Death Pathway 2: Return of the Controversy

I originally published a post on the LCP in November 2012 before the independant review was announced

Unfit to Care: Dinosaurs and Bad Apples

[Guest post by Connor Kinsella]

At great risk to the reputation what has always been one of the more respected organs of the health and social care blogosphere, I’ve been invited to contribute to the Not So Big Society blog. This may turn out to be about as welcome as a knighthood for Piers Morgan, but before I outstay my welcome I want to draw attention to an issue which, in public at least, remains remarkably under-discussed. It’s more than just the Elephant in the Room. It’s a bloody great dinosaur crouching on the mantelpiece belching loudly while everyone sits on the sofa wondering what’s happened to Patch the family Labrador.

 

I come to this subject on the back of a previous NSBS post. In Nursing Degrees aren’t the Problem, Zarathustra looks at poor care and the perceived erosion of compassion within the nursing profession, often attributed to the elevation of nurse training to degree and diploma level. The ‘too posh to wash’ argument is, as Zarathustra points out, thoroughly flawed on a number of counts, but one highly significant issue raised in the piece is the seeming impotence of practice tutors, mentors and academic supervisors to weed out the sort of students who really shouldn’t be let loose on an ant farm let alone caring for the sick and the vulnerable.

 

Failures in care can and do arise from the sort of systemic factors highlighted so ably by this blog among many others. Poor or non-existent resources, savage cuts and the sort of target-obsessed management twonks who punctuate every other sentence with ‘going forward’ are never going to further the cause of good quality care. But many years of mental health nursing and social care training delivery have left what is (to me at least) one undeniable conclusion. There are far too many individual workers who are simply not up to the task of working professionally and appropriately with vulnerable people.

 

And I’m not talking about the headline makers: the Shipmans and Allitts, nor the ‘care’ staff of Winterbourne View. I’m looking toward the day-to-day awfulness of the sort of workers who, as Zarathustra points out, could and should have been rooted out at an early stage long before they have gone on to cause misery to every patient, client, service user and colleague that has the misfortune to cross their path.

 

If you’re reading this as a health and social care professional, you probably know who they are. The ones who attract enough complaint letters to wallpaper a small room. The ones who know better than decades of random-controlled trials and decide that the holistic tree-bark infusion they read about on the internet is so-oooo much better at treating depression than “any of that CBT and medication nonsense.” The ones who think of clinical supervision as a) a tool of Satan or b) a personal affront to their professionalism and years of experience. And the ones who seem to think communication skills are the ability to post snaps of their buttocks on Facebook but who can talk to neither colleague nor service user without causing them to run sobbing to the nearest cupboard.

 

In the first (and ultimately overlong) draft of this post I embarked on a trip down memory lane to describe my fantastically dysfunctional intake of student Registered Mental Nurses way back in the early 1980s. This was as ghastly a bunch of ne’er do wells, inadequates, love addicts, perverts, substance misusers and pure textbook psychopaths as were ever let loose on the mentally ill.

 

But this was a skewed sample. The old institutions of the sort where old-timers like me first cut our mental health teeth were replete with flawed characters, and my cohort of student drama queens and underwear sniffers (yes, really) went barely noticed among the general monstrosity of a Victorian asylum. But as time went on and my clinical and training career took me to all corners of the health and social care universe, I really did begin to wonder what it is about this most demanding of fields that attracts so many unsuitable staff. Whether it’s damaged people seeking self-help, taking solace in working with those even more fragile than themselves or (more worryingly) meeting a need for power and control over society’s most vulnerable, this is perhaps a research study yet to be carried out. For even the power of Athens and Google fails to yield much in the way of answers.

 

Not that having the odd psychological peccadillo is always a harbinger of bad care. Some I have worked with have used difficult life experiences to very appropriate and professional effect without compromising those professional boundaries which are so often crossed by the wayward.

 

This is where we return to Zarathustra’s post. In particular a paper cited there (forgive the repetition) which I read at the author’s recommendation and can highly recommend again to anyone reading this, particularly if you have any responsibility for mentoring or supervising students, probationers or junior staff.

 

Kathleen Duffy’s 2003 Failure to Fail paper is the ‘go to’ qualitative study of factors influencing the assessment of nursing students’ clinical competence. Or more to the point, incompetence. If you’ve ever wondered how the care equivalent of Dr Mengele can somehow manage to hop from one disastrous placement to another without sanction, the all too familiar quotes from mentors and lecturers have the sort of chilling resonance that will ring bells for any care professional who has experienced student placements featuring laziness, disinterest, lack of empathy and even personal hostility and threats but have been too ‘nice’, too ‘conscientious’ or in some cases, even too scared to criticise or fail a student. This is indeed an eyebrow raising paper.

 

But sooner or later we come back to the big picture. As we’ve seen only too graphically at Winterbourne View and Mid-Staffordshire, dysfunctional environments may not be the genesis of dysfunctional staff but can certainly provide an environment where the bad apples can fester and even flourish.

 

In one NHS Trust I worked for, it was common for poorly performing clinical and/or managerial staff to be shuffled off to a desk, given a laptop and assigned to some ‘special project’ with a Mickey Mouse job title and the licence to carry on irritating and hindering people to their heart’s content, only on a less damaging scale than they achieved as manager of a ward.

 

On the other hand, the more successful, therapeutic environments I’ve come across over the years do things a little differently. Strong leadership is demonstrated by canny recruitment, proper and functional supervision, and a robust approach to casting aside those who haven’t the competence or attitude to care.

 

It is of course difficult to simply rid ourselves who aren’t performing to the required standard. For starters, what is the required standard? We can easily identify the member of staff who is consistently late or doesn’t turn up at all, but how do we tribunal-proof the getting shot of that care assistant with the interpersonal skills of a sofa, or has an attitude to superiors leaving managers checking the underside of their cars for bombs?

 

Please don’t go having nightmares about bad apples or even that dinosaur on the mantelpiece, but make no mistake. They’re out there. 

That Old Chestnut

[Guest post by Sharon Levisohn]

Mother came home from hospital on Friday, having been in over Christmas and New Year. She has advanced COPD (emphysema) and had a respiratory virus that resulted in pneumonia.

However, her lengthy stay was not due to her illness – a week of steroids and antibiotics settled that insofar as it could be – but the inability to plan a discharge to meet her ongoing needs. The hospital wanted to send her home with three (local authority funded) home care visits plus daily district nurse calls. The social worker could not authorise the home care package without it “going to panel” and of course there would be no more panel meetings until January 7th. Then the hospital suggested a nursing home placement but, despite full-time oxygen dependency and limited mobility, my mother did not meet the criteria for a funded admission. Next they suggested a short admission to a cottage hospital. That was rejected as they thought, frankly, that the journey would kill her. Plan D was to be discharged home with the support of the (health-funded) Re-enablement Team; however, she was not open to this as her condition was too far progressed for rehabilitation. All this time, Mother was in an acute bed – one of those infamous bed-blockers – on a ward with confirmed Norovirus, while the family and I rode the Waltzer of uncertainty and conflicting updates, always aware that she might just give up the long battle with COPD.

What is the point of this personal anecdote of woe over the festive period? I suppose it is not a unique case; even on the ward there were several other patients unwillingly playing the Cherchez La Femme game of discharge co-ordination. How many patients and families in how many hospitals were going through similar experiences? What vexed me – and as a former nurse I am not criticising the frontline ward staff – was that the hospital did not seem to know what qualifying factors were applied to the various options – one might have assumed that they had confirmed Mother’s eligibility before informing her and the family only to dash their hopes. The other bugbear is the responsibility for funding. Surely, if a risk assessment has shown that a frail elderly terminally ill patient has been assessed as needing input from various agencies in order to be at home with the people and dogs and personal touches she loves, which give her a little quality of life, and if we believe that it is better for the elderly to live at home so far as is possible, surely then the funding needs to be provided? Or shall we simply abandon that principle as practically unviable?

Moving On and Looking Back

Forgive me for the slightly self-absorbed post. Blogging by its nature can be the epitome of self-absorption but I attempted to write with a look to the wider world, particularly in the sector I know best, social care. I put this in the past tense as this will be the last post I write.

When I started writing, I had the voice of a social worker and AMHP (Approved Mental Health Professional) in a Community Mental Health Team. I was trying find that voice amid the policy and processes that we found ourselves, as practitioners, caught up in and trying to extend outward some of the frustrations and observations garnered from the ‘frontline’. It felt and it feels like that policy happens from afar, away from the homes I visited, the wards we attended, this was my world and it felt like a completely different world from the one defined by officials in the Department of Health when they remember ‘social care’ is a part of their remit.

I believe wholeheartedly in social work as a profession and social workers as professionals but I became frustrated at the lack of professional leadership. There is no doubt that the last year of my professional life has been one of the most challenging. I’ve worked in social care for 20 years (gulp – I look younger, I promise!) as anyone can imagine, I’ve seen many changes in that time. ‘Reconfigurations’ were nothing new to me. Working with change and in organisations that change frequently is one of my fortes but the most recent one was the most painful by far. While parts of my job, I loved – particularly when I was able to work with and alongside individuals and families and walk with them through some of those moments of crisis – working in an organisation and delivering services which were being ripped to pieces was difficult. Defending organisational decisions became impossible. The fight was still there inside me to promote and present a better way of working and honest interactions with everyone who needed our service, I saw waiting lists grow and discharges of people who I felt would benefit from more support. I saw the effect of the programme of cuts in the NHS in a very visceral way. I was and am very lucky. I have been able to walk away. I find myself in a job that excites and interests me and presents many new challenges. The same ease with which one can move on cannot be said for those who are reliant on the support of social care services and I remain acutely aware of my privilege in being able to.

I found a different (but related) job and thought I’d be able to continue writing with the passion I never stopped having but I can’t. The situation has changed and the voices need to be heard from the frontline I’ve stepped back from. I have become the person I resented for so many years. As a social worker, I always had a hint of scorn for those who took the ‘desk jobs’ and moved away from the direct work with people who use the services we provide but I’ve become one of those people.

In defending myself to the old me, I’d say that changing the world can happen in different ways. I am no less committed to the same ethical standards of making the world of health and social care better for those who use services. I am seeing that social work and social care happens in many different places. Is it an attempt at justifying my decision to leave social work behind? Yes, probably but that’s something I’m reflecting on a great deal at the moment.

I have been disillusioned by the time I spent working in the statutory sector as a social worker. As a parting salvo as I head off into the sunset, I want to reflect on a couple of themes that revolve around social care at the moment.

Kneejerk funding decisions lead to more expense, both in terms of quality of life and finance in the longer term. I’ve seen panic cuts both at a national and local level. The problem with panic cuts is that the things that are easily destroyed cannot be built back up in the ‘good times’.

‘Choice and control’ the buzzwords of change ring very hollow to me now as I saw in both the NHS and the local authority, the way that data and information is manipulated to meet performance targets that are meaningless to people who use services. Choice is one of the most nefarious words in the sector in my opinion. ‘Choice’ is very much defined by what organisations allow to be chosen and the confidence, communication skills, advocacy support of the individual doing the ‘choosing’. I railed against processes that favoured ‘he who shouts the loudest’ but it was to no avail. Presented by the government as a panacea of positivity, I have seen the downside of ‘choice’. It has been the creation of a two-tier service in adult social care that provides those who are able to choose with fantastic opportunities but those who may not have the capacity/support to choose are left lagging behind, in poorer, oft forgotten services. With funding drying up and fewer third sector organisations able to pick up the slack, there is a massive void of support which often falls on family and friends – the ‘informal’ support networks that the government still feel able to criticise.

Dementia care is a particular interest of mine. Professionally I have worked in the area for a number of years. Dementia is moving further forward in terms of government policy making and the so-called ‘dementia challenge’ which is currently trying to increase diagnosis rates. That’s all well and good and I won’t enter that conversation but I will say this. In order for dementia to be better understood by the public it has to be better understood by the government agencies who are supposed to be providing the information. There is a horrendous lack of information about the role that supportive social care services play in improving the quality of life for people with dementia. As I worked alongside a ‘memory clinic’ which had been decimated by cuts, I laughed hollowly at the words of the government ministers about increasing diagnosis rates in primary care and for hospital inpatients. See my first point about panic cuts and lack of cohesion. Reading some of the Department of Health missives you’d be at a loss to think they ever discussed any of their plans with anyone with a current social care background. Perhaps the new Chief Social Worker (or one of them anyway) will provide a sticking plaster to this but it’s very apparent at the moment that there is no cohesive, current social care voice in the government department and it makes some of their policies woeful. The level of ignorance even of government ministers who clearly haven’t been briefed by people who understand social care would be embarrassing if it weren’t desperately sad.

Lastly about Social Work itself. I retain my social work registration and will now until 2014 at the very least. I suspect far beyond that as I don’t want to give up my registration. I am very proud to be and to have been a social worker. The ethics and values of the profession can really shine a light and guide many of our colleagues in allied professions and we shouldn’t be shy of realising our own worth. Often I hear social workers talk of status and comparing ourselves unfavourably to nurses, teachers, doctors, psychologists etc. We shouldn’t need to constantly compare. We have a fine profession with its own knowledge base, standards and codes. Having worked in a multi-disciplinary mental health team (and I think being an AMHP helped with this as we are known to be a stubborn and independently minded bunch) I never felt anything but an equal to the other professionals I worked alongside (and challenged – psychiatrists – I’m talking to you ;)). We do need to ‘sell ourselves’ more and we can’t rely on waiting for ‘good press coverage’. Do the job, however hard, with the ethics and values at the heart and remember why we are there – it isn’t to promote organisational will but to walk alongside and guide. Sometimes there are difficult, coercive decisions to be made but reference to values and ethics become all the more important there. The nature of a job that sometimes has a coercive function is that ‘hearts and minds’ will never be particularly straightforward. I didn’t become a social worker to make friends or to swan in adulation of my ‘goodness’. I went into it because I felt it gave me more opportunities to make a positive difference in someone’s life. More often than not, certainly over the last couple of years, it became more about saying what wasn’t possible than what was – but if I could deliver that with as much humanity and empathy and transparency as possible, it could be a start.

Many thanks to Zarathustra for this space and for the support he has offered to me.

And thanks to everyone for reading, commenting and responding over the last year or so. My reasons for stopping are work-related but not in a bad way. I just think my voice has changed now and it’s important that those ‘on the ground’ have the way left open to them to find it. I won’t say I’ll never write again, I may at some point in the future, but if I do it won’t be anonymously I will, though continue to knock around on Twitter I expect!

Goodbye

Beyond Winterbourne

Yesterday, the Department of Health published ‘Transforming Care : A national response to Winterbourne View Hospital’ (PDF)  the ‘final report’ about learning and developments following the case which highlighted, via a BBC Panorama documentary, the systematic abuse which was embedded in the running of a private hospital for people with learning disabilities ‘with a stated purpose of providing assessment, treatment and rehabilitation’.

The failings were found not only in operation of the hospital  but in a complicated and confused health and social care system which on the one hand seems to have been moving away from ‘institutionalisation’ over the past few decades while on the other hand commissioning services which embed institutionalisation and powerlessness into failing and very expensive systems’. The case of Winterbourne View also highlighted the failure of the regulator, the CQC, to respond to information provided by a whistle-blower and of local authorities and commissioning NHS Trusts to actually quality assure the services which are being provided.

Another related report which was also published yesterday (PDF)  came from Family Mosaic – a housing association which provides supported living services which highlights its own failings in terms of poor care and proactively looks at new policies and ways to turn this around. In a way, the Family Mosaic document – is a testament to an organisation which wants to learn pre-emptively and the organisation should be applauded for producing it.

I want to look at some of the issues in both these reports as I think they are  linked,.

Lessons from Winterbourne View

The introduction to the report sets the context of Winterbourne View Hospital – a placement for 24 adults with learning disabilities. The report explains that 48 patients had been referred there since its opening in 2006. The average cost of a placement was £3500 per week and

‘13 were referred by commissioners within 20 miles

12 were referred by commissioners within 20-40miles

14 were referred by commissioners between 40-120 miles

9 were referred by commissioners over 120 miles’

14 separate English NHS commissioning bodies had acquired places there plus some unspecified (presumably a problem with exact data) from Wales..

You’d think that maybe there’d be quite a lot of quality assurance going on with all that money streaming in.

Both the Serious Case Review and this report pick up on the amount of lost opportunities in terms of communication between agencies – between commissioners and between primary and secondary health care services. There has been a lot of confusion – not least from the Secretary of State about the position of Winterbourne View but that fact that it was a hospital and received detained patients (rather than a care home which it has been incorrectly yet frequently referred to) means some of the responsibilities and monitoring processes would be different.

The police, hospitals, commissioning bodies, local authority (who was responsible for safeguarding alerts), CQC Inspectors and Mental Health Act Commissioners seemed to have failed to ‘join the dots’.

While the Serious Case Review goes into detail about what went wrong, this report is more interesting in terms of what is going to happen next.

What is happening as a result

Immediately the CQC changed some of the systems for pulling in whistleblowing information and started an inspection programme for learning disabilities settings.

There was to be (and is to be) a focus on more local settings where possible as distance from family and familiar settings is crucial. Where it is not possible the placing authority should remain in close contact and plan moves back to local areas as soon as possible. A long term distant placement is not an option.

Hospital the report states, which should be obvious I guess, is not a long term placement and should only be used for the minimum time necessary.

If it is necessary at all.

The report talks about the need to listen to people with learning disabilities and their advocates as ‘not listening’ was a big failure. It’s important that listening is beyond hearing what someone might say as well – particularly if there are communication difficulties. It’s important that those who don’t have families to advocate for them are heard as well. Fortunately the report touches on the need for strong advocacy services to be developed.

What will happen

The Department of Health has set a timetable for June 2014 for a ‘rapid reduction in the number of people with challenging behaviour in hospitals or large scale residential care’.  These numbers will be monitored by the DoH.

I am interested when the report talks about ‘people with challenging behaviour’ if they are just referring to people with learning disabilities. My hope is that they aren’t and this will apply equality to those people who have more advanced dementias and may display behaviours which could be interpreted as challenging due to communication difficulties

There is an emphasis on ‘personal care plans’ being developed which partly shows the failing of the personalisation agenda to date as it has completely passed by swathes of people with the highest needs. Maybe there’ll be some attempt to ‘catch up’ now. Let’s hope.

Interesting to that the report nudges the CQC to consider the ‘model of care’ delivered in terms of regulation and compliance. .Personally I’d see that meaning that these larger institutions inherently carry a ‘higher risk’ but it will be interesting to see how that develops.

Interesting that the report focuses (rightly) on the involvement of ‘families and self advocates’ in driving quality and change. My only comment would be a plea for the Department of Health not to forget those people who have very high support needs and who are, due to their cognitive impairments, not able to ‘self-advocate’ and who do not have family advocates. There is a gap here and often these people are at high risk of abuse due to the lack of ‘supporting voices’. There must be a way for formal advocacy to speak on their behalf.

Strengthening Corporate Responsibility

The report also looks at the organisational failings of Castlebeck and the lack of responsibility taken by the organisation itself.  The report urges the CQC to take more enforcement action organisationally if necessary and there has been a move to appoint ‘Corporate Compliance Managers’ – presumably to hold large organisations to account.  The Department of Health will also be looking at the way the CQC are able to ensure the ‘fit and proper person; test which is applied to registration can apply to organisations – whether a board member is nominated to be responsible. However the powers do not exist in legislation for the CQC to check more than one appointed person. This is something that strays into the ‘to be decided’ part of the action plan but no doubt will be an interesting space to watch.

Improving Practice

The report highlights good practice in the hope it will be modelled  more broadly. A voluntary register for people working in adult social care is being mooted. Personally I favoured full regulation of the social care workforce but that’s likely to be too costly to organisations who are working on minimum wage payments to many staff whom they don’t necessarily want to professionalise even though the work is crucial. The low status of social care work is inherent in the attitudes of employing organisations. Training is important though and so is modelling of good care. While compassion doesn’t cost, environments in which it can flourish are better sustained when staff aren’t under constant pressure and are treated, themselves, with respect.

Whistleblowing mechanisms are mentioned and tightened where they haven’t been already.

Particularly interesting to me as a (now) ex-AMHP and BIA was mention of the Mental Health Act and Mental Capacity Act. The report confirms that 73% of the people are Winterbourne View were detained under the Mental Health Act. They should have had statutory protections of appeals and access to IMHAs. It also makes one wonder under what grounds the other 27% were being detained. Was it –really- ‘informal’? Were DoLs ever used? If not, were there any questions asked by those visiting about why or why not?

One of the most interesting ‘key actions’ to me is that

‘The Department of Health will work with CQC to agree how best to raise awareness of and ensure compliance with Deprivation of Liberty Safeguards (DoLs) provisions to protect individuals and their human rights and to report by Spring 2014.

I have a particular interest in DoLs – their use and their lack of use so will certainly be keeping a VERY close eye on this. I’ll try not to be cynical. I’ll really try.

Family Mosaic’s proactive report

Family Mosaic’s ‘No Going Back’ report (PDF) unfortunately has faded into second place in this post but it almost deserves more than one post to itself however the themes link in so tightly with the Winterbourne View Review.

I’d recommend that both reports are read together and it is commendable that Family Mosaic as a provider organisation have looked proactively at how they can do better in terms of challenging institutionalisation and poor practice among their own staff.

The report looks at the history of ‘deinstitutionalisation’ and the move to Community Care principles but also where the failings have crept back and cultures where care may be delivered in different settings but where the quality has been in question and abuse has resulted.

The organisation provides examples of poor and indeed, abusive care in its own settings to look at how to improve and what to offer in terms of building a better culture of delivery of care.

One of the interesting aspects they consider is the lack of ‘whistleblowing’ so that staff who might witness poor care and who have been on the requisite training may not feel they are in a position to report it or may not recognise it when they are involved in the delivery.

The report focuses on aims and action points for the organisation as a whole including a more open policy towards whistleblowers and those who raise concerns internally.

It explains clearly basic expectations for delivery of services to service users by staff and all in all, it is a fantastic piece of work by Family Mosaic who should be commended.

Conclusion

These two documents offer a way forward for delivery of care and attitudes towards those who need care. I wish we had a Winterbourne View type document and review of care for older people, particularly older people with dementia and hopefully when the document refers to ‘people with challenging behaviour (a term I don’t really like to be honest’ it isn’t only referring to those in learning disabilities settings – however I fear it is.  We need to have a wholesale reappraisal of large institutional settings for care delivery – be they hospitals for people with learning disabilities or 90 bedded nursing homes for people with dementia. Age/cognitive ability/family involvement/means to self-advocacy cannot determine ones right to dignified and high quality care.

Family Mosaic have presented a good model that moves beyond care for those with learning disabilities – I hope more providers take notice and take a proactive response.

However, there will be costs and if the government is truly intent on building better services across the board and for all sectors, there has to be an understanding that the money will have to come from somewhere.

I hope it will happen. The right noises are being made. I just hope the results are equally satisfying.

Nursing degrees aren’t the problem

On the Andrew Marr show today Ann Clwyd MP was speaking angrily about the poor care her husband received while at the University Hospital of Wales. She argued that nurses no longer display compassion, and one of the reasons for this was because, “since they made nursing a degree course the wrong kind of people are entering the profession… we do not need a load of snooty-nosed pen pushers”.

A couple of days ago Jo Brand gave a response in the Guardian to Mrs Clwyd’s recent statements on nursing. Her view was that nurses are not any less compassionate than they used to be, but that poor management, spending cuts and privatisation were eating away at standards of care. She too raised the question of nursing degrees, though she describes it as “a complex issue that is difficult to read.” She expressed concern that it might have “closed the door to a wealth of potentially impressive nursing staff whose academic skills were not up to degree level.”

I fully appreciate Mrs Clwyd’s anger and upset at her husband’s (lack of) care. Who wouldn’t be angry? But I don’t think nursing degrees are part of the problem, and I’d like to give some reasons why I think that. I hope this goes without saying, but in doing so I am not attempting in any way to excuse or minimise the failings with regard to her husband. Patients are entitled to dignity and compassion at all times, and if he did not receive it that is clearly unacceptable.

Nursing has been an all-degree profession in Scotland and Wales for some years now, and is in the process of switching over in England. I’ll declare an interest here in that I’m a degree-educated nurse who graduated with first class honours from a well-regarded Russell Group university. It was a tough, challenging course, which stretched me far harder – particularly emotionally and physically – than my previous degree in the humanities.

The first point to make is that the difference between a nursing degree and a diploma really isn’t very much. The length of time is exactly the same (three years) and crucially, the clinical placements are exactly the same. Whether a student is doing a degree or a diploma, they spend half their time in university and the other half out on placement – in hospital wards, outpatient departments, community teams. At the end of the third year, they spend the last three months of the course in a clinical area, taking on all the responsibilities of a staff nurse under the supervision of the qualified staff. At my university, the difference between a degree or a diploma was little more than whether you did a dissertation or an extended essay in the third year.

So, if the clinical placements haven’t changed, what about the suggestion that bringing in degrees has attracted a horde of snooty people who are, to use the media expression, “too clever to care”? Personally, I don’t see that it has. When I was a newly-qualified staff nurse on a ward, I certainly didn’t think that my fancy education meant I was too intelligent to wipe a bum. On the contrary, I felt very strongly that I needed to gain the respect of the nursing assistants I was now leading, and that meant demonstrating that such tasks weren’t beneath me. I really don’t see why having more intelligence would make you less compassionate, or that being clever makes you a bad nurse. On the contrary, when I think of the most outstanding nurses I’ve ever worked with, they’ve all been intelligent people. As for the bad ones, they’ve usually been…well, a bit dense. Nursing requires you to juggle a caseload, calculate medication doses, keep accurate records, liaise with patients, carers and fellow professionals, and think on your feet in rapidly-changing situations. Funnily enough, it helps to have something between your ears.

Then there’s the argument that degree courses are deterring people who would otherwise make good nurses. Again, I’m not convinced. I’m willing to stand corrected on this, but I haven’t heard anyone say, “I was planning to apply for nursing, but now they’re abolishing the diplomas, I’m not going to.” In an era of mass education, university degrees simply aren’t the elite qualifications they used to be perceived as. These days it’s practically a rite of passage school leavers to head off to university, and most people with a reasonable amount of intelligence and self-organisation can pass a degree. Some of the students on my course struggled with the essays, particularly mature students who had been out of education for some years. But crucially, those who kept at it did pass. They might not have got stellar grades, and they might have had to re-submit the odd essay, but they did get through. Once they’d done this, a nursing graduate who scraped a third is just as qualified as one who sailed through with a first. As for those few who flunked completely despite opportunities to resubmit work, they really didn’t come across any great loss to the profession.

Finally, it’s important to remember that many things can affect patient care and dignity besides nurse education. The ratio of nurses to patients. The ratio of qualified nurses to unqualified nursing assistants. Levels of support – is there a ward receptionist to deal with phone calls and queries so the nurses can get on with caring for patients? Equipment issues – for example, is the ward getting enough fresh linen? The calibre and personalities of the senior nurses. Even cultural factors can play a role. Those who gaze wistfully back to regimented wards under the dictatorship of Matron might wish to recall that back then Britain was more, well, regimented. When the NHS was founded it was the era of national service, with the Second World War still fresh in everyone’s memory. The values of nursing at the time were essentially military values. We don’t have that culture in Britain any more.

That said, there is the question of whether enough is being done to weed out bad student nurses and stop them qualifying. It makes a good headline to say it’s because universities only want them to write essays. But as is so often the case with a good headline, the reality is more complicated than that. For people who are interested in this topic, a good read is Kathleen Duffy’s seminal 2003 study on “failing to fail” student nurses. Unlike in the tabloid headlines, her focus wasn’t so much on the universities, but on the mentors; the qualified nurses who teach and supervise students while they’re out on placement.

I’m a mentor myself, and I regard it as one of the most rewarding parts of my job. Every few months I have a student nurse with me for six weeks, so they can develop their knowledge and clinical skills. It’s up to me to support them and also to assess both their skills and their professional attitudes. I’ll not just be looking at their ability to perform a task, but whether they interact well with patients and families, whether they respect confidentiality, actively seek out learning experiences, and so on.

For the most part, the students I’ve had come to me have been excellent. Keen, bright, eager to learn. But there remains the question of what to do with a bad student. Hence why Duffy’s paper was required reading when I did my mentorship training. She identified various reasons why a student might not be performing but still pass a placement, which she placed in four categories.

• Leaving it too late – not identifying and addressing problems until the last week of the placement, perhaps not having a mid-placement meeting as you’re supposed to.
• Personal consequences – an awareness by the mentor that this could result in a student’s career ending before it’s begun, with all the ways that might affect them and their families.
• Facing personal challenges – a lot of nurses simply don’t like failing students because they feel it’s not a “nice” thing to do, particularly in a profession that’s supposed to put a premium on being nice.
• Experience and confidence – mentors not feeling sure of their judgement in these matters, or perhaps being worried about getting a hostile response from the student.

Obviously none of these are valid reasons for passing an under-performing student nurse. Ultimately it’s our responsibility as mentors to flag up problems promptly and address them, for the benefit of the public. The take-home message from Duffy’s research is that if the wrong people are being allowed to qualify as nurses and join our ranks, then it isn’t the university’s fault. It’s our fault.

Patient Stories – Will we learn?

Today the Patients Association published a report ‘Patient Stories’ (PDF). It focuses on thirteen different stories. These are stories directly about the experiences of patients through hospital systems and discharges. Some are told by family members when the person involved and some are told directly.  Some are anonymised and one is from a doctor who received treatment herself.

The format of ‘telling stories’ is a good one because it makes for interesting reporting. It personalises tales that we know about poorly managed hospital discharges which take place before they should because we hear the voices of those directly affected and it is easy to see the lack of humanity in some of the systems that exist in acute health care.

Sometimes what is remembered is a single comment which may have been made by a busy member of staff in an offhand manner, for example, in relation to Margaret Allen, her sister writes

‘my (other) sister called the hospital to enquire after Margaret’s health before her death. The answering nurse replied that Margaret was ‘screaming away nicely’ and held the phone out for my sister to hear her cries’.

There are some shocking details in some of the stories of miscommunication, arrogance and rudeness of staff, basic care not being given but sometimes it is these snippets of language which are telling in terms of respect and attitudes of professionals towards staff.

While it may be possible to write these off as ‘individual stories’, I think that would be an massive error because there is an enormous amount of learning and themes which can be traced – not just through these stories but through the similar ones that have emerged over many years.

There is a consistent lack of flexibility and a lack of listening in these processes.

An example would be in the story of George Robertshaw who was admitted to hospital and was discharged in a way that his GP felt was ‘unsafe’ due to it being so rapid and was discharged in thin pyjamas in the winter – so that when carers did arrive to him he was cold, hungry, very thirsty and still not well.

His daughter writes

‘Following my father’s death, I again spoke to someone to inform them of my father’s demise and that I would be making a formal complaint re procedures. She told me directly that she would ask a nursing director to phone me back in a day or two, This never happened. No call, no communication, no nothing. I again rang and I was told that they had informed whoever it would be and that they would remind them. I got the impression that the relevant person was present but did not wish to speak to me and was telling the person on the phone what to say

Again, this could be claimed to be an isolated incident but as a rule of thumb and as someone who takes quite a lot of verbal complaints about the services that I provide, I tend to assume for everyone one person who complains or whose family complains, there are far more who will not have the confidence, strength or understanding to do so. It is important that systematic errors are challenged and improved but it is also important that clarity of information and respect are given to those who use services.

I wonder if that same Nursing Director would have been so slow to respond to her own manager? No? Then treat the people who use the services, particularly if they have a complaint with at least enough respect to contact them in the same time frames – even if it’s a matter of updating them with no additional information.

An organisation which is not willing to take or deal with complaints, cannot be a ‘learning organisation’ which is willing to improve.

I don’t have time to identify the issues in all the stories but it is worth reading as a snapshot of some of the care which is being given in hospitals in this country.

Of course there are good stories, and there are fantastic staff. The very first section of the report is based on positive feedback but we cannot ever become defensive about the systems as they exist and must treat each of these experiences as areas of learning. Sometimes it isn’t always about resources, it’s about respect and it’s about listening and responding.

Yes the NHS is wonderful and many of us have personal stories of gratitude, I have many myself, but if there is anything that can be done by any one of us to make things better, we absolutely must.

The main lesson I will take from these stories is to make sure that every interaction is bounded in dignity and respect. Mistakes happen but they can be resolved by listening and learning from those who experience them.

Defensive organisations that won’t encourage criticism are dangerous organisations. These lessons are just as important in all social care organisations as it is in health care.

The saddest thing about these stories is that we have heard similar before. There have been commitments between increasing ‘compassion’ in nursing and care staff but the systems need to become more compassionate too and far more responsive and flexible.

This is a series of awful stories and experiences but they must be learning experiences so that some positive may come amid the extreme pain and grief caused.

Social Work and Moving On

In a couple of weeks I will be leaving social work. Or will I? I am moving into a job where my social work qualification is not an essential requirement. I am moving away from ‘frontline’ practice in the way that I have always understood and defined it.

Being diligent, I remain registered as a social worker by the HCPC (Health and Care Professions Council) and there is no doubt, therefore, that I can continue to  legally be entitled to call myself a ‘social worker’ but the job I will be doing is not ‘social work’.

I am incredibly proud of being a social worker so it is a shift for me. Of course, as I will be remaining in the sector, my experience will be crucial in the new role but I will no longer be building that same types of relationships on a personal level that I do (or at least I hope to) now. I will be working in a different way.

The next few weeks, then, will be filled with reflections. I am saying a lot of ‘goodbyes’. I have been in my current post for many years and the current council for even longer. I am saying goodbye to the people who are on my ‘caseload’ – some of  whom will be reallocated and some of whom will be discharged from the service. I am trying to get everything done but I know the way life works isn’t about neat closures.

I’m also saying goodbye to a local area I have worked in for many many years. Familiar streets, blocks of flats, estates which have so many faces and memories entrenched in them. There are roads and buildings I can’t walk past without remembering some of the people that lived within them and gave them the flavour and character of a neighbourhood.

I think of some of the people I worked with who had no one else to remember them. Isolated, detached from families by distance, ill-health or circumstance. Then I think of the families I saw, the warmth and kindness and hope within some of the depths of poverty and the tragedies that life can fling at people without recourse to ‘fairness’ or ‘equity’.

I’ve had the honour to work with some immense people who have opened up to me and allowed me to share some of their most difficult moments and I have worked alongside people who have struggled so long and hard with such dignity or pain.

I have put in services and tried to offer suggestions but – increasingly, I have also removed and denied services to those whom I felt would have an improved quality of life if they were provided.

I’ve learnt a lot about the value of good health and knowing ones limits. I’ve learnt enough about the effects of alcohol to turn me near enough teetotal (not entirely mind!). I have learnt enough that even the best planning can’t protect one from accidents or fate.

Ill health affects across all social classes, cultures and belief systems. I have walked into houses which have made my jaw drop, some through opulence and some through squalor. I have tried not to judge but to listen and respond – sometimes it can be predominantly about listening and hearing.

I have had good and not so good managers and feel so fortunate in my current role to work in a very supportive team and organisation so it is with sadness that I see how the cuts over the past couple of years have ripped the heart out of a service and professionals who really were, even if it didn’t always look like it from the outside, trying to do their best.

‘Doing our best’ will not be sufficient anymore. While a government talks of parity of esteem between mental and physical health and further integration or establishing the ‘dementia challenge’ which focuses on better diagnosis, it’s important that we do not allow those who spread the cheap and hopeful words around freely to believe that parity of esteem will not cost. Establishing good and supportive dementia services which focus on what happens AFTER diagnosis will cost and that integration has to involve more change that asking everyone to sit in a room together and do team building exercises.

When I look at adult social work and mental health social work, the two areas I have worked in and I see how things have changed, it is not only this government I look at with despair, it is the previous government too.

Ed Balls played political games with social workers and bought into the Sun criticism in the wake of the tragic death of Peter Connolly. All main political parties have backed the privatisation of care services without building in sufficient protection and until the personalisation agenda actually offers the same benefits to someone with dementia without a supportive family as it does to an independent adult with a physical disability I will see that it is not yet a success.

So I’ve seen a lot of changes but not all bad. I see a great hope in the profession as we can work harder on developing an independent voice that doesn’t need a battling professional organisation which can’t stop its bickering and pettiness or a ‘Chief Social Worker’ chosen by civil servants with no knowledge of what the heart of social work is to ‘speak for us’.

Let us speak for ourselves and find more ways of doing so. Social Work is a profession to be proud of – we just need to make sure more people know about it – and we need to put some more fight into it. Fight politically, fight against cuts which affect those whom we work with, challenge within the organisations in which we work and remember that we need to create and build a profession to be proud of for ourselves – because no one else will.

Not a ‘media officer’

Not a soap opera

Not a fly on the wall documentary

Not a professional organisation

Not a ‘college’

Not a Trade Union

Not a government-appointed ‘chief’

We have to claim the profession back from the narrow definitions that successive governments seem to be forcing us into. Social Work happens outside local government – something I am about to have a far better understanding of.

It’s going to be a weird few weeks for me as I grapple with my own professional and personal identity. I rather feel I won’t give up the fight wherever I go – I hope not. There’s still a lot more to be done.

pic by soraya nulliah @ flickr

Dementia Friends

The Department of Health has, today, launched the Dementia Friends scheme.

It’s a lovely scheme to promote greater awareness of Dementia by recruiting an army of  volunteers. These volunteers will be trained to have an ‘understanding of dementia’  As the website itself says, if you become a ‘Dementia Friend’

We’ll equip you with an understanding of dementia and how you can help, and the rest is down to you. We want Dementia Friends in every community – in every hospital ward, post office, place of worship, and on every street. Our target is to reach a million people by 2015, and we’re confident we’ll not only meet this target but will beat it

Wow, that’s great. Really it is. I’m (for once) not being sarcastic. I work with a lot of people with dementia and having to explain it to them and their family members, I see the fear and lack of understanding and I wish that there were a greater knowledge in dementia in the community and this seems to fit the bill.  In my social work training course, over two years, I had one lecture on older people – I can’t even remember if dementia was mentioned. That’s plain wrong. It needs to be a meaningful part of every training programme and on many courses.

First I thought Dementia Friends would be like a massive new befriending scheme for isolated people without family and friends and excluded by community  as the site says

Alzheimer’s Society research found that nearly two thirds of people with dementia feel lonely, and almost half reported losing friends following their diagnosis. With one in three people over 65 developing dementia, it’s vital we change this picture.

But reading more I see its  about encouraging people who are Dementia Friends not to abandon those of their family, friends and social circles who have dementia and  not to ‘drop’ them as the illness progresses. Which is also a very good goal.

I guess I just see a disproportionate amount of people who don’t have family/friends/social networks or maybe I’m seeing them after their networks have abandoned them.

Early Diagnosis

One of the aims of this scheme is apparently to encourage earlier diagnosis of dementia. Again, a very laudable aim. The Guardian previews Cameron’s announcement

Cameron will say: “Through the Dementia Friends project, we will for the first time make sure a million people know how to spot those telltale signs and provide support. There is still a long way to go in fighting the disease, but together we can improve the lives of millions.”

…

The scheme will provide free coaching sessions on how to spot the signs of dementia and provide support to people with the condition.

Each Friend will be awarded a special “Forget-me-Not” badge once they have completed their training, so that they can be easily identified as being able to assist people with dementia.

So when the dementia (and remember there are lots of causes for forgetfulness and confusion other than ‘dementia’)  is ‘spotted’, I imagine the hope is that the Dementia Friend will encourage the person they have potentially ‘spotted’ to get screened.

All good. Again back to the Guardian which says

The rate of successful diagnosis is expected to double from 42% at present to 80% – a target set by Cameron earlier this year when he launched his challenge.

Healthcare professionals will also be required to ask all patients aged between 65 and 74 about their memory as part of their standard health check. Simple diagnostic tests will be expected to be done on site, cutting waits that at present can be as long as 18 months.

Post Diagnosis Support

So we are able to identify and diagnose dementia earlier. Really that’s great. It allows people to have more time to adjust and to make plans regarding their needs in the future. We have more people who are aware of the needs of people with dementia in their own social circles and prepared, we hope, to be more tolerant and supportive.

However we can’t allow the happy clappy Department of Health talk to get away with the fact that dementia services and provisions have been slashed to bare bones. There is little left to provide to people who have early diagnoses, particularly if they don’t have that family support because the resources just are not there.

I’m all for early diagnosis if people want that (and not everyone does but that’s an individual thing) but if this is the same government that has launched a savage attack on local authority social care services which were barely fit for purpose at the best of times then I can’t help but be cynical about some of these provisions.

I’d like to see more research and provision of different types of care both in residential settings and at home so we aren’t at the mercy of large private companies creating ever larger residential and nursing homes in suburbs where the cost of property is low that house up to 80+ residents with dementia in places that are difficult for family to access without cars.

I’d like to see some of this ‘dementia challenge’ money put into allowing local authority assessments to build cost of non-directed advocacy into support planning – that would make an immediate change in the quality of life of those with dementia.

I’d like to see some honesty around the poor quality care for people with dementia currently in social care and hospital settings. Maybe some of that money could be invested in paying care staff better and more importantly improving training.

Big Society

This is very much a ‘big society’ volunteer type role. Good luck for those who participate. I’ll likely join up myself but lets not forget that this means distribution of volunteers may not be equal and those who have no community as such will not have the same benefit of access to these who volunteer.

So a good initiative and well done but lets not forget that if the government aim is to increase diagnosis, they have to be prepared to put more money into improving what happens and what support is available after diagnosis.

The ‘Red Tape Challenge’ does Health and Social Care

We all knew it would come in time. This wonderful government idea to slash all that awful ‘red tape’ that stops people doing what the government otherwise would stop them doing finally arrives at Health and Social Care.

I had a brief look at some of the provisions detailed as ‘red tape’ for which the government is asking for comment and quite frankly, I am horrified.

What I might see as essential protections, they are presenting as ‘red tape’ and asking for feedback about potential abolition.

This is a consultation so it’s really important that as many people as possible to contribute and in the joyful spirit of openness, the website allows up to see the live commenting on others. I wonder how those with less technological access or knowledge are able to comment quite so openly about some of the provisions up in the air.

But openness and accessibility only seems to go so far and for the government departments responsible they seem to be after whipping up public distaste of ‘red tape’ although actually, we really do need to move from the idea that bureaucracy is necessarily bad.

There is a separate website entirely to focus on ‘ regulatory enforcement’ and where it might be unnecessary.I feel robust regulation (and thus, enforcement which has to follow as a result) is essential. The big problem with social care and health regulation since the CQC was established was the ‘light touch’ type approach which had been taken and the ‘back office’ regulation and not enough enforcement.  I really really hope that it is not cut back further. I want to see more regulation and stronger enforcement, not less of it.

But back to the ‘red tape challenge’. I want to share some of the provisions ‘up for discussion’ that the government has classed as ‘red tape’.  I’m solely concentrating on what is up under ‘Quality of Care and Mental Health Regulations’ as I felt that was the area I knew best. The numbers refer to the list of these ever so demanding provisions in the Excel list here.

39 is that oh so burdensome (!!!) regulation that requires the Care Quality Commission ‘to monitor and access for monitoring purposes, people who are deprived of their liberty’ and necessity to report this to the Department of Health.

40 is a nice one about requiring people ‘who assess Deprivation of Liberty’ to have an enhanced CRB.  – clearly unnecessary because.. er.. people who lack capacity and may potentially be subject to DoLs aren’t likely to be vulnerable, right? I think there’s an issue about effectiveness of CRBs in general but a bit worrying that that’s considered ‘red tape’.

43 is much more worrying as it is the obvious ‘red tape’ which introduced IMCAs as a safeguard for ‘those who have noone to speak on their behalf’ making them mandatory in abuse and review situations. RED TAPE??

55 is another ‘good one’ which ensures that IMHAs are ‘of an adequate standard’ because clearly, that is unnecessary (!?!)

Obviously there are many many more – I’ve just, for reasons of time, picked out a few that interest me personally but do have a look at them and COMMENT.

I’m frankly insulted that some of these provisions are even considered to be ‘red tape’  but as there’s an open consultation, it’s important that as many people as possible who know and understand the implications of removing them, to contribute.

If the government want to know what ‘red tape’ is in terms of adding unnecessary burdens, I’ll gladly explain about how useful (or not) it is to spend time recording how much time I spend on ‘smoking cessation’ work or time spent ‘clustering’ people according to diagnosis into tiny little tick boxes which are, clinically, unhelpful in order to get the ‘Payment by Results’ systems which will never work well, up and running. THAT’S red tape.

But it seems to be red tape that potentially infringes on the rights of those who might be least able to protect their own that they are classing as ‘red tape’ here.

Contribute to the consultation and let’s tell them how important some of these provisions are.

Oh, and someone should tell the Department of Health that the GSCC doesn’t exist anymore as they seem to have forgotten on their Professional Standards page (published this week!) but we know how much interest the Department of Health has in social work and social care so shouldn’t really be surprised.

Pic by Martin Deutsch@Flickr