomes, interviews with patients and staff, and observation on the wards. Two outcomes were measured: respecting and involving people who use services, which includes care, dignity and respect for privacy, and meeting nutritional needs. Forty-five of the 100 hospitals met both standards in full; 35 met both standards but needed some improvement, and 20 were not even delivering care that met minimum legal standards. Of those 20, Sandwell General hospital and the Alexandra hospital in Worcestershire—both quite near my own constituency —were found to be putting patients at unacceptable risk of harm.

If we look in more detail, we see that 60 of the hospitals were found to be meeting a good standard in respecting the dignity and privacy of patients on both the wards observed by the CQC. Staff behaved in a way that respected patients; they were positive, sensitive and respectful; they involved patients in decision making and explained treatment options properly. Where there were problems on this measure in the other 40 hospitals surveyed, not one of the hospitals was found to be failing on both the wards observed. It is noteworthy that the report found a large degree of variation in practice, and I will return to what I think that says about management and leadership later.

On the nutrition outcome measure, 17 hospitals were failing to reach an acceptable standard. Patients in need of assistance at mealtimes were not getting help; food was placed out of reach; there was no monitoring of whether patients had eaten their meal and there were constant interruptions during mealtimes. For example, a clinical round would suddenly start during lunchtime. Age UK’s report, “Still Hungry to Be Heard”, found that 157,000 people left hospital malnourished in 2008, and that the figure had increased to 185,000 in 2009. Astonishingly, 239 patients died from malnutrition in 2007.

New research published last month found that across the NHS, 9 million meals are returned uneaten per year at a cost of £22 million. One of the problems is whether we can serve three appetising meals of decent nutritional value for less than £5 per patient, which is what my own local hospital budgets for. I would say that we cannot.

As I see it from the two reports, when the scale of the problem is considered across the entire older population who are being cared for in our hospitals, it is not as great as is often reported by the media in the immediate aftermath of yet another report. However, for the older patient on the end of the worst care, it amounts to cruelty and neglect by staff.

[Andrew George (St Ives) (LD)]

My hon. Friend makes a very good case. On the key findings of the CQC report, which the media seem to report as a failure of nursing when the bulk of them are really issues of care, will she also cover the issue of the resources that appear to be going into hospital wards, particularly with the increasing acuity and turnaround of patients, and nursing and care staff to patient ratios, which appear to be on the edge in many cases?

[Margot James]

I thank my hon. Friend for making a very good point. I will return to the resourcing issue. I do not have statistics on the staff to patient ratio, but it is noticeable that it is much better in paediatric wards than in wards with large numbers of older people. Perhaps we can learn from that.

I was talking about cruelty and neglect. Staff are paid to care in institutions that are for the most part monopoly public services; the patient has no choice but to be there. In Age UK’s 2010 research, 21% of patients said they were not always treated with dignity and respect, and there has been no improvement in that figure since 2002. The figure is fairly consistent with the CQC findings and it seems to be consistent with other reports. It leads me to think that the problem we must address is twofold: first, the overall figure of one in five being essentially ignored—or worse—in our hospitals is simply too high, and secondly—the worst aspect—nothing ever changes that figure. Despite all the reports and information, nothing actually changes that figure.

Care is failing one in five of our older patients two or three times a year. The new research confirms that failure, but no effective action is taken to remedy it or to reduce the problem. I hope that as a result of our collective ongoing efforts, we will finally make a significant impact on the problem. It is likely that one of the reasons for the inaction that has persisted for a decade or more has its roots in a wrong or partial diagnosis of the causes of the problem, so I will turn to the various causes that have been advanced by research and informed commentators on this state of affairs.

The causes that I have read about can be grouped under the following headings: leadership, management, resourcing, training and what I loosely call societal. The leadership of individual hospitals such as Stafford—to take the worst example—sets out daily through a series of explicit and subliminal messaging what it is important for staff to deliver in that institution. At most, the focus from the top will resonate further down the line in only one or two areas. Staff know, either consciously or unconsciously, that if they deliver on one or two variables, they will not be seriously picked up for partial or non-delivery elsewhere. That is the same in any large organisation. Often, the overriding concern at the top in NHS hospitals is about meeting financial targets, just as it was in Stafford. In other cases, rigidly applied clinical outcomes might bear little relation to how a patient is treated by staff before and after their care or surgery.

Leadership does not come only from the chief executive and key board members. I served on the board of an NHS trust that was answerable, in a mechanistic, command-and-control way, to the Department of Health, which in turn was accountable to the Secretary of State—I am going back 10 or 12 years. Political pressures on a Secretary of State are principally financial, but they also concern global outcomes in politically sensitive areas such as cancer. The day-to-day treatment of patients is often delegated to a regulatory quango, but irrespective of the party in power, the Secretary of State will survive the occasional embarrassment and discomfort caused by yet another report. That explains the extraordinary situation whereby the care problems at the James Paget University hospital in East Anglia were serious enough to warrant a warning notice from the Care Quality Commission, but nurse training at the same hospital was well rated by the Nursing and Midwifery Council.

Although overall management and culture is set by the board, the main divide between good and bad management depends on the effective deployment of resources, the motivation and discipline of staff, and the systems for gathering customer—or patient—intelligence. The CQC noted that in some wards, levels of under-resourcing made poor care more likely—the point raised by my hon. Friend the Member for St Ives (Andrew George). Patients commented to the CQC about how hard pressed the nurses seemed, and that was confirmed by comments about the report by nurses writing on blogs. Even allowing for a certain amount of, “They would say that wouldn’t they?”, some of the remarks seemed heartfelt and genuine.

Interestingly, however, none of the hospitals where care was found to be poor was found wanting in all the wards inspected. Unacceptable levels of care were seen on well-resourced wards, and excellent care was found on wards that were understaffed. That indicates that the issue has more to do with ward leadership and the personalities and values of nurses in leadership roles than with the overall budget at the disposal of hospitals where problems were encountered.

[Andrew George]

I am not sure that I draw the same conclusion as my hon. Friend. She suggests that resourcing is not particularly relevant when considering the quality of care achieved, but surely she accepts that the situation is far better, and high levels of care more likely, when resources are adequate.

[Margot James]

I agree that care is more likely to be good when resources are adequate, but poor care has been observed on wards that the CQC regarded as well resourced. I do not draw a neat and fast conclusion, and having worked in business for many years I accept that resourcing is important. It is difficult to generalise from the available research, but I take my hon. Friend’s point.

On nurse training, the CQC found that half of hospitals were ailing in the areas of privacy and dignity; staff had little training in matters of privacy, dignity, rehabilitation and dementia. Training, and the lack thereof, is a symptom of the growing and unregulated use of health care assistants. In a report out today, the Royal College of Nursing states that in some parts of the country, 40% of staff on a ward are health care assistants. I will return to that point.

Another important issue is the general training of nurses. Consensus seems to suggest that although Project 2000 brought benefits to nursing status and career paths, the effect on care has been less positive. Earlier this year, Camilla Cavendish, a journalist from The Times, undertook extensive research across the country. Her observations suggest that Project 2000, which moved training from hospitals to universities and gave it degree status, has led to nurses spending too little time on wards during their training, and they are under-prepared to deal with patients when they graduate. Project 2000 has also led to gaps on wards, which have been filled by health care assistants. Such assistants are supposed to be supervised by nurses, but although I have no evidence either way, I wonder whether nurses have the training for such supervision.

Patients often think that health care assistants are nurses, and it is not always easy to distinguish the two posts. Health care assistants, however, have almost no training and perform non-medical tasks such as providing help with feeding and washing. I am sure there is a degree of mission creep into areas that require some form of training, and I shall return to that point. Perhaps it is no wonder that many nurses feel that certain aspects of caring are menial work.

[Andrew George]

My hon. Friend suggests that nurses see caring as menial, but that is not an observation I would make. I had the opportunity to shadow nurses in four wards, and they told me that they wished they had more time to perform a caring role in addition to their clinical duties. Such a role would fulfil the observational function that nurses are trained to perform in order to continually assess a patient and review their diagnosis. That nurses believe themselves to be above a caring function is not a conclusion that I would draw, and I believe that it besmirches the professional standing and pride felt by a lot of nurses.

[Margot James]

My hon. Friend makes some good points. Camilla Cavendish visited hospitals across the country as part of her research and spoke to many patients and nurses, and the view I have mentioned was expressed not only by patients but by nurses. I am sure that such cases are in a minority, and I certainly do not intend to besmirch the good reputation of the majority of nurses. However, the research leads me to believe that a minority of nurses either do not have time for care or feel that although care is not beneath them, it should be carried out by staff at a different level. That is a legitimate view and has been expressed in a variety of nursing journals and other forms of media by retired nurses who have visited hospitals. My hon. Friend should not dismiss that element of concern, and I emphatically do not wish to besmirch the reputation of our many good nurses. However, when we read in the CQC report about the problems engendered by the very poor care that some patients receive, we realise that we cannot afford to dismiss any of the conclusions reached by people who have done a lot of research.

I want to move on to some societal observations. The ever-increasing use of scientific and technological advances brings many benefits, but it also creates a work environment that requires nurses to concentrate on aspects of treatment and care that isolate them from the patients whom they are serving. The workplace in general outside hospitals is becoming more mobile. People connect with one another far more via devices of various sorts. That presents a risk to the caring professions that needs managing.

Then there is the issue of the pool of talent from which nurses and other caregivers are drawn. This summer saw an explosion of violence, avarice and selfishness on our streets on a major scale. Although work is ongoing to identify the cause of that phenomenon, it is clear to many of us that the fault lines in our social fabric are every bit as wide and deep as suggested by the research undertaken by my right hon. Friend the Secretary of State for Work and Pensions, before he came into government. These incidents affect all walks of life. Much more could be said on that point, but I do not intend to elaborate on it now. For the purposes of this debate, the implication is that nurses are as much a reflection of modern Britain, with its drawbacks—a society in which a significant minority seem to be more aware of their rights than their responsibilities—as well as its strengths.

Likewise, patients and their families reflect society. Melanie Reid, a columnist for The Times, spent a year in a spinal injuries unit following a tragic accident. She wrote an excellent piece on the nursing debate three weeks ago. She said:

“If you want to change nursing, you have to change society. You also have to change the patients. Today’s sick are…not deferential sufferers in silence. They and their relatives can be aggressive and unreasonable.

Everyone’s a professional complainer. During my spell in hospital, I saw some patients whom, had I been forced to cope with their constant demands, I would have smothered at dawn. Instead, the staff treated these people with civility and good humour.”

I shall turn now to some conclusions and recommendations. I shall conclude with what I think needs to change and I hope that the list of areas to which I refer will provide a platform for further consideration by the Government. I note that the Government are already making positive changes in some of the areas, and that is welcome. My priorities for change would centre on the importance of food and nutrition in hospitals and the standards in that respect; the accountability of boards and chief executives for the care of patients; resource allocation; the inspection regime; hospital complaints procedures; and nurse and health care assistant training.

[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.

[Neil Carmichael (Stroud) (Con)]

One matter that needs to be thought about carefully in this debate if not elsewhere is, of course, the integration of the NHS and social care, because that will help the process along and deal with many of the issues to which my hon. Friend is referring.

[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.

[Andrew George]

I am grateful to my hon. Friend for giving way to me a fourth time, which shows how patient she is with me. Quite apart from falling into the trap of conflating care with nursing in some of her remarks—she did make the point about needing to ensure that there is a clear distinction between care assistants and nurses—does she not also agree that in terms of the management on wards, a lot of nursing time is taken away from the patient interface as a result of the enormous amount of bureaucracy and paperwork required and the pressure that many nurses come under from bed managers, who appear to overrule them when it comes to determining when a patient should be discharged or admitted to a ward?

[Margot James]

I thank my hon. Friend for his observation, and I certainly agreed with the first point he made. I shall conclude in a minute as I am aware that many Members wish to speak.

The CQC should be resourced to ensure that its inspections include weekend visits. All the observations it makes in its recently published report were based on visits it paid during the week—for cost reasons, I imagine—but I was delighted to hear the Secretary of State announce yesterday that there will be more inspections. I hope, however, that the Minister will discuss with the CQC the possibility of visits being paid at weekends, when—I hear—care can sometimes deteriorate rapidly.

Some complaints are very serious, and I am not commenting on serious medical negligence, but with many complaints the system comes over as a sledgehammer to crack a nut. A patient or family member should be able to make an informal, non-legalistic and reasonable complaint and receive a sensitive hearing from a senior member of staff, rather than be instantly given a form that starts a three-week process of churning and often ends in Members’ surgeries. I ask the Minister to discuss with the Justice Department how we enable that but avoid opening the hospital to legal challenge, which is one of the motivators to the heavy-handed system we have at present.

We must be able to distinguish between the training needs of nurses and health care assistants.

[Andrea Leadsom (South Northamptonshire) (Con)]

It seems that the nursing profession lacks some accountability. What does my hon. Friend think about the idea of bringing back matrons, who are visible on the ward and who manage nurses?

[Margot James]

I thank my hon. Friend for that intervention, and I am attracted to that good idea. Somebody must be in charge of the ward—a nurse manager or a matron. Although that happens in the best wards, it is not universal.

We must look at the training of health care assistants, who increasingly perform sensitive, caring roles; the system cannot be left as informal as it is at present. There must be minimum standards and training. We know that there is pressure to register health care assistants. I am not sure that that is necessary, but training and minimum standards certainly are.

I challenge where Project 2000 has got us. Nurse training could remain at degree level but follow a more apprenticeship-based model. I ask the Minister to meet the Nursing and Midwifery Council to discuss how the nursing degree can learn from the apprenticeship model so that far more time is spent on the ward, alongside the academic study that has brought such benefits.

There is much more to be said, and I look forward to hearing from other hon. Members and learning from their contributions. I thank the many organisations that have been in touch with me and helped with my research since I secured the debate last week.

[Several hon. Members]

rose—

--- Later in debate ---

[Margot James]

It is a pleasure to speak under your chairmanship, Mrs Brooke. We have had an extremely illuminating and, at times, distressing debate. I am very grateful to all hon. Members who took part, including those who have had to leave, for bringing so many aspects of this difficult problem into the open and for making so many constructive suggestions about how we might improve things. I should like to set out a few of the lessons that I have learned from hon. Members during the debate.

My hon. Friend the Member for Suffolk Coastal (Dr Coffey) set an example of the importance of the job that we sometimes have of challenging the institutions on which so many of our constituents depend. I wish her and my hon. Friend the Member for Waveney (Peter Aldous) every success in dealing with the hospital on their patch and working with the CQC to bring about a quicker resolution to the problems that they encounter there.

I found noteworthy the issues facing rural areas to which my hon. Friend the Member for Suffolk Coastal referred, because I represent a suburban area. It is interesting to note that ambulance response times can be so long in rural communities. It is very important that the NHS is able to be flexible enough to cope with all the communities in our country.

The hon. Member for Blaenau Gwent (Nick Smith) gave us the benefit of his experience as a member of the Public Accounts Committee. I was pleased that he focused so much on the residential home sector, which is so relevant to the lives of many older people and about which a similar level of concern has been expressed in many reports. I was horrified, although slightly amused, I suppose, by the tambourine example. It was so powerful and so wrong. It will stay with me as a reminder of the many challenges that we have ahead in dealing with this issue.

I mentioned the issue with the James Paget hospital that my hon. Friend the Member for Waveney is dealing with. He raises the question that many Governments have grappled with—how to get resourcing out of the acute sector and into the community, the area of prevention and helping people with long-term medical conditions. That is very important. I wish the present Government well in seeing whether they can crack that pressing problem, which has been with us for least two decades, to my recollection. My hon. Friend also mentioned what I think is a very good idea—mandatory malnutrition rates and finding out what can be done to ensure that we target that area of deficiency in the NHS.

My hon. Friend the Member for Truro and Falmouth (Sarah Newton), who has secured a Back-Bench debate on the Dilnot report to be held two weeks today, which I am sure as many Members as possible will attend, focused on the complaints process, which I touched on briefly. It is important that the Government learn from the ombudsman’s report, “Listening and Learning”, and implement improvements.

My hon. Friend also mentioned something I have come across in my work with older people in the NHS—language skills. It is completely unacceptable if any carer—any caring member of staff—cannot communicate competently in English with older people, and we should tackle that. She also touched on the rural dimension and on the fact, which was terrible to hear, that her constituents have only one hospital, which inevitably makes people frightened to complain; there is no other choice.

The hon. Member for Wirral South (Alison McGovern) talked movingly about dignity and about older people in society, on which I hope we will hold a debate at some point. The hon. Member for Leicester West (Liz Kendall), whom I congratulate on her new role as shadow Minister, said that the topic could be a debate in its own right, and I am sure that a Member will secure one at some point. I share her belief in the importance of values: most people who work in the NHS have the values that we expect, and as she said, they have to be empowered to make choices and decisions that reflect those values.

The hon. Lady talked about many important areas and enlightened us about the Royal College of Nursing’s staff-to-patient ratios. It is quite wrong that the accepted ratio in a ward with a considerable number of older people is 1:10, whereas a paediatric ward is quite rightly staffed at a ratio of 1:4. The Government should also consider what can be done about concerns regarding the skill mix and the management of resources.

The hon. Lady made some interesting observations about the history of the NHS—how it began in response to cures and to treating people with illnesses that were likely to get better, and how it has not quite kept pace with the number of people who grow to an old age, some of whom need help with care and, perhaps, dying with dignity.

The hon. Lady made a point, on which neither I nor any other Member had focused, about doctors, who provide a huge amount of care in hospitals.

The hon. Member for Bolton West (Julie Hilling) commanded our attention with the moving story of the dreadful time that she and her family had experienced with her mother. I think I can speak for everyone when I say that we wish her mother a continued recovery. It was impossible to determine how the story would end when the hon. Lady was speaking, but it is marvellous that after all the family has been through her mother is on the mend, and we hope that she will recover as much of her former joy of life as possible.

I am grateful for and most encouraged by the Minister’s reply to the debate. He reminded us of the Government’s recent decision to ensure that ageism is not tolerated in the NHS or the Department of Health, which is a good development. He cited many examples of good work and guidance, of which he said there was no shortage, of leadership and management and of spreading good work and guidance into more areas of the delivery of NHS care. I am particularly delighted that he has promised to discuss with the nursing Minister, my hon. Friend the Member for Guildford (Anne Milton), my proposals on nurse training, and how an apprenticeship model should increasingly underpin the degrees nurses take to qualify.

I hope I have covered the important issues that Members have raised today. I thank those who supported my bid for a debate to the Backbench Business Committee and all those who attended this afternoon and made such an important contribution.

Question put and agreed to.